Triage of an overloaded colorectal MDT list
Your colorectal multidisciplinary team meets once weekly and can hear 14 cases. Twenty-three referrals arrive by Wednesday for Friday. Three are marked urgent: a 58-year-old with iron-deficiency anaemia and a caecal mass on CT; a 34-year-old with a 9 cm rectal lesion and no staging imaging; and a 71-year-old with a 2 cm polyp referred as 'query malignancy' with a normal colonoscopy report attached. One referral is a single line from a general practitioner: 'please see and advise', with no histology and no imaging. Two patients have opted out of discussion at the MDT but still want to be considered for surgery. The coordinator asks you to triage the list and decide what happens to the rest.
1. Set out the criteria you would use to triage, and apply them to the overloaded list.
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Criteria: risk of harm from delay; whether the MDT decision actually changes management this week; diagnostic certainty and completeness of information; patient preference; and the opportunity cost of a slot.
Applying them:
- Caecal mass with iron-deficiency anaemia - high probability of cancer, high harm from delay. It needs a staging pathway and a surgical opinion. Bring it, even if the decision is 'request CT chest and repeat imaging urgently'.
- 34-year-old with a 9 cm rectal lesion, no staging - the treatment decision cannot be made, but the MDT can own the urgency: request staging and imaging within days, flag for specialist referral. Bring it, because the plan is the decision.
- 2 cm polyp with a normal colonoscopy report - the referral is internally contradictory. This is a correspondence problem, not an MDT problem; query it with the referrer rather than spending a slot.
- 'Please see and advise' with no data - return within 24 hours with a proforma, not a rejection.
Remaining cases: list by harm-from-delay, carry forward the rest with a documented reason and a date. Record the triage decisions so that anything deferred is visible and chased.
2. How would you handle the two patients who have opted out of MDT discussion?
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Respect the opt-out as a valid expression of the patient's autonomy, and do not treat it as an administrative obstacle. In practice this means three things.
First, do not present identifiable information about them at a meeting they have declined. Second, find out what they were actually declining, because patients often object to being discussed by a room of strangers rather than to multidisciplinary input as such. Offer alternatives: clinician-to-clinician advice with their consent to share specific information, a smaller discussion, or a written opinion.
Third, make sure the opt-out does not quietly become a lower standard of care. Their surgical eligibility still needs a decision, so agree explicitly who will make it, on what information, and how it will be recorded. Confirm the opt-out in writing, revisit it if their situation changes, and make sure the clinician who takes responsibility for their care knows the MDT has not reviewed the case.
3. Write the 60-second presentation you would give for the caecal mass case.
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"58-year-old woman, fit and independent, no significant comorbidity. Referred with a three-month history of fatigue and iron-deficiency anaemia, haemoglobin 82, ferritin low. Colonoscopy was incomplete; CT colonography shows a 4 cm caecal mass with locoregional nodes, no liver or lung lesions reported. No histology yet - biopsy was not possible at the incomplete colonoscopy due to poor preparation. She is aware of the suspicion, wants to know the plan, and is keen on surgery if it is an option.
The question for the MDT is: do we proceed on radiological suspicion with repeat biopsy and staging, or repeat colonoscopy first? I would propose staging CT chest today, repeat colonoscopy with biopsy in the next slot, and a surgical outpatient appointment booked now so nothing waits on histology."
Structure: who, why, key findings, what is missing, the explicit question, and a proposal the meeting can accept, amend or reject.