READING ROOM WITH A VIEW DOUGLAS GREEN, MD

The Wisdom of Tumor Boards A successful face-to-face group . . . makes everyone work harder, think smarter, and reach better conclusions than they would have on their own. —James Surowiecki

Does a group reach better conclusions than we would have on our own, [1]? Usually, it does not. Can a group reach better conclusions than we would have on our own? It can, and Cass Sunstein and Reid Hastie explain how, in their book Wiser: Getting Beyond Groupthink to Make Groups Smarter [2]. Both diagnostic and interventional radiologists participate in tumor boards. A tumor board is a face-to-face group that must first identify a set of treatment options for an individual cancer patient and then select the one best option. The guidelines presented for identification and selection in “Wiser” have the potential to help tumor boards reach better conclusions [2].

THE GUIDELINES FOR IDENTIFICATION Start with the criteria that will be used for selection. The best treatment option is the one that holds the highest promise for palliation or cure, with a risk profile that is acceptable to the patient. Starting with the selection criteria primes the mind “to produce relevant solutions that are not wildly outside the realm of acceptable solutions” [2]. Withhold criticism and evaluation during identification. Criticism and evaluation are indispensible during selection, but they can inhibit members of the group from suggesting potential treatment options.

Promote diverse solutions. The task of the tumor board leader, who is usually the primary caregiver for the patient being discussed, is to elicit potential treatment options from as many tumor board participants as have something to offer. The composition of a tumor board makes this task easier. The specialist participants— medical oncologists, radiation oncologists, oncologic surgeons, and interventional radiologists—are likely to have something to offer and are likely to speak up. Adopt a means of recording the potential solutions. This factor is more important if many potential solutions are offered. Usually, just a handful of treatment options are suggested at a tumor board meeting, in which case this guideline can be set aside.

THE GUIDELINES FOR SELECTION Review the criteria that will be used for selection. Tumor boards generally reach an acceptable consensus by combining independent individual evaluations. This consensus can be influenced by “irrelevant social factors such as status, talkativeness, and likability of the sources” [2]. To mitigate this risk, anonymous balloting can be effective. The consensus can be influenced additionally by financial incentives. The fee-for-service payment model could bias individual evaluations in favor of an expensive intervention. As we move away from the fee-for-service model, this perverse incentive should become less problematic.

DOUBLE-CHECKING Behavioral scientists have catalogued the mistakes we make when we reach conclusions on our own. We hope that, by

meeting in face-to-face groups, we can reach better conclusions. However, this goal is not always achieved, even when groups follow the guidelines. What can be done to test the conclusions reached by a tumor board before treatment starts? “Red teams” are contrarian subgroups that are charged with challenging the selected therapeutic option. Red teams perform the job of devil’s advocate, but they have been shown to be more effective than an individual, perhaps because “having more than one dissenter provides social proof of the validity or at least the significance of the divergent views” [2]. Soon, tumor boards will be able to turn to decision support systems for help with identification and selection. IBM’s Watson supercomputer, having vanquished Ken Jennings (a contestant on the television game show Jeopardy!), has been repurposed to help oncologists “identify individualized evidence-based treatment options.” In addition, Watson rank orders these treatment options to help guide selection [3]. By following the guidelines for improving the identification and selection of the one best treatment option, and double-checking with a red team or decision support systems, we should be able to increase the likelihood that tumor boards are successful.

REFERENCES 1. Surowiecki J. The wisdom of crowds: Why the many are smarter than the few and how collective wisdom shapes business, economies, societies, and nations. New York, NY: Doubleday; 2004. 2. Sunstein CR, Hastie R. Wiser: Getting beyond groupthink to make groups smarter. Boston, MA: Harvard Business Review Press; 2015. 3. IBM Watson. Available at: http://www.ibm. com/smarterplanet/us/en/ibmwatson/implementwatson.html. Accessed March 2, 2015.

Douglas Green, MD: University of Washington, Department of Radiology, 1959 NE Pacific St, Seattle, WA 98195-0001; e-mail: [email protected].

ª 2015 American College of Radiology 1546-1440/15/$36.00 n http://dx.doi.org/10.1016/j.jacr.2015.03.028

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The Wisdom of Tumor Boards.

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