12 Multidisciplinary Care of the Vestibular Schwannoma Patient: Building a Skull Base Team

10.1055/b-0039-169166

12 Multidisciplinary Care of the Vestibular Schwannoma Patient: Building a Skull Base Team

Jeffrey T. Jacob, Matthew L. Carlson, Colin L. W. Driscoll and Michael J. Link

12.1 Introduction

A strong multidisciplinary team, who shares a similar mindset in their approach to patient management, is a central component in providing optimal, comprehensive care for vestibular schwannoma (VS) patients. Establishing a multidisciplinary network of specialists within an established neurosurgical, otorhinological, and oncologic environment can present unique challenges. The ability to offer the complete spectrum of options available to treat VS in addition to other complex lateral skull base pathologies involves building a highly subspecialized team that successfully integrates all the available strategies and tailors treatment to what is most appropriate for each individual patient.

Counseling patients who are diagnosed with VS can be challenging. Given the variety of treatment options, presenting patients with an unbiased review of the advantages and disadvantages of various modalities is important for shared-decision making and supports true informed consent. It has been shown that patients themselves can be biased and committed toward a particular treatment strategy based on their initial consultations, the Internet, and other factors.s. Literatur ^, s. Literatur Furthermore, providers can be biased toward a certain modality depending on their comfort level, availability of radiation treatment platforms, or personal bias toward treatment strategies.

12.2 What Constitutes a Vestibular Schwannoma Team?

Undoubtedly, the most important aspect in building a successful skull base program is the people. The team itself can be led or co-managed by a variety of experienced practitioners, inclusive of a primary surgical team (e.g., neurosurgeon + neurotologist) or a combination of providers (e.g., neurosurgeon + neurotologist + radiation oncologist). There are excellent examples of providers in each of these specialties who have jointly contributed to the management of VS patients at many high-volume centers. While the titles are not important, whoever is seeing the patient should have experience with all forms of treatment, or be able and willing to bring in members of the team who do if they are not versed in one particular aspect of care.

12.2.1 Building an Effective Skull Base Team

Collectively, the team should have a unified vision in the general approach and management of patients. Important and often overlooked, the team must share mutual respect for all members. Respect for one another is likely the single most important trait for a successful team, both anecdotally and even as identified in systematic analyses defining healthcare teamwork competencies.s. Literatur In addition, a cooperative and positive attitude, courage to disagree with each other, and even a sense of humor encompass almost equally important traits for the members of an effective healthcare team.s. Literatur

Practicing as part of a team has very unique benefits to both the patient and the provider. A team approach brings in more perspective regarding the most appropriate management and may enlighten other members to options or issues they did not individually consider. Furthermore, it reduces fatigue both in the consultation aspect of seeing patients and among surgical colleagues during particularly long procedures and tedious dissections. Experienced input from a second set of eyes at critical decision-making points may improve the outcome. Often understated, the reduced psychological burden that comes from group decision making is invaluable. Moreover, collaboration also emphasizes the importance of being intellectually honest regarding the evaluation of complications and outcome.

The tireless multispecialty teamwork must occur seamlessly at all levels: from leadership to midlevel providers, schedulers, support staff, nursing, and even among billing staff. All personnel must understand the team approach. We have found that allowing the members of the team to interact with each other, by way of in-service education, joint conferences, multidisciplinary rounds, and joint clinics, has helped foster this relationship. Furthermore, the members of the team frequently have joint appointments to one another’s department, which serves both to facilitate the relationship and to further reinforce the close partnership of the skull base team throughout the institution.

There is increasing evidence that overall outcomes are improved when VS surgeries are performed at high-volume centers and by high-volume providers through a team-based approach. This approach has demonstrated superior short- and long-term outcome, with shorter lengths of stay and reduced hospital cost.s. Literatur Nonetheless, it is also the case that high-volume centers and high-volume surgeons tend to take on higher risk surgeries and perform more complete resection, as compared to lower-volume centers, which can artificially skew the risks and complications of treatment.s. Literatur While it is difficult to categorically make the case for centralizing VS and other complex skull base surgery to a select few centers and providers, there are clear data to suggest that higher case volume may be a proxy of better access and outcomes that benefit patients due to refinement and standardization of clinical protocols, surgical technique, and streamlined postoperative care.s. Literatur

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