Table 5.

Key Informant and Focus Group Data

TDF Domain	Key Informant Themes identified as Barriers	✖ group thinks this is not a barrier ✔ group agrees this is a barrier ☐ group divided			Sample Quote
		Surgery	Oncology	Diagnostic Specialists
Memory, Attention and Decision Processes	Presenting physician not prepared	✖	☐	✔	“MCCs are complex and there are occasions where people present and they come to a conclusion and (then they) suddenly realize, ‘oh I missed this detail’”
	Chair does not control flow of discussion	✖	✔	✔	“Sometimes the chair forgets they’re the chair and gets involved in the discussion as one of the experts” “Sometimes we don’t get through all the cases because some people go on and on and the chair doesn’t control it”
	No standard format for case submission	✔	✔	✔	“very rarely does (the MCC form) get filled out adequately, some people don’t fill it out at all and their cases still get on MCC, then they don’t show up and we have to actually try to figure out what their question is” "at rounds they’re like ‘well what about this margin’ and you’re like ‘oh I can’t believe I have to go through the slides again'. It would be much easier if they told us ahead of time what the specific question was because you have to do a total review of the case, which could take hours”
	No standard format for case presentation	✔	✖	✖	“So I find that having a structure to the presentation so you know what is your question, a very brief history … this is the scan and this is the imaging … when people ramble you don’t even know what they’re asking you just lose focus and you probably don’t even get as much information.”
	The right specialists are not in the room	☐	✔	✔	“I’ve seen that … if nobody from rad onc happened to be there, then that case has to be skipped over and it can’t be discussed...that just completely limits the discussion”
	No documentation standards	☐	✖	n/a	“(At rounds) there is somebody writing and they will ask me, what did you say … .and this piece of paper, I’m like where does this paper go? I wish … sometimes I know some patients have been discussed and I don’t know where to get that information”
Environment	Inadequate time within MCC to discuss all desired cases	✖	✔	✔	“there is never enough time for anything, everything is pushed to the limits”
	Lack of time to prepare for MCC	✔	✔	✔	“There should be a little column to what the pathologic issue is (ie: what the specific question is), especially for pathology – radiology can scroll up and down in the films where have to look at slides. We can’t do it on the spot”
	MCC times limited by specialist availability	✔	✔	✔	“There is never a Monday at 12 o’clock (time of MCC) that I am free, so I would have to plan for well in advance and completely rearrange a weekly schedule to be available … it’s a tough (meeting) time that doesn’t consider the challenges surgeons face. If they put it Monday at 7 am or 5 am I would be there every week”
	Inadequate administrative supports	✔	✖	✔	“We have zero administrative support. Resources are an issue, that is a huge thing”
	Inadequate physical resources	✔	✔	✔	“Technology is always an issue … ..always … .a lot of wasted time – we definitely have inadequate support for that” “Someone broke the microscope, so we have no microscope. I don’t know whose responsibility it is to replace it but it hasn’t been there for eight months”
Social Influence	Ineffective communication	✔	✖	✔
	Negative group dynamics	✔	✔	☐	“It’s petty … you know the personalities and what happens, so it can be uncomfortable”
	Bullying	☐	✖	✔	“I have been belittled at those rounds” “It’s to a point in this disease site where one of the surgeons walked out because of the way they were treated”
	Lack of psychological safety	✔	✔	✔	“We are supposed to come in like it’s a safe place and residents always feel like they are being judged”
	Inneffective communication/ Certain individuals dominate the conversation	✔	✔	✔	“whoever would yell the loudest was ultimately (listened to)”
Knowledge	Limited evidence to guide treatment plans	✖	✖	✖	“(A lack of evidence) enhances the discussion. Part of the impetus behind MCC in the first place is there is not a perfect answer for every single scenario”
	Conflicting recommendations (art of practice)	✖	✔	✔	“It’s the nebulous stuff … that makes it hard”
	Belief that use of email is equivalent to discussing case in MCC	✔	✖	n/a	“Email is not a sufficient way to discuss patients”
Goals	Lack of consensus regarding MCC purpose	✔	✔	✔	“This gets to the heart of why certain rounds may have more tension … it depends on whether you are obliged to have consensus (regarding treatment plan) at the end … if you are obliged to have a consensus things might be more heated because then you are bound to following through (on the plan) that you may not agree to”
Social/Professional Role and Identity	Intrinsic belief that participation in MCC is outside of the scope of treating physicians’ professional role	✖	☐	✖	“That option is not available as a (diagnostic specialist). You must be present” “Not all of the surgeons always attended”
Beliefs about Consequences	No consequences to physicians who do not attend or participate in MCC	✔	✔	n/a	“it’s a barrier when they put on a case and then they don’t show up”
TDF Domain	Key Informant Themes identified as Facilitators	✖ group thinks this is not a facilitator ✔ group agrees this is a facilitator ☐ group divided			Sample Quote
		Surgery	Oncology	Diagnostic Specialists
Social Influence	Strong collegiality and teamworking	✔	✔	✔	“those (rounds) are valuable to me and I think I speak for my colleagues … you are there to be collegial to your other colleagues … you are there because it is part of your role as a professional collaborator”
Environment	Standard case submission (intake form) increases efficiency	✔	✔	✔	“I think this is where you would have a stick, right. This is where you have to stick to say ‘if you do not meet this minimum standard for submission then the case isn’t going to get discussed … if you are not uploading your images, the radiologist is not going to look at them’”
	Rotating attendance schedule reduces MCC participant burnout	✖	✔	✔	“if we did have rotated priority that would be helpful, we are always kind of scrambling … we do have a sort of rotating schedule because if we don’t then someone is missing around somewhere”
	Adequate administrative supports improve efficiency of MCC	✔	✔	✔	“for years, we had every single brain tumor patient in the book written down, it was all in there and what the decision was, so it was a central repository … that is where you need administrator’s support”
Beliefs about Consequences	MCC allow for opportunities of learning	✔	☐	✔	“learning opportunities for residents could be improved”
	MCC empower physicians to make treatment decisions	✔	✔	n/a	“I had a contentious case where the patient is going to say, I want to see the multidisciplinary team’s opinion … in two cases I was able to show them (the MCC’s decision) and that stopped all of the argument”
	MCC can standardize decision-making for complex cases	✔	✔	n/a	“MCCs help create a framework for decision making”
	MCC allow physicians to obtain second opinions from colleagues efficiently	✔	✔	n/a	“it is just like having a curbside counsel with one of your colleagues”
	Decisions made in an MCC setting mitigate medico-legal risk	☐	☐	n/a	“You want insurance more than anything”
Reinforcements	CME (continued medical education) credits promote MCC participation	☐	☐	☐	“if you are relaxing on Friday and you have absolutely nothing to do then I think yeah then you would show up to get CME credits. And listen to the discussion. But I agree with you that I don’t think anybody because of that I think people who go because they get value out of getting their cases discussed” “getting CME credits for something that you do is always nice … but I don’t think anybody would go just because of that”
	Billing codes (i.e.: remuneration) promote MCC participation	☐	☐	☐	“we don’t get paid for it, but we don’t miss it, even if we have no cases to present … I billed for a case which is like $11” (implying that the billing is not an incentive) “lack of payments is a barrier” “everyone can bill except for pathologists. We treat it as our job and we are delighted to do it because there is no financial and we cannot bill because we are salaried”