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Vital Signs

Multidisciplinary clinics prove to be the bee's knees

By Matthew C.Wiencke

What makes DHMC's multidisciplinary thoracic oncology clinic tick? To find out, just visit the local science museum's indoor-outdoor hive and "watch those bees," says Gwendolyn Natola, project manager for the clinic. "The bees come in and it looks so chaotic—they're flying around and dancing—but it's actually a lot of choreography." The clinic "is very much like that," she says.

Confer: The one-day-a-week clinic, at the Norris Cotton Cancer Center, is a bustling place. Clinicians and nurse practitioners who specialize in lung cancer and other thoracic cancers confer in a central room, in between seeing patients in adjacent exam rooms. Oncologists, surgeons, a pulmonologist, a radiation oncologist, a nurse manager, a clinical trials coordinator, social workers, palliative-care specialists, and smoking-cessation counselors buzz in and out. This allows patients to see everyone they need to all in one day. To coordinate the activity, a central "intake unit" handles all phone calls and follows detailed algorithms to determine how patients should be scheduled—according to if they need a needle biopsy, say, or a bronchoscopy.

"It simply means that we try to slot people in the most efficient way so that patients don't get sent to the wrong doctor early on," says Dr. Peter DeLong, the clinic's pulmonologist.

The clinic "also allows the providers to talk among themselves in real time, or even confer with a patient together and, in complex cases, decide the best treatment," says Dr. David Johnstone, a thoracic surgeon. Another advantage is that providers are more aware of colleagues' research and clinical trials.

Grab: And for patients, return visits are often avoided. "Currently I can see a patient . . . that I cannot performa bronchoscopy on but that's probably amenable to surgery. I can walk outside the room and grab a surgeon who can look at a scan right there with me," says

It's a hive of activity in DHMC's thoracic oncology clinic, which Gwen Natola, in the foreground, manages.

"It looks chaotic . . . but it's actually a lot of choreography.

DeLong. Then the appointment for surgery can be made right on the spot. "So what could take three or four days has been condensed to 10 or 15 minutes," he adds.

Hugh Sullivan, a lung-cancer patient who also has pulmonary fibrosis, was referred to Dr. Candice Aitken, the clinic's radiation oncologist , when his surgeon determined that he was not a candi date for surgery. He received three treatments using a precise, high-dose radiation system that i s timed to the patient's respiratory cycle so it targets the tumor and causes little damage to adjacent healthy tissue. "I had radiation on Wednesday," says Sullivan. "Thursday morning I played golf. I had no ill effects at all." His tumor was eradicated, and three months later he felt fine—just a little short of breath because of his fibrosis.

Lung cancer is the leading cause of cancer death among both men and women, yet there are about 330,000

longterm survivors, according to the American Cancer Society. At Dartmouth, the multidisciplinary approach to thoracic cancers goes back to the late 1980s, when the Comprehensive Thoracic Oncology Program (CTOP) was formed. CTOP was a weekly conference at which clinicians from different disciplines discussed cases. "So the multidisciplinary approach . . . had really been existing here for considerably longer than the actual clinic," says Dr. William Nugent, a cardiothoracic surgeon.

Model: The multidisciplinary clinic model has taken hold at DHMC for other conditions as well—breast cancer, amyotrophic lateral sclerosis, craniofacial problems, polycystic ovarian disease, and juvenile arthritis and rheumatic diseases. Dartmouth's nationally known Spine Center was the first such clinic.

In the thoracic oncology clinic, Natola enjoys working with all the busy bees. "This particular clinic has providers that never say no," she says. "They always do the best thing for patients."

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Dartmouth Medical SchoolDartmouth-Hitchcock Medical CenterWhite River Junction VAMCNorris Cotton Cancer CenterDartmouth College