Relationship-building key to addressing oncologist shortages in rural care

Rural oncologists reported the loss of expertise and professional support as key impacts of the departure of “linchpin colleagues,” according to a new Dartmouth-led study published in the journal JCO Oncology Practice. The study, which shares insights about the effects of specialist scarcity in rural settings, is helping researchers understand what strategies may work best in addressing gaps in care.

The research team sought to understand physician perceptions of and experiences with specialist scarcity in their referral networks, their strategies for delivering care after the departure of a colleague, and the impacts from these shortages on patient care. They conducted interviews with 20 oncologists of varying professional backgrounds and expertise from five different rural network sites across the U.S.

“As part of our research, we developed a ‘linchpin’ score to identify those physicians who were locally unique for their specialty,” explains lead author Erika Moen, MS, Ph.D., associate professor of biomedical data science and of The Dartmouth Institute for Health Policy and Clinical Practice at Dartmouth’s Geisel School of Medicine.

“We hypothesized that those physicians would be viewed as especially critical in the delivery of multidisciplinary care to patients and would be harder to replace if they were to retire or relocate.

“One of our key findings was that when physicians were asked to talk about the direct impacts of a linchpin colleague’s departure, they really highlighted the loss of expertise and loss of trust,” says Moen, who notes that expertise and trust rated even higher than increased patient volume in the results.

“I think that just speaks to the importance of relationship building for diseases like cancer, where you’re often delivering complex treatments to patients across a team,” she says.

Shortages of cancer specialists in rural areas across the U.S. are well documented and can lead to a number of challenges for local care teams. These include fewer subspecialists to collaborate with and refer patients to, long distances to treatment centers, and limited access to clinical trials and specialized services. These barriers can lead to delays in diagnosis and treatment, poorer outcomes, and increased financial burden for patients.

“A lot of the research that has highlighted oncology workforce shortages has been focused on head count measures,” says Moen. “While these measures can be helpful in identifying areas that have, for example, a low density of oncologists, we wanted to take a more dynamic approach in thinking about workforce shortages and understand them from different perspectives.

“In doing this, we utilized ‘social network analysis,’ which recognizes the importance of relationships between physicians and the delivery of multidisciplinary cancer care.”

In their study, the team identified three major themes related to specialist scarcity. The first theme described the effects of physician shortages on care team expertise, collaborative relationships, and patient volume.

“The second theme uncovered strategies oncologists used when facing physician shortages,” she says, “including referrals to outside health systems or generalists who were practicing outside their sub-specialization, and reallocating time from their other responsibilities.”

The third theme identified unintended consequences of these strategies, including greater patient travel burden, less optimal or delayed treatment, reduced access to clinical trials, and increased physician burnout and lower job satisfaction.

Despite the significant challenges rural oncologists face with specialist scarcity, Moen believes there are opportunities to develop interventions. “The use of virtual tumor boards could be one way to help establish stronger relationships between specialists, even if they’re not collocated at the same site,” she says. “Changing payment policies to ensure recruitment and retention of physicians in rural areas may also help.

“That’s where, I think, research like ours can prove valuable,” she adds. “Mapping the relationships between strategies after an oncologist leaves, with the downstream consequences on clinical care, can help guide resources to lessen the negative effects of departures and shortages.”

Rural oncologists reported the loss of expertise and professional support as key impacts of the departure of “linchpin colleagues,” according to a new Dartmouth-led study published in the journal JCO Oncology Practice. The study, which shares insights about the effects of specialist scarcity in rural settings, is helping researchers understand what strategies may work best in addressing gaps in care.

The research team sought to understand physician perceptions of and experiences with specialist scarcity in their referral networks, their strategies for delivering care after the departure of a colleague, and the impacts from these shortages on patient care. They conducted interviews with 20 oncologists of varying professional backgrounds and expertise from five different rural network sites across the U.S.

“As part of our research, we developed a ‘linchpin’ score to identify those physicians who were locally unique for their specialty,” explains lead author Erika Moen, MS, Ph.D., associate professor of biomedical data science and of The Dartmouth Institute for Health Policy and Clinical Practice at Dartmouth’s Geisel School of Medicine.

“We hypothesized that those physicians would be viewed as especially critical in the delivery of multidisciplinary care to patients and would be harder to replace if they were to retire or relocate.

“One of our key findings was that when physicians were asked to talk about the direct impacts of a linchpin colleague’s departure, they really highlighted the loss of expertise and loss of trust,” says Moen, who notes that expertise and trust rated even higher than increased patient volume in the results.

“I think that just speaks to the importance of relationship building for diseases like cancer, where you’re often delivering complex treatments to patients across a team,” she says.

Shortages of cancer specialists in rural areas across the U.S. are well documented and can lead to a number of challenges for local care teams. These include fewer subspecialists to collaborate with and refer patients to, long distances to treatment centers, and limited access to clinical trials and specialized services. These barriers can lead to delays in diagnosis and treatment, poorer outcomes, and increased financial burden for patients.

“A lot of the research that has highlighted oncology workforce shortages has been focused on head count measures,” says Moen. “While these measures can be helpful in identifying areas that have, for example, a low density of oncologists, we wanted to take a more dynamic approach in thinking about workforce shortages and understand them from different perspectives.

“In doing this, we utilized ‘social network analysis,’ which recognizes the importance of relationships between physicians and the delivery of multidisciplinary cancer care.”

In their study, the team identified three major themes related to specialist scarcity. The first theme described the effects of physician shortages on care team expertise, collaborative relationships, and patient volume.

“The second theme uncovered strategies oncologists used when facing physician shortages,” she says, “including referrals to outside health systems or generalists who were practicing outside their sub-specialization, and reallocating time from their other responsibilities.”

The third theme identified unintended consequences of these strategies, including greater patient travel burden, less optimal or delayed treatment, reduced access to clinical trials, and increased physician burnout and lower job satisfaction.

Despite the significant challenges rural oncologists face with specialist scarcity, Moen believes there are opportunities to develop interventions. “The use of virtual tumor boards could be one way to help establish stronger relationships between specialists, even if they’re not collocated at the same site,” she says. “Changing payment policies to ensure recruitment and retention of physicians in rural areas may also help.

“That’s where, I think, research like ours can prove valuable,” she adds. “Mapping the relationships between strategies after an oncologist leaves, with the downstream consequences on clinical care, can help guide resources to lessen the negative effects of departures and shortages.”