Understaffed and Overbooked: The Problems with Maintaining Specialty Care in Rural Areas

Dr. Chino welcomes Dr. Erika Moen and Dr. Dan Zuckerman to discuss new research highlighting how specialist scarcity is felt by oncologists practicing in rural environments. Dr. Moen is the first author on “Rural Oncologists' Perceptions of Specialty Scarcity and Repercussions for Care Delivery: A Qualitative Study,” which is featured in JCO OP’s January 2026 issue.

TRANSCRIPT

Dr. Fumiko Chino: Hello, and welcome to Put Into Practice, the podcast for the JCO Oncology Practice. I'm Dr. Fumiko Chino, an Associate Professor in Radiation Oncology at MD Anderson Cancer Center, with a research focus on access, affordability, and equity.

Rural oncology care has many challenges, including travel distance, limited specialty care, sparse clinical trial infrastructure, and financial barriers leading to worse outcomes and access for patients from diagnosis through survivorship care. Oncologists practicing in rural areas often have difficulties coordinating care with geographically distant providers and limited availability. This is made worse by known workforce gaps.

I'm happy to welcome two guests today to discuss new research highlighting how specialist scarcity is felt by oncologists practicing in rural environments. Dr. Erika Moen, MS, PhD, is an Assistant Professor of Biomedical Data Science at Dartmouth. She is a health services researcher and leads a multidisciplinary team working to leverage network analysis to optimize cancer care delivery and patient outcomes. The long-term goal of Dr. Moen's lab is to improve equitable access to coordinated cancer care with a particular focus on rural populations. She is the first author of the manuscript, "Rural Oncologists' Perceptions of Specialty Scarcity and Repercussions for Care Delivery: A Qualitative Study," which was featured in JCO OP's first issue of 2026.

Dr. Dan Zuckerman, MD, FASCO, is the director of GI oncology and staff medical oncologist at St. Luke's Cancer Institute in Boise, Idaho. The center encompasses eight locations and is the region's largest provider of cancer care, treating a catchment area of over 20 counties. He is past president of the Idaho Society of Clinical Oncology and has been active in ASCO, including past chair of the Clinical Practice and Innovation Committee.

Our full disclosures are available in the transcript of this episode, and we've already agreed to go by our first names for the podcast today.

Erika and Dan, it's really wonderful to speak to you today.

Dr. Erika Moen: Hi, Fumiko and Dan. It's great to meet you both, and I'm looking forward to this discussion.

Dr. Dan Zuckerman: Me as well. Thanks, Fumiko. Nice to meet you, Erika.

Dr. Fumiko Chino: Erika, do you mind starting us off on how you got interested on how to try to optimize multidisciplinary care and why your focus is specifically in rural populations?

Dr. Erika Moen: Yes, absolutely. When I was a new assistant professor, I knew I wanted to focus my research program on bringing together my methods expertise in patient-sharing network analysis, which involves using healthcare administrative data to identify networks of physicians who share the same patients, with my research interest in cancer care delivery.

I remember reading an oncology workforce report published by JCO OP, and in that paper, there was a map visualizing county-level metrics of the number of oncologists per capita. And one of the things that immediately struck me was what I was seeing in rural areas. There would often be one county that had a relatively high density of oncologists, and it would be surrounded by counties with none. I wondered what the multidisciplinary referral networks of those physicians looked like and how physician departures or retirements would impact those patients and care teams. And because rural areas have known workforce shortages, and the delivery of high-quality cancer care depends on relationships between multidisciplinary specialists, these networks of physicians seemed critical to study and to support to maintain access to care for rural communities.

Dr. Fumiko Chino: What a great summary about how you got interested in this and trying to marry the data science of it all with the actual care delivery, like what matters to patients on the ground, which is: “Am I going to be able to see a specialist focused on melanoma or am I just going to have to see a general oncologist?” So that's a phenomenal narrowing in on "this is the reason why I'm doing the research that I want to do."

Now, Dan, congratulations on your recent nomination for the ASCO Board of Directors. I know that you have been passionate about improving quality care delivery for decades. Can you speak to your efforts in your home state and within ASCO to ensure that the science and technology and practice pattern advancements that we see at academic centers actually make it into the community?

Dr. Dan Zuckerman: Yeah, I think about the 44 counties in Idaho, and I'd have to guess that most of us are concentrated in three or four of those. But you know, a great example: so I've been practicing out here for 18 years, when I left fellowship, we came to a center where we had autologous stem-cell transplant but not allo. And so you sort of ask about one of the greatest innovations recently in oncology has been CAR T-cell therapy. And we were thinking about and watching our patients with leukemias and lymphomas being sent to places like Seattle or Salt Lake and thinking about, as Idaho grew and our population, urban and rural, how could we provide for that?

And so, really back in 2015, when I was director of our Cancer Institute, we got buy-in from our leadership, thankfully, to start building an allogeneic stem-cell transplant program with an eye to do allo, but also with an eye to know that we needed sort of that expertise in cellular therapies, all the way from lab to processing, to having the physicians and APPs and pharmacists to do that, so that we could deliver CAR T-cell within Idaho. And it took three years to build an allo program, and then we had planned to deliver CAR T-cell in 2020 and the pandemic happened. That delayed us by a year or two. But, you know, it's an example we're proud of, but it took a massive lift. I think originally it was close to a two-million-dollar pro forma with 19 FTEs, and we were fortunate to have leadership at St. Luke's and also a group of physicians who were willing to make that lift because we're not an academic center. But that's sort of one example where we've been successful in being able to bring some subspecialty care to a rural area, but it is incredibly difficult. And we still have gaps. So obviously I'm highlighting a place where we've been successful.

Dr. Fumiko Chino: No, I love that you mentioned CAR T-cell because I know we did a recent podcast episode about access to CAR T and how providing CAR T within the community is obviously the next step, and yet it's so challenging. There's these logistic challenges, but you also have to have actual buy-in from the institutions to build the programs because they will not build themselves. And I think: Oh, you don't have CAR T-cell in your community within your county, within 10 counties? You didn't even have it within your state! And so, that's a phenomenal effort, and it required so much investments in people and dollars and just time. So, I completely respect that.

And it dovetails really nicely into the next question to Erika, which is: the manuscript on deck that we're talking about really talks about the access to specialty care and how that can be very challenging in rural areas. Do you mind giving us an overview of the manuscript, kind of what you did, what you found, what you're excited about in terms of the next steps?

Dr. Erika Moen: Sure. So, our study conducted and analyzed qualitative interviews from 20 oncology physicians across five sites that served a rural catchment area. And it was part of a larger project evaluating patient-sharing networks for cancer care. And we identified three major themes. The first was participant experiences related to the effects of physician shortages on care team expertise, collaborative relationships, and patient volume. The second related to the strategies that oncologists use when facing physician shortages, including referrals to outside health systems or generalists practicing outside their subspecialization, and reallocating time from other responsibilities. The third theme described the unintended consequences of these adaptive strategies, including greater patient travel burden, less optimal or delayed treatment, reduced access to clinical trials, and increased physician burnout and lower job satisfaction.

We then developed a conceptual map showing the connections between these themes in the broader context of an oncology physician's departure. And I think I'm really excited about the effort to map some of these themes together because I think it can be informative depending on the adaptive strategies that are being used to try to manage a workforce shortage; different interventions might be more or less effective to ensure that the care teams and the patients are supported.

Dr. Fumiko Chino: It's really interesting. It reminds me of, you know, I grew up in Indiana, and not a tiny town, but a small-town Indiana. My mom was practicing oncologist, and her referral patterns, so, for example, when she retired, her referring physicians had to figure out, “Well, who do we trust now? Who are we going to reroute our consults to now that you are no longer in service?” As it turns out, as someone who started a practice and then actually ultimately hired my sister, it was a very easy dovetail.

Dr. Erika Moen: No, but I think that's exactly right. And the importance of trust really came through as a prominent challenge that was faced by physicians that did have someone depart. And I think it's just a human experience we can all relate to.

Dr. Fumiko Chino: So Dan, I'll ping it right over to you because I would really love your thoughts about how the themes outlined in this study is something that you may find in your practice. So, for example, I know that you work at a large center, but with many referral in the community. For example, in GI oncology, I could imagine if someone retired who was a gastroenterologist in the community, that you would have this whole cascade of potential difficulties for you. Do you mind speaking about that?

Dr. Dan Zuckerman: Yeah, no, for sure, Fumiko. And on a personal note, it's funny that we both have parents who are oncologists. So I, unlike your sister, I'm actually practicing with my dad here and he's imminently retiring. And what you mentioned about that legacy and that expertise and that trust in the community and what that means and who he'll hand his practice off to certainly resonates.

But certainly talking about subspecialty care, and I think, you know, Erika and her group's paper really honed in on a key linchpin physician is often the surgeon. And so I do mostly GI medical oncology and for us, you know, we had two HPB surgeons for, you know, sort of the middle part of my career. And then the senior surgeon, who we had poached from Seattle and was, you know, sort of towards the tail end of his career, retired. But he was doing quite a bit of volume, but also was the sort of respected physician, was sort of the leader for that. And that definitely for at least a year or two was a challenge for us in terms of replacing his expertise, of putting more volume on his junior physician.

Probably more pointedly, and I think Erika's paper points this out, is that we for a long time had a urologic oncologist who was just the key person for our GU program, was doing all the RPLNDs, the cystectomies. He was just 55, had a background in the military, and realized that he could go to the local VA and dial down for quality-of-life purposes because he was exhausted, because he was that key physician. So, he was seeing so many patients, he was the heart of the program, and then all of a sudden he left. And right in the midst of it now, we're scramble- literally scrambling in terms of are we sending these patients down to University of Utah, which is sort of our closest partner academic center? Is it the community urologist, who you know, haven't done that many cystectomies in a while and haven't done an RPLND in a decade, that we rely on?

And so, yeah, we definitely feel it as a concrete example in our GU oncology program with just the departure of one physician has caused quite a bit of scrambling and quite a bit of changes in practice patterns. You know, Erika's paper also mentions possibly suboptimal care, so our patients not doing the standard neoadjuvant immunotherapy-chemotherapy with followed by cystectomy; are we doing more bladder preservation simply because we just don't have a surgeon to do it and patients don't want to travel? And so, the downstream impacts from the loss of expertise when you already have a scarce physician population are deeply felt every day.

Dr. Fumiko Chino: Erika, one thing that really struck me from your work is that there was real difficulty, it seemed like, recruiting a truly rural sample provider. So, for example, all of the physicians in the study were at centers who had large rural catchment areas, but almost all of them worked at NCI-designated cancer centers. And I do typically think of those as being pretty well-resourced. So, it's very different than, for example, again my mom's community practice, where she was at one point the only radiation oncologist. So, I would love to hear from you about that perspective of sometimes even getting the voices of the people you want to hear from, how challenging that is.

Dr. Erika Moen: Yeah, I agree completely. I'll start off by giving a big thanks to the physicians who did participate in our study, and perhaps some of them are listening. We did have more success recruiting when we were able to leverage a personal connection or a local champion, and these were often at other NCI cancer centers. We did try to recruit at outreach or community sites within those larger health systems and we had some success there. But I think it's going to be really important to understand which of our findings can generalize to community-based practices that aren't part of a larger integrated health system and identify the challenges that are more unique to care delivered outside of the context of a large health system. So yeah, I mean our sample is what it is, and I think some of the challenges will be universal but probably even greater or amplified in the places with fewer resources.

Dr. Fumiko Chino: And I'll just say even for, for example, my mom's practice, which she, you know, was an independent practice, since she retired it has now been part of this sort of large conglomerate oncology practice. That may be also just how the wind is blowing in America in terms of consolidated care.

Now Dan, there was a recent JCO OP analysis that was about the use of telemedicine oncology, and it highlighted that even after the telehealth boom of the pandemic, rural patients were still less likely to use telemedicine. They continued to have, for example, higher utilization of emergency services. And I'd really love your perspective on this. I know that you had recently helped transition your benign hem program to be an e-consult-based workflow. So I assume you're pretty familiar with some of the access issues that rural patients face.

Dr. Dan Zuckerman: Yeah, that's a great point, Fumiko. And I think there's sort of two parts to that. The telemedicine piece is interesting. On face value, I think- I and I think my colleagues had assumed that rural patients, especially because of travel distance, really just, you know, time in the car and gas money, that there might be a higher uptake. And I actually was surprised to see that it's not as high. And I think the reasons for that are manifold, but you know, some of them are technological, just is simply that patients don't have adequate Wi-Fi access or maybe predisposed also I think culturally to not want to engage with the technology. Rural populations often tend to be a little bit older and patients who just prefer, you know, to give me that line and say, "Hey, I'm sort of old-school, I just want... I'd actually rather spend three hours in the car and drive down to see you than log on," because of that experience.

That's an interesting point that we've definitely seen even in Idaho, that there has not been widespread uptake. You know, that said, there are some patients who do fine with the technology and prefer the convenience, but it's not as penetrant as I thought it might be.

In terms of the e-consultation, that's been a great way for us to be able to handle classical hematology, which, you know, probably comprises 20, 30 percent of all our volume, simply to make room and improve access for patients. And that's sort of been a win all around in the sense that we've been able, you know, getting questions about, you know, macro-cytosis in people with alcohol history or somebody who has a thrombocytosis and the PCP didn't appreciate that they'd had a splenectomy. I mean, you know, sort of stuff that I think we would might label garbage or just not even rising to the point of requiring even a hematology, we can handle on the back end. And that way the primary care provider, they get an answer quicker, the patients don't have to get in the car. I mean, that's super frustrating when you see a patient and they've driven three hours to see you and then you're sort of trying to not exactly cover for the PCP, but just make it clear this is just a nothing burger. I'm sorry you had to come here and spend all this time and money and find someone to watch your kids and then get a bill from my health system because it's a, you know, billable encounter.

So, from the e-consultation perspective, actually the biggest barrier, I'll just tell you Fumiko, as you can imagine, is we weren't interested in doing work for free. And so, the biggest barrier was really just: how do you get credit to the physicians? And so, finally - it's not that complicated but finally someone agreed on the back end to have a dummy RVU. So, that's the system we use. A note goes into Epic, the provider can read it, the patient can see it, they don't have... the patient doesn't have to do anything, and they don't get a bill, but the physician who took, you know, four to seven minutes to review something pretty easily gets a quote dummy RVU credit. And I don't know if I'm embarrassed or just honest to admit that that was actually the sort of final barrier to getting that program up and running. And it's worked well to improve access.

Dr. Fumiko Chino: That's such an interesting workaround that you've created within your health system, and I think it really actually is very telling, which is when we think about how to truly generate better integrated care, less wasteful care, truly important, like meeting of the minds of this specialist for this specialty problem, reimbursement is so important. Trying to figure out how do we get things paid for - it's actually one of the major concerns about, for example, the current environment in which reimbursement for even telemedicine might go away, which could create huge access problems in rural populations.

Dr. Dan Zuckerman: You mention that, Fumiko, and I don't think we're alone, but unfortunately, you know, I think it had to do with something with the government shut-down and lack of funding, but that we, I think we're not alone as a health system that put a moratorium on allowing for telemedicine visits, simply because they weren't being reimbursed. And patients were scratching their head because, like, a week before they could do it and the week after they couldn't. And yeah, that's been a terrible thing for access for those patients who do want to take advantage of telemedicine.

Dr. Fumiko Chino: We're kind of at the tail end of the podcast. I want to leave a little bit of space at the end to talk about any issues that you feel like we haven't covered. We've talked a lot about the potential problems related to providing specialty care in the rural environment, but we haven't really talked about any solutions. You know, I'd love to hear any thoughts as we walk out the door in terms of thinking about - I know, for example, in the paper, Erika, you mentioned something like a community-based virtual tumor board, and I certainly can think about that as being really nice to bring a community together to actually talk about difficult cases and actually so for people to actually meet each other and to become familiar with each other and to start trusting each other. I can imagine that's actually a very compelling solution.

Dr. Erika Moen: That would be a good solution for the issues around losing someone you trust and someone who you are familiar with in terms of the way that they think about cases or the way they think about their workflow. And so I thought that could be a way to manage that, but it's not going to solve all the problems. So that's why I do think solutions have to be multi-level and multi-faceted, whether there can be navigation when you're now spanning two health systems that don't share electronic medical records. Can there be some proactive work there? But I think sometimes it does come more as a shock to the system, in which case maybe, you know, you're in a reactive mode, and then it gets to be harder in terms of managing those challenges in real time.

Dr. Fumiko Chino: Any last thoughts from you, Dan?

Dr. Dan Zuckerman: Well, I'd just like to say, you know, reading Erika's paper and thinking about rural- you know, oncology in rural America, I appreciate that it captured some of the qualitative aspects of the fact that your group interviewed oncologists in rural areas, taking care of rural patients, that a lot of it was the loss of expertise and camaraderie and trust that can be leading to burnout as much as volume issues, which I tend to agree with. Yeah, I mean, it sucks when you lose a partner and you have to increase your volume and your workload and you're seeing 24 instead of 20. But, like one of your participants had said, it's just like you can sort of just turn up the dial or order... get another APP, and yes, we all know how to work harder. And that does contribute to burnout, but it may not be as appreciated how much we still value, as oncologists, caring about our colleagues and the expertise and the lack of penetrance of expertise into rural areas. And so, I thought that was a useful point that one of your participants said: "Okay, we have more volume, but I'm exhausted, but I survive." And I often feel that way, and I'm sure, Fumiko, even in academic center, we all feel that way, but getting the expertise and getting distribution of expertise into rural areas is really, really difficult and is an ongoing challenge. And I think your paper highlighted that well.

Dr. Fumiko Chino: Absolutely, you really have to have a passion for the work, and that is what carries you through.

So, on that note, I want to thank you so much for this great conversation today. Many thanks to both Dr. Moen and Dr. Zuckerman for your time as well as for our listeners' time.

You will find the links to the papers that we discussed in the transcript of this episode. If you value the insights that you hear from the "JCO OP" Put Into Practice podcast, please take a moment to rate, review, and subscribe wherever you get your podcasts. I hope you'll join us next month for Put Into Practice's next episode. Until then, I hope your 2026 is off to a wonderful start.

The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions.

Guests on this podcast express their own opinions, experience, and conclusions. Guest statements on the podcast do not express the opinions of ASCO. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement.

 

Disclosures

Dan Zuckerman

Leadership

Company: OncoHealth Medical Group, PA

 

Consulting or Advisory Role

Company: Oncology Analytics

Company: AstraZeneca

Company: Revolution Medicines

 

Erika Moen

No Relationships to Disclose

Fumiko Chino

Employment

Company: MD Anderson Cancer Center

 

Consulting or Advisory Role

Company: Institute for Value Based Medicine

 

Research Funding

Company: Merck