Background
Methods
Clinician characteristics (Total n= 16) | ||
---|---|---|
Specialty
| Surgical Oncology | 7 |
Dermatology | 5 | |
Primary Care, with focus on melanoma follow-up | 4 | |
Gender
| Male | 12 |
Female | 4 |
Results
Shared responsibilities in melanoma follow-up
‘CONTINUING CARE’ factors | Variables | ‘COMMUNITY REFERRAL’ factors |
---|---|---|
Inclined melanoma unit clinicians towards specialist or ‘in-house’ follow-up e.g. by surgeon or melanoma unit dermatologist or melanoma GP
|
Inclined melanoma unit clinicians towards enabling follow-up by community doctors e.g. dermatologist, local GP or skin cancer clinic
| |
▪ Higher risk of recurrence or new primary disease (prior melanoma, tumor thickness, ulceration, mitotic rate, family history, skin type, number of moles etc) |
Clinical
| ▪ Lower risk of recurrence or new primary disease |
▪ Indications for extended post-surgical monitoring e.g. pain, hematomas, lymphodema, affected functioning | ||
▪ Patient request for ‘in-house’ follow-up by someone with identified melanoma expertise |
Patient Psychosocial
| ▪ Proximity and travel to unit pose significant burdens; potential barrier for patient attending scheduled visits (live far away, have poor mobility etc) |
▪ Patient allegiance to specialist with preference for attending with them personally | ||
▪ Patient prefers follow-up with own family physician or local referring doctor, or happy to participate in shared care | ||
▪ Patient very anxious; requires high emotional support and reassurance | ▪ Patient organizes and coordinates follow-up with preferred providers and follow-up consistent with recommended schedule | |
▪ Patient uncomfortable with referral to local doctor for follow-up | ||
▪ Patient knowledgeable, confident and conscientious in conducting skin self-examination | ||
▪ Patient lackadaisical about skin surveillance and needs ongoing education and reinforcement of self examination | ||
▪ Patient lives close by or is able and willing to travel to unit for appointments | ||
▪ Emphasis on specialisation in follow-up; ie specialist training and/or location in melanoma unit to facilitate early detection of disease 1 |
Melanoma Clinician
| ▪ Professionally comfortable with sharing follow-up with non-specialist clinicians; especially when preferred by patient and/or addresses other psychosocial needs |
▪ Sense of overall responsibility for ones patients; professional obligation to provide ongoing care or oversee quality of skin surveillance provided by others | ▪ Sense of obligation to expand capacity of one’s practice to accommodate new melanoma patients | |
▪ Value of health system efficiency and maximizing benefits for greatest number of patients i.e. focusing specialist care for those at greatest need / highest risk | ||
▪ Value of knowing patient well and patient-doctor rapport to facilitate education, early diagnosis and treatment ie doctor is familiar with patients’ skin, character, lifestyle, preferences; and patient comfortable to ask questions or return if worried | ||
▪ Value of efficient care for individual patients i.e. reducing burdens of travel and cost of follow-up relative to clinical returns for those with lowest risk of disease | ||
▪ Clinical interest in observing surgical and clinical outcomes over the long-term; being able to personally monitor developments | ||
▪ Enjoyment of psychosocial aspects of follow-up ie regular contact with ‘well’ patients | ||
▪ Professional courtesy and goodwill towards referring doctor; inclined to offer continued contribution to follow-up even if specialist in-put not clinically necessary | ||
▪ Alternative follow-up with community doctor not available or accessible to patient |
Community Doctor
| ▪ Local doctor perceived to be knowledgeable, skilled and competent in providing melanoma follow-up 1 |
▪ Local doctor’s skills and interest in follow-up unknown; specialist feels need to supervise follow-up more closely | ||
▪ Local doctor known to melanoma unit; eg has other successful shared care arrangements with specialist clinicians | ||
▪ Patient has no or poor relationship with local doctors | ▪ Local doctor known to be interested and motivated to conduct melanoma follow-up | |
▪ Specialist or patient perceive local doctor not to have the knowledge, skills, capacity or interest to conduct melanoma follow-up | ▪ Patient has established good and trusting relationship with local doctor | |
▪ Value of research roles and responsibilities of specialist unit; benefits of longitudinal data on patient outcomes |
Organizational (melanoma unit)
| ▪ Limited capacity of specialist melanoma unit clinicians (surgical oncologists in particular) to provide long-term routine skin surveillance for patients at low risk of recurrence or new disease |
▪ Institutional benefits of constituency and support-base for a specialist unit from maintaining ongoing relationships with current and past patients |