COVID-19 has disrupted the American healthcare system in unprecedented ways. One major shift is an accelerated use of telehealth, which existed before the pandemic occurred, but underwent rapid evolution and integration into the healthcare system. Telehealth is here to stay because it increases convenience and improves access for many patients, particularly those who live far from hospitals. In cancer medicine, normalization and reimbursement for telehealth have broadened access to leading cancer institutes, supporting patients seeking out second opinions. Top institutes such as MD Anderson and Memorial Sloan Kettering Cancer Center advertise easy, time-saving virtual visits with their specialists. We consider the potential benefits and unintended consequences of this telemedicine revolution. Specifically, we predict that these services will not be used in lieu of, but in addition to, face-to-face cancer care. Second opinions are common in oncology. An estimated 6.5% to 36% of patients with cancer seek them out, usually to gain reassurance or to consider the range of treatment options.1, 2 Second opinions may benefit both patient and primary oncologist. A 2016 systematic review by Reutters and colleagues reported that second opinions generally verify the original diagnosis or treatment (43%-82%) and that patients found second opinions to be helpful and reassuring.2 With the sudden increase in telehealth options for second opinions, patients and providers will have greater access to top oncology institutes—a particular benefit for patients with rare, unusual, or complex cancers or presentations. While healthcare access can always provide benefits, there are potential concerns. Currently, a great majority of patients actively opt out of seeking second opinions, feeling confident in their primary oncologist's diagnosis and/or treatment plan.1 Yet, as well-known cancer institutions establish permanent telehealth programs and as ease and access increase, pursual of second opinions may grow. The benefits of second opinions on patient outcomes have not been shown, and some patients experience more uncertainty in their treatment and in their initial provider.3 Instead of seeking second opinions through their providers, patients will have an easier time accessing specialists independently, which may impact primary provider/patient relationships. One potential consequence of patients accessing consultation from multiple oncologists is the bystander effect, a psychological phenomenon in which the presence of others discourages an individual from offering help or intervening on someone's behalf. The bystander effect tends to manifest in medical care when many specialists are involved in patient care without established coordinated care procedures.4 The medical bystander effect has even been identified within a large medical center when relationships were not established among care teams and specialists across the institute. With the popularization of telehealth, coordinated care will need to occur beyond institute walls, across states and countries. Patients who source second and third opinions will have multiple teams reviewing cases, and allocation of responsibility may be unclear, with no one group feeling pressure to manage the patient's care. This can lead to delayed or inappropriate treatments. Some cancers lack a standard treatment protocol; a discordance in treatment plan due to many providers giving contradictory input can also lead to further anxiety and confusion for the patient. For instance, in newly diagnosed multiple myeloma, there are several treatment options that are considered acceptable, and not all have been tested head-to-head. A patient may receive contradictory recommendations from several providers, resulting in loss of trust in their local provider, though this may be unjustified given the true clinical uncertainty. Thus, while access to oncologists from top centers may benefit patient care, there may also be unforeseen outcomes that must be considered and addressed. In oncology, utilization of healthcare rarely matches need. Rural and remote communities are associated with considerably worse health outcomes than their urban counterparts. Specialist visits are associated with lower preventable hospitalizations and lower rates of mortality, acting as a major contributor to the discrepancies between rural and urban population health.5 Rural clinics have sought to integrate telehealth into their practices for decades, establishing systems for rural providers to access specialists for diagnoses and treatment plans. Virtual oncology programs have been created to serve these remote communities, often with great success and better health outcomes for patients.6 The upsurge in the use of telehealth in cancer centers offers opportunities for rural healthcare to expand their access to specialists and build relationships with clinics for collaborating patient care. These benefits will likely continue beyond the life of the pandemic, aiding in mending the vast inequities in US healthcare. As with every medical innovation, there are potential unintended and unforeseen consequences in the sudden expanded access to telehealth. One possible consequence is that the technology may accelerate faster than rural clinics are able to support. Oncology telehealth programs between rural communities and larger institutes take planning, training, and time. There is a respect and support built into the relationship. With advertisements for oncology telehealth visits easily found online, patients may seek second opinions outside of their provider's established relationships. This can lead to poor communication and delayed treatments. Furthermore, patients seeking medical consultation outside of their clinic's program (which is likely government-funded) may end up with a financial burden that does not improve care. While shopping for oncologists and seeking multiple opinions were once more common among higher socioeconomic statuses, there is a risk of financially unstable communities spending money unnecessarily. The ease in access for patients in rural communities may in fact be a detriment to their medical care. Telehealth holds great promise for improved oncological care. To ensure that patients and providers receive telehealth's many benefits without suffering from its potential drawbacks, we recommend that training, collaboration, and guidance occur on a local and nationwide level. Providers should be prepared to discuss second opinions with their patients. They should learn the benefits and risks of second opinions, clearly convey them to their patients, and be proactive in collaborating with referred specialists. Similarly, cancer institutions that are advertising telehealth second opinions should establish protocols to collaborate with patients' primary oncologists, creating systems to easily share and update medical information to ensure patient safety. Government funding should be allocated to creating telehealth oncology programs to support underserved communities. Tools to successfully use telehealth services should also be funded in these communities. Telehealth is here to stay. We must adapt to ensure it improves patient care and take advantage of its versatility to reduce healthcare inequity. Vinay Prasad discloses research funding from Arnold Ventures; royalties from Johns Hopkins Press, Medscape, MedPage; consulting fees from UnitedHealthcare; speaking fees from Evicore, New Century Health; and Plenary Session podcast has Patreon backers. Jennifer Gill has no potential conflicts to disclose.
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Apr 26, 2024
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