We conducted an in-depth qualitative study at the University of Florida Health Cancer Center (UFHCC). The UFHCC is a 192-bed hospital serving North Central Florida, specializing in 14 cancers, such as blood cancer, lymphoma, breast cancer, and head and neck cancer. The cancer center serves surrounding rural counties, which make up 20% of the patient population. The University of Florida Institutional Review Board (202000243) approved the study, and all participants consented to participate before interviews began.

Inclusion criteria consisted of participants being clinicians (oncologists, nurse practitioners, or physician assistants) who provided care to individuals with a cancer diagnosis and were willing to participate in an interview. We sent an email and 1 reminder email to all medical and radiation oncology clinicians at our cancer center with a description of the study and a link to an online screening questionnaire. We diversified the clinician type of our sample by asking participants for referrals toward the end of the interview. Further, we used our professional networks to contact clinicians, and we posted recruitment messages to social media, accompanied with keywords targeted toward clinicians working in cancer. A total of 59 unique recruitment emails were sent between July and December 2020. Interviews were conducted simultaneously with recruitment, as the first interview occurred in July. During this time, the number of COVID-19 cases in the state of Florida peaked in October before plateauing in December [18]. Pharmaceutical companies were also beginning to seek approval for vaccines.

Potential participants filled out a short online form to indicate their interest and to schedule an interview. Prior to the interview, participants were provided with a statement of their rights. All interviews were completed by 1 of 3 authors (JA, CH, and CB) using a semistructured interview guide about 3 different communication topics in cancer care (secure messaging, teleoncology, and online information seeking). Questions about communication using teleoncology during the COVID-19 pandemic made up 1 of 3 sections of the interviews. Members of the research team collectively wrote the interview guide to align with our goals of understanding clinicians’ perceptions of teleoncology. The clinical member of the research team (author MJM) reviewed the interview guide before it was finalized. Specific questions included asking clinicians about the challenges they encountered in moving to telehealth to communicate with patients, its advantages/disadvantages, and what strategies were developed to facilitate telehealth interactions. Interviews were conducted using the videoconferencing software Zoom and were audio-recorded and professionally transcribed.

The constant comparative method [19] was utilized to analyze the interview transcripts using an inductive, thematic approach. Thematic analysis is a valuable method for examining the perspectives of different participants, highlighting similarities and differences, and generating unanticipated insights [20]. Interviews continued during data analysis until no new themes emerged and thematic saturation was achieved [21] through recurrence, repetition, and forcefulness of the data [22]. The second author (GT) uploaded all transcripts to Atlast.ti v. 22 (ATLAS.ti Scientific Software Development GmbH), a software management and analysis program. Two authors (GT and CB) conducted open coding using an adapted version of Strauss and Corbin’s guidelines, [23] assigning in vivo codes. Codes were collapsed into categories, after which thematic properties were identified using axial coding. For example, each participant’s interview was examined for information relevant to 1 of the posed inquires (ie, benefit or barrier) and Atlas.ti was used to assign a code. Codes were compared and combined to generate themes, which were then examined for text that conveyed similar messages, after which those were separated into their own group (i.e., property). Codebooks were developed for each research inquiry throughout the analytical process by the second author (GT) and were discussed with the senior author (CB) to refine themes and properties before creating finalized versions. The second author (GT) created analytical notes and memos throughout the analysis process, which increased the ability to identify poignant descriptions to illustrate themes and properties. This strategy was used to increase the trustworthiness of findings as well as promote transferability [24]. The senior author (CB) used the final codebooks to conduct closed coding of all transcripts, after which the second author (GT) validated the analysis. At this point, we shared the analysis with our clinician coauthor (MM) and study principal investigator (JA) for further validation of the results.

A total of 21 clinicians participated in the study (36% enrollment rate). Interviews averaged 44 minutes in length and resulted in 285 transcribed pages. Of the 21 participants, 13 (62%) were female; the average number of years postresidency, fellowship, or schooling among 18 (86%) participants was 8 years (range 1-33); and 3 (14%) participants were still in residency. One (5%) participant was a physician’s assistant, and another (5%) was an advanced practice registered nurse. Most clinicians (n=17, 81%) were affiliated with the UFHCC, while the other 4 (19%) were employed at cancer centers in the south, northeast, and western U.S. Most clinicians primarily worked in outpatient settings, and 14 (67%) were in medical oncology departments and 7 (33%) in radiation oncology. Each participant reported that they used teleoncology with patients during the pandemic.

Our qualitative analysis revealed a total of 6 themes: 3 (50%) themes related to the benefits of teleoncology and 3 (50%) themes about the challenges of teleoncology. We describe each theme next and include thematic properties, when present, to provide a richer description of the themes. Additional exemplar quotes associated with each theme and property are in Tables 1 and 2.

The COVID-19 pandemic led to a major shift in the way cancer care was provided to patients for a sustained period. As there have been calls for teleoncology to be more present in cancer care [5,6], it is important to understand this almost universal experience of teleoncology from the perspective of clinicians delivering care. After conducting 21 interviews with oncology clinicians about their experiences pivoting to teleoncology during COVID-19, we found that utilization of the technology has many benefits but also has several challenges to be overcome if it is to continue as a viable option for appointments and consultations. Clinicians believed that teleoncology has nonmedical benefits for patients, such as reducing travel time and expenses related to the consultation, as well as medical benefits, such as limiting COVID-19 exposure and allowing clinicians to get a better sense of the patients’ lifestyle, environment, and incorporating family members. Challenges also comprised nonmedical and medical issues. Nonmedical factors were technology related, such as problems with internet connectivity and lack of familiarity with videoconferencing technology. However, clinicians perceived shortcomings in teleoncology because they could not have physical contact with patients, which inhibited their ability to conduct a physical exam. Further, instances occurred in which patients were disappointed and frustrated that clinicians were late to the Zoom appointment.

This study adds to the growing literature on teleoncology by highlighting the perspective of oncology clinicians. The previous literature about teleoncology has focused on the experience of using the technology as a tool to reach patients in rural settings and developing countries [25-28]. Our findings align with the literature emphasizing the benefits of teleoncology to reduce travel time and costs, but in the case of COVID-19, teleoncology was mandated as the primary method of care for patients with cancer. Adoption of new technology can be slow, especially in health organizations because organizational (eg cost, complexity, impact) and individual factors (eg age, attitude) determine when and if innovations are accepted [29]. Due to the pandemic, health systems decided to universally adopt teleoncology, even though there was uncertainty among end users (ie, clinicians), otherwise known as forced adoption [30]. As a result, clinicians in our study dealt with the benefits and challenges of teleoncology concurrently, without the ability to address and fix challenges.

However, being compelled to use teleoncology pointed out a benefit that seems to be missing in the previous literature, that of the ability to “see” the patient and their family. In this case, “seeing” could mean several things: (1) viewing the patient’s health and symptoms (as opposed to telephone only); (2) observing the patient in their home environment, which further allowed for better rapport building and connection; and (3) witnessing the patient within the context of their family situation, as family members who could not normally attend were able to. Interestingly, 1 clinician discussed how teleoncology was akin to a home visit because it was an opportunity to observe the patient in their own environment. Knowledge of a patient’s physical living space could benefit clinicians in providing care [31]. In all cases, the ability to “see” had the potential to improve care for the patient by better understanding their situation.

Challenges of teleoncology were noted as including technical difficulties, which are well established in the literature. A recent study among clinicians found that poor internet connectivity is the biggest barrier to telemedicine [32]. Lack of access to technology, which enables the use of teleoncology, is also a significant issue that has implications for health equity in cancer care delivery. Compared with younger patients, older patients with cancer are less likely to have an email address or own a smartphone and are less likely to use a patient portal to communicate with their oncology care team [33]. In addition, patients faced similar hurdles as clinicians to forced adoption of teleoncology. Digital literacy—the awareness, attitude, and ability to appropriately use digital tools and facilities to identify, access, manage, and construct new knowledge and communicate with others [34]—is a major factor that has widened the digital divide. Older adults (65+ years old) have the lowest adoption rates for using new technologies [35]. However, internet adoption among older adults has risen steadily over the past decade and a half [36]. An intervention that trained older adults to use technological devices found improvement in technology confidence and a significant increase in technology use [37]. Other than an email with instructions, patients received little guidance about shifting to teleoncology.

Another challenge faced by clinicians was the inability to conduct physical examinations. Although tools such as a weight scale, blood pressure cuff, pulse oximeter, and thermometer can be administered by patients while using telemedicine, such tools are sometimes not covered by insurance and may be prone to errors due to lack of calibration and patients’ inexperience [38]. It is important for clinicians to physically examine patients, but it is not necessary for certain types of appointments. As clinicians in our study acknowledged, teleoncology is beneficial for follow-ups and instances when patients are not experiencing any discomfort.

Interestingly, 1 of the themes that emerged was a different expectation from patients about how appointment start times should be managed. Clinicians observed that patients assumed the clinician would be present at the start of the Zoom appointment, even though it is commonplace for patients to wait for the clinician during in-person appointments. Patient satisfaction is negatively impacted by longer wait times and affects perceptions of information, instructions, and the overall treatment provided by clinicians [39]. Among patients with cancer, over 80% in an outpatient oncology clinic felt that waiting for their appointment had an emotional cost [40]. Further, over one-quarter of patients suffered a major emotional impact by seeing other sick people in the waiting room [40]. Although better coordination and communication is necessary when scheduling teleoncology appointments, patients do have the benefit of waiting in their home rather than in the clinic. If patients were made aware of possible delays or received periodic updates about the status of their appointment, perhaps fewer patients would abandon the Zoom appointment. There is the potential to damage the clinician-patient relationship when clinicians are delayed. Uncertainty and lack of communication between the patient and the health care team can have negative implications, but keeping patients informed and expressing empathy are ways of improving the interaction [41,42].

There are several practical implications from this study for those working in clinical settings as either clinicians or administrators. First, clinicians should receive training about communicating effectively with patients using teleoncology. Our study identified challenges to using teleoncology that could be remedied with slight modifications to clinicians’ behavior. For instance, patients satisfied with encounters using telemedicine appreciated relational experiences with clinicians and when an effort was made toward building a patient-centered relationship [43]. Clinicians should also look at the camera to ensure good eye contact and foster rapport and trust [44]. Training can also include how to involve family members present on-screen and methods to managing appointment times. Second, the health care team can inform patients when scheduling about what to expect before the appointment begins. Notifying patients of potential delays and having clinicians update patients during appointments while they are waiting can reduce uncertainty. While patients are waiting, health care teams can use the opportunity to emphasize the importance of health promotion through COVID-19 risk reduction by playing videos and other educational content. Lastly, it is important to ensure that patients are prepared for the appointment by testing out the technology in advance and having flexibility about what type of technology they can use. Since the Health Insurance Portability and Accountability Act (HIPAA) relaxed its guidelines for COVID-19, tools such as Apple FaceTime, Facebook Messenger video chat, Google Hangouts video, and Skype can be utilized [44]. Patients should be offered the choice of technology to use for teleoncology in order to avoid downloading and learning new applications. For teleoncology to be successful and a valid method of care delivery, ultimately, the responsibility falls on the health care system to better accommodate the technology than placing the burden on clinicians. However, the rapid increase in teleoncology visits during the pandemic has revealed that it should have a larger role postpandemic. In 2021, at least 30 states considered legislation to revise telehealth coverage standards [45]. In addition to ensuring that all patients can access teleoncology services, including telehealth as part of routine follow-up care has been recommended because it allows for efficient discussions of laboratory and imaging results, as well as side effect management [16].

Although we attempted to diversify our sample by recruiting clinicians from different health systems, the majority of participants were from 1 health system. Therefore, our results may not extend beyond the health system and be generalized in other contexts. There may also be the possibility of selection bias, as participants in our study volunteered. Most participants were oncologists, but understanding the experiences of other types of oncology clinicians is critical. Interviews took place toward the end of 2020 after teleoncology use spiked in the previous months. At the time of the interviews, teleoncology was relied upon less frequently. Developments related to COVID-19 have caused frequent shifts in health care protocols, which highlights the need for further research to examine the long-term implications of teleoncology.

We interviewed 21 cancer clinicians during the COVID-19 pandemic to understand the benefits and challenges of using teleoncology to replace in-person appointments. The rapid adoption of teleoncology resulted in several obstacles, such as issues around internet connectivity and miscommunication about appointment times. Benefits included reduced travel time for patients and limiting their exposure to COVID-19. Clinicians appreciated the ability to learn more about patients by observing their living conditions, which provided insights into the patient’s lifestyle. Future work is warranted to explore the attitudes and perceptions of patients, along with clinicians, in various types of cancers to understand how the technology is adapted to different types of diseases. Future research should also include family members and caregivers to understand their role in the facilitation of teleoncology and how their involvement can alter depending on the type of visit.