Table 2 Factors considered in melanoma follow-up that determined the use of shared care-a summary of melanoma clinicians’ perspective

▪ 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