Daniel Nikcevich, MD, saw a boat heading straight for him during a fishing trip in rural Minnesota.
Thinking it must be the Department of Natural Resources, the Essentia Health oncologist started to pull out his license. It was not until the boat came up beside him that he recognized who had singled him out.
"It was one of my patients," Dr. Nikcevich said. "[He asked] me when he was scheduled for his next CAT scan."
Dr. Nikcevich was fishing in a place so isolated, he did not have cell service to check on his patient's appointment. Instead, he made a note to ask someone from the office to call the patient the following week.
That the serendipitous meeting even occurred is a testament to Essentia's oncology care model and commitment to being present in the areas he serves.
Essentia is based in Duluth, the fifth-largest city in Minnesota with a population of approximately 90,000. The system spans across Wisconsin, Minnesota and North Dakota and has a footprint that is about 85% rural, Dr. Nikcevich said.
The system's main cancer center is in Duluth, but as part of the care model, each oncologist is required to travel to a rural site to see patients. Dr. Nikcevich has been traveling to Deer River, 100 miles west of Duluth, once a week since 2018.
"We've discovered that when you're present in rural areas, people will come to you and they'll seek care," he said. "You think about, 'Where did they go before?' I believe the answer is, most of the time, they didn't go anywhere. They didn't seek care."
Patients in rural areas often live in what is known as a cancer care desert, a challenge with which health systems across the country have been grappling for years. Essentia leaders have been focusing on the issue since 1978, though the health system did not establish the Essentia Institute of Rural Health until 2010.
Dr. Nikcevich, who is part of a rural health subcommittee at the Alliance for Clinical Trials in Oncology, is quick to make the distinction that geography is not the only factor creating cancer care deserts.
"It pertains not only to seeing someone who can deliver cancer care but receiving standard of care," he said. "Think about how that impacts people that might be under-resourced, underprivileged, minority groups and so forth. A cancer care desert could be in a rural area and could be in an inner city as well."
Cancer care deserts can also extend beyond lack of access to the inability to participate in clinical trials. Part of the Alliance for Clinical Trials of Oncology's mission is to analyze how trials can be designed and implemented with equity and access in mind. Dr. Nikcevich noted that a benefit to having more broad and diverse clinical trial participation is being able to generalize results with respect to a larger population.
Part of serving a broader population means adapting to the needs of specific communities, even if that means forgoing some technology and tools. For Dr. Nikcevich and his most rural patients, that amounts to eschewing virtual care.
"My experience is that patients don't like it," he said. "They may not have access to broadband hardware, they don't have a smartphone, they may not be familiar with it, they're perhaps older. … It's not something that's in their life."
And when it snows? Minnesota averages 36 to 70 inches of snowfall per year, depending on the region.
"Everyone shows up," Dr. Nikcevich said, highlighting Minnesotans' adeptness at braving bad weather. "No one will cancel, everyone will still be there."
Dr. Nikcevich does credit one technical innovation to Essentia's rural cancer care success: integrated EMRs. He said working across different EMRs would be "doable" but added that it would be "cumbersome."
The biggest factor in Essentia's strategy for addressing rural cancer care deserts, beyond resources and clinical trials, is the expectation set for every oncologist: to be present in the communities they serve.
"It requires a substantial commitment to make it happen, but we're very upfront about this," Dr. Nikcevich said, noting his colleagues could share their own versions of his fishing trip story. "Everyone has their site; that's what we do."