Geographic Mobility of Hematology–Oncology Fellows and Its Association with Regional Cancer Care Disparities in the United States
This study reveals that hematology-oncology fellows in the United States exhibit significant geographic mobility favoring higher-income and less racially diverse regions, a trend that exacerbates cancer care disparities but may be mitigated by targeted interventions at the fellowship-to-practice transition.
Original paper licensed under CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). This is an AI-generated explanation of the paper below. It is not written or endorsed by the authors. For technical accuracy, refer to the original paper. Read full disclaimer
Cancer remains one of the most formidable health challenges of our time, yet the ability to treat it is not shared equally across the United States. While nearly one in five Americans lives in a rural county, the specialists who manage complex blood cancers and solid tumors are overwhelmingly concentrated in cities. In fact, more than half of all U.S. counties lack a single oncologist. This gap creates a dangerous reality for patients in underserved areas, who often face delayed diagnoses and lower survival rates simply because the nearest expert is too far away. The path to becoming a hematologist-oncologist is long and rigorous, involving medical school, residency, and a specialized fellowship. Each of these stages requires a doctor to find a training program, and these programs are not evenly distributed across the map. As a result, the journey from a medical student to an independent physician is often a journey of repeated relocation, moving from one city or region to another. Understanding where these doctors go, and why they choose to stay or leave, is essential to solving the puzzle of unequal cancer care.
A recent study by researchers at Augusta University and other institutions sought to map this journey in detail. They looked at 703 doctors who had just finished their hematology-oncology fellowships between 2019 and 2022. The researchers tracked these physicians through three critical career transitions: moving from medical school to residency, moving from residency to fellowship, and finally, moving from fellowship to their first job as a practicing doctor. By analyzing where these doctors started and where they ended up, the team could see how the landscape of cancer care is shaped by the movement of its future providers. They also examined the characteristics of the counties where these doctors lived and worked, looking at factors like income, population density, and racial demographics to see if the doctors were moving toward areas with the greatest need or away from them.
The study revealed a clear pattern of movement that favors wealthier, less diverse regions. Across all three stages of training, the highest rate of doctors staying in the same geographic region was found in the West, where retention hovered between 71 and 83 percent depending on the stage. In contrast, the Northeast saw a significant drop in retention during the residency-to-fellowship stage, with only about half of the doctors staying in the region, though this number recovered by the time they took their first jobs. The South and Midwest consistently showed lower rates of keeping their trained oncologists. When the researchers looked at how far doctors traveled, they found that a large portion moved more than 500 miles during their first transition from medical school to residency. However, contrary to the idea that doctors move further and further away as they advance, the proportion of those making such long-distance moves actually decreased with each step. About 40 percent moved more than 500 miles for residency, but that number dropped to roughly 33 percent for fellowship and 29 percent for their first job.
Despite this decrease in long-distance travel, the direction of movement remained consistent. Trainees consistently moved away from counties with lower incomes and higher proportions of non-Hispanic Black residents, heading instead toward counties with higher median household incomes and fewer Black residents. This trend intensified as they moved through their training. By the time they reached their first job, the doctors had shifted toward more rural counties than they had started in, reversing a pattern seen in earlier stages where they had moved away from rural areas. The study also found that the type of medical school a doctor attended mattered. Graduates from the top 50 medical schools in the country, based on National Institutes of Health funding, were less likely to move more than 500 miles for their first job compared to graduates from other schools. They also traveled shorter distances on average. In contrast, graduates from osteopathic or international medical schools were the most likely to relocate long distances and the least likely to stay in the same region where they trained.
The researchers used statistical models to understand what drove these decisions. They found that doctors who started their training in counties with higher incomes tended to move farther away, while those from more rural or populous counties tended to move shorter distances. This suggests that the density of training opportunities in big cities keeps doctors close, while those starting in rural areas often find their next step nearby as well. However, the final move into practice showed a different dynamic. Doctors were drawn to areas with higher incomes and lower rates of unemployment, likely influenced by the financial pressures of student debt and the desire to practice in markets that can support higher salaries. The study noted that this movement away from underserved areas happens early in a career and sets a trajectory that is difficult to change.
The authors argue that the transition from fellowship to the first job is a critical moment where policy could make a difference. Because doctors are currently moving toward wealthier areas, targeted interventions such as loan repayment programs or incentives for practicing in rural or underserved communities could help redirect this flow. The study suggests that the current structure of fellowship training, which often emphasizes research and academic medicine, does not fully prepare doctors for the realities of community practice, where most cancer patients receive care. By creating training pathways that include community rotations and by aligning financial incentives with the needs of the population, it may be possible to build a more equitable distribution of oncologists. The data indicates that without such changes, the gap in cancer care between wealthy and underserved regions is likely to persist, as the natural movement of physicians continues to favor the areas that need them the least.
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