Why does it take 3-4 months to see a dermatologist???

[Anfield rd]

Seriously this is f*** up... It's bad enough to wait 1-2 weeks to see my PCP, but with dermatologist it's just ridiculous. Can you explain why the patient queues are so long?

If there is such a demand for dermatologists, and if the dermatology is so popular among medstudents, WHY ON EARTH WON'T ACGME INCREASE THE NUMBER OF DERM RESIDENCY SPOTS? I am usually not fond of conspiracy theories, but it seems that dermies are overprotective of their specialty, i.e. they are artificially keeping the # of new trainees low to keep the supply low... Please prove me wrong on this one...

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[tacrum43]

Seriously this is f*** up... It's bad enough to wait 1-2 weeks to see my PCP, but with dermatologist it's just ridiculous. Can you explain why the patient queues are so long?

If there is such a demand for dermatologists, and if the dermatology is so popular among medstudents, WHY ON EARTH WON'T ACGME INCREASE THE NUMBER OF DERM RESIDENCY SPOTS? I am usually not fond of conspiracy theories, but it seems that dermies are overprotective of their specialty, i.e. they are artificially keeping the # of new trainees low to keep the supply low... Please prove me wrong on this one...

A referral might help.

 

[taXi]

A referral might help.

Or it might not...
I noticed a lesion on my mother's nose in December--looked like skin CA to me. I said, "See a dermatologist." She called around, could not get an appointment until March, so she went to her pcp. He biopsied, indeed is skin CA. Still can't get a derm appointment until mid-February.
So, okay, I concede, the referral helped, but not much. Regardless, she should not have needed a referral anyway. I agree with the OP; there are not enough dermatologists being trained.

 

[Patrick O]

I in no way support all of these viewpoints..... but I met a number of older dermatologists that state there isn't as big a shortage of dermatologists as you think. They are just clustered in prime locales where there is an abundance of dermatologists. This is due to many reasons, the major one being financial in nature....cosmetic procedures in affluent societies for example. Also, there are many people who go through training only to work part time or hardly at all in the end. Thats a shame (if that is a true statement...to work so hard to get into the field to hardly work) given the competitive nature of getting into the specialty. A funded position that doesn't fulfill its intended role...that being to serve society with a specialist in diagnosing and managing diseases of the skin.

Don't forget that many derm residents are also drawn to dermpath. I wonder how many derm trained dermpaths practice dermpath exclusively. Don't get me wrong I love dermpath (I am a pathology resident) and think dermatology trained residents have every right to enter this field, but in the end it could contribute to to less practicing clinical dermatologists.

I'd like to know what others think.

 

[diosa428]

Or it might not...
I noticed a lesion on my mother's nose in December--looked like skin CA to me. I said, "See a dermatologist." She called around, could not get an appointment until March, so she went to her pcp. He biopsied, indeed is skin CA. Still can't get a derm appointment until mid-February.
So, okay, I concede, the referral helped, but not much. Regardless, she should not have needed a referral anyway. I agree with the OP; there are not enough dermatologists being trained.

For lesions on the face, near the eyes, I know that people in oculoplastics will remove them. I think ENT docs will also remove lesions on the face.

 

[Anfield rd]

I in no way support all of these viewpoints..... but I met a number of older dermatologists that state there isn't as big a shortage of dermatologists as you think. They are just clustered in prime locales where there is an abundance of dermatologists. This is due to many reasons, the major one being financial in nature....cosmetic procedures in affluent societies for example. Also, there are many people who go through training only to work part time or hardly at all in the end. Thats a shame (if that is a true statement...to work so hard to get into the field to hardly work) given the competitive nature of getting into the specialty. A funded position that doesn't fulfill its intended role...that being to serve society with a specialist in diagnosing and managing diseases of the skin.

Don't forget that many derm residents are also drawn to dermpath. I wonder how many derm trained dermpaths practice dermpath exclusively. Don't get me wrong I love dermpath (I am a pathology resident) and think dermatology trained residents have every right to enter this field, but in the end it could contribute to to less practicing clinical dermatologists.

I'd like to know what others think.

You're contradicting yourself: 'there isn't shortage, but they are clustered, and many don't work'. It is little consolation for me that somewhere 'in the prime locales' out there bunch of dermies are doing cosmetic procedure, when I have to wait for months to see one. Oh and I live in a large metro area. Another argument you're raising doesn't make sense: 'there are enough dermies out there, but many of them don't work'. WTH does it mean? Im a dermpath fellow myself, and I know there aren't that many derm-trained dermpath fellows to make a significant dent in the overall number of dermatologist who do dermatology.

 

[Gravi69]

Im a dermpath fellow myself, and I know there aren't that many derm-trained dermpath fellows to make a significant dent in the overall number of dermatologist who do dermatology.

Umm...dermpath fellow as in derm -> dermpath or path -> dermpath?

Because if it's the former, you really shouldn't be having this problem. You should be able to self-diagnose.....

Seriously this is f*** up... It's bad enough to wait 1-2 weeks to see my PCP, but with dermatologist it's just ridiculous. Can you explain why the patient queues are so long?

If there is such a demand for dermatologists, and if the dermatology is so popular among medstudents, WHY ON EARTH WON'T ACGME INCREASE THE NUMBER OF DERM RESIDENCY SPOTS? I am usually not fond of conspiracy theories, but it seems that dermies are overprotective of their specialty, i.e. they are artificially keeping the # of new trainees low to keep the supply low... Please prove me wrong on this one...

 

[Anfield rd]

Umm...dermpath fellow as in derm -> dermpath or path -> dermpath?

Because if it's the former, you really shouldn't be having this problem. You should be able to self-diagnose.....

Huh? I'm pathology trained, and I'm subspecializing in dermatopathology. And it's not about me, it's about patients having access to the services they need.

 

[Patrick O]

I am not contradicting myself. For one thing I don't want to get into a squabble with one my colleagues (if you are a dermpath fellow) but I have been around enough dermatologists and dermatopathologists to assimilate this information (my wife practices clinical dermatology). I am just throwing out there some views that I have picked up along the way. Second, in your original post you mentioned that it takes a long time to see dermatologists. The fact is the number of derm-trained dermpath fellows is increasing...and you should now this ...your a dermpath fellow. It is one of the reasons dermpath fellowships are so competitive...because you compete with clinically trained dermatologists. It has to make a dent if dermatologists are signing out biopsies exclusively and not seeing patients. This situation exists, and it is not far and few between.

Your quote of my statement, "Another argument you're raising doesn't make sense: 'there are enough dermies out there, but many of them don't work'. WTH does that mean?
It means what it says.... there are dermatologists that train, only to not practice or practice like 2 days a week so they can, for example, raise families. I am not saying this with a derogatory undertone... having a family is important.... it is a reality. But it contributes to a "shortage". Add offices that only accept out of pocket, or mostly cosmetic endeavors and there is another answer to the void.
Being a dermpath fellow you should know most of the reasons for the "shortage". There are many factors at play. And yes, another big one is the number of ACGME spots. There is an ever expanding boom of PAs and NPs that are being hired to fill some of these voids.

My final comment is that with the exception a few people (including myself), the vast majority of posters on the derm forum are med students that are trying to get a derm spot. Not the best source to get an answer to your questions in my opinion.

 

[Anfield rd]

I am not contradicting myself. For one thing I don't want to get into a squabble with one my colleagues (if you are a dermpath fellow) but I have been around enough dermatologists and dermatopathologists to assimilate this information (my wife practices clinical dermatology). I am just throwing out there some views that I have picked up along the way. Second, in your original post you mentioned that it takes a long time to see dermatologists. The fact is the number of derm-trained dermpath fellows is increasing...and you should now this ...your a dermpath fellow. It is one of the reasons dermpath fellowships are so competitive...because you compete with clinically trained dermatologists. It has to make a dent if dermatologists are signing out biopsies exclusively and not seeing patients. This situation exists, and it is not far and few between.

Your quote of my statement, "Another argument you're raising doesn't make sense: 'there are enough dermies out there, but many of them don't work'. WTH does that mean?
It means what it says.... there are dermatologists that train, only to not practice or practice like 2 days a week so they can, for example, raise families. I am not saying this with a derogatory undertone... having a family is important.... it is a reality. But it contributes to a "shortage". Add offices that only accept out of pocket, or mostly cosmetic endeavors and there is another answer to the void.
Being a dermpath fellow you should know most of the reasons for the "shortage". There are many factors at play. And yes, another big one is the number of ACGME spots. There is an ever expanding boom of PAs and NPs that are being hired to fill some of these voids.

My final comment is that with the exception a few people (including myself), the vast majority of posters on the derm forum are med students that are trying to get a derm spot. Not the best source to get an answer to your questions in my opinion.

kk dude, no hard feeling, we can disagree civilly. I saw a post with dermpath board numbers somewhere on path forum recently, which said that something from all the people who took dermpath boards, 50 were path trained vs something like 15-20 were derm trained. Now, 20 dermatologist who are diverted away from clinical practice to dermpath does not make a dent in overall pool of dermatologist graduating each year (I dont' know exact number, and I'm too lazy to google it, but it goes in hundreds).

If the dermatologist graduate from the training programs and then decide not to practice derm, then this means that the market is failing to force them to work, my guess because the low number of ACGME spots shifts the supply line way to the left. Doctors from other specialties are just as eager to have families etc, but the shortage is not as acute.

G'luck to all of you getting the spot, I wish there were more spots for you to take.

 

[manning18]

I in no way support all of these viewpoints..... but I met a number of older dermatologists that state there isn't as big a shortage of dermatologists as you think. They are just clustered in prime locales where there is an abundance of dermatologists. This is due to many reasons, the major one being financial in nature....cosmetic procedures in affluent societies for example. Also, there are many people who go through training only to work part time or hardly at all in the end. Thats a shame (if that is a true statement...to work so hard to get into the field to hardly work) given the competitive nature of getting into the specialty. A funded position that doesn't fulfill its intended role...that being to serve society with a specialist in diagnosing and managing diseases of the skin.

Don't forget that many derm residents are also drawn to dermpath. I wonder how many derm trained dermpaths practice dermpath exclusively. Don't get me wrong I love dermpath (I am a pathology resident) and think dermatology trained residents have every right to enter this field, but in the end it could contribute to to less practicing clinical dermatologists.

I'd like to know what others think.

It sounded like this person was saying that the Dermatologist shortage maybe partially the result of an unevenly distributed supply of Dermatologists. This is the case with many other fields as well.
In certain major Metro areas, for example, there maybe an adequate (or possibly excess) supply of Derms, so there is no appearance of a shortage. In smaller areas, though, there maybe SEVERE shortages. This may cause the shortage to seem more severe than it truly is, when the reality is that some areas have enough Derms (maybe more than enough/capita) and other places need more very badly.
My friend's wife had to wait 3-4 months to see a Derm in a smaller metro area (Medical Derm). It maybe less likely that one would have to wait this long in a major metro area, though I believe the OP mentioned this was the case for their relative. As for why there are more Derms in major areas, part of it would be b/c they may have more affluent patients willing to pay cash for cosmetics. Besides that, if you're making a nice living ($300K+) anyway, you can afford to live nicely almost anywhere, so why move to a smaller area? There's less to do and you don't need to move there to have a nice life.
I'm not sure about Dermatopath, but the loss of 15-30 Derms who go into Dermatopath can add up over time. It probably would not make a major difference.
Derm is very competitive b/c it's lucrative and has an excellent lifestyle. Many of the people entering the field do so for these reasons. After completing Derm residency, I have heard that many Derm attendings only work part-time, presumably to focus more on their personal lives (i.e. family). That is the case in my area. If this is true, it would lower the availability of Dermatologists since some may only have 2-3 clinic days/week (or less).
I THINK this is what the poster was trying to say and would agree that he brought up valid points. Please correct me if needed.

 

[doctalaughs]

There are a few reasons why it takes so long to see a dermatologist:

1. Fewer dermatologists practice in cities with low insurance reimbursements. It has less to do with cosmetics demand and more to do with the managed care environment. Look at major cities such as NYC or Boston, for example. Wait in Boston is 3-4 months because insurance pays nothing. NYC derms dont even take insurance because they can't live in NYC by taking insurance. Malpractice premiums also have some influence.

2. Depends on what you say on the phone to the receptionist. If you say "I have a black ugly lesion that is growing and bleeding" they should be trained to fit you in right away. If you say, I need a mole checked... well you might be waiting 3-4 months.

3. It is true that the ACGME limits spots in derm... if they didn't, the specialty would expand, pay less, become less competitive and fewer people would go into it... so you'd have a few more, lower quality dermatologists which no one really wants. Same thing exists in optho, ortho, etc.

 

[MOHS_01]

The "shortage" is political first and foremost... there was a recent study on national wait times and derm wait times were shorter than many specialties, including OB-GYN.

Many dermatologists work part time, and many control their practice mix by limiting disease/insurance/new vs established, etc.

It is very naive to believe that throwing more people in the mix will alleviate distribution problems. Look at every single failed primary care initiative, rural health program, etc.

 

[Cirrus83]

Or it might not...
I noticed a lesion on my mother's nose in December--looked like skin CA to me. I said, "See a dermatologist." She called around, could not get an appointment until March, so she went to her pcp. He biopsied, indeed is skin CA. Still can't get a derm appointment until mid-February.
So, okay, I concede, the referral helped, but not much. Regardless, she should not have needed a referral anyway. I agree with the OP; there are not enough dermatologists being trained.

Yeah, there's definitely ridiculous waits even if you have confirmed skin cancer. Our professor was actually telling us about a medical student whose melanoma had metastasized and actually managed to kill her before her appointment for removal. It was a very aggressive mutant and caught very early, but she had still no chance since it was a 2-3 months wait. Presumably this was a wait for a mohs surgeon.

Really sucks though to not be able to get anything done for months when you have something that'll kill you well before then.

 

[MOHS_01]

Yeah, there's definitely ridiculous waits even if you have confirmed skin cancer. Our professor was actually telling us about a medical student whose melanoma had metastasized and actually managed to kill her before her appointment for removal. It was a very aggressive mutant and caught very early, but she had still no chance since it was a 2-3 months wait. Presumably this was a wait for a mohs surgeon.

Really sucks though to not be able to get anything done for months when you have something that'll kill you well before then.

The metastatic melanoma patient that your professor spoke of is truely tragic.

HOWEVER --

Reality check -- the melanoma, if that aggressive, had spread PRIOR to diagnosis and there was nothing that could be done; the median survival for metastatic melanoma is 6-9 months. Actually, there was a pretty good study that showed that even up to a six month wait does demonstrate any adverse effects with regards to prognosis.

I never make a biopsy proven melanoma (or even a changing mole for that matter) wait for more than a week, regardless of how booked out I am.

 

[DrDre311]

Yeah, there's definitely ridiculous waits even if you have confirmed skin cancer. Our professor was actually telling us about a medical student whose melanoma had metastasized and actually managed to kill her before her appointment for removal. It was a very aggressive mutant and caught very early, but she had still no chance since it was a 2-3 months wait. Presumably this was a wait for a mohs surgeon.

Really sucks though to not be able to get anything done for months when you have something that'll kill you well before then.

This story is analogous to the popular misconception that people are routinely denied life-saving surgeries and booted out into the cold, dark streets by surgeons if they can't pay.

I'm pretty sure that no doc with knowledge of a potentially lethal condition would be able to say "Sorry, brah, can't fit ya in til, say, October. Sucks for you, huh?"

If the situation you describe happened and melanoma was suspected then she should have been referred to a dermatologist who could see her immediately, or seen acutely by somebody willing to biopsy it and cut it out with adequate margins. But as MOHS points out, removing the primary doesn't do a whole lot for survival if you have brain mets.

 

[droliver]

Presumably this was a wait for a mohs surgeon.

Melanoma is not an indication for MOH's surgery BTW.

 

[MOHS_01]

Melanoma is not an indication for MOH's surgery BTW.

Yeah, I did not even want to get into that. I will NOT do micrographic surgery on an invasive MM regardless of the location, and I remain on the fence about LM when not performed in conjuntion with immunostains. Single cell melanocytic hyperplasia is extremely difficult, if not impossible, to interpret adequately on frozen sections.

BTW, for those less intimately involved with the technique -- the reason that melanoma is not routinely treated with Mohs is twofold -- 1. no one has definitively shown that melanocytic tumors demonstrate contiguous growth (and there is evidence to the contrary) and 2. Prognostic indicators are often changed following definitive excision due to finding a deeper component than what was appreciated in the biopsy. The micrographic technique relies on 1 being true, while quality patient care is dependent upon 2.

 

[Strength&Speed]

..

 

[droliver]

Yeah, I did not even want to get into that. I will NOT do micrographic surgery on an invasive MM regardless of the location, and I remain on the fence about LM when not performed in conjuntion with immunostains. Single cell melanocytic hyperplasia is extremely difficult, if not impossible, to interpret adequately on frozen sections.

In addition, when you're talking about wide surgical margins being indicated (0.5 - 2.0 cm radially), there is no utility for a tissue sparing technique like MOH's to being with. If you do proper excisions, it's rare that you're going to get involved or close margins.

 

[MOHS_01]

In addition, when you're talking about wide surgical margins being indicated (0.5 - 2.0 cm radially), there is no utility for a tissue sparing technique like MOH's to being with. If you do proper excisions, it's rare that you're going to get involved or close margins.

On standard melanoma excisions I agree wholeheartedly -- the problem comes in when dealing with lentigo maligna on extremely sun damaged skin, where it is often quite difficult to ascertain clinical margins (even with the assistance of a Wood's lamp).... not to mention that your "margin status" is only as good as the pathologist reading it out. Often times there will be almost contiguous single cell melanocytic hyperplasia that may extend subclinically for a long way. This is only complicated by the fact that intraobserver agreement is not the best when dealing with melanocytic lesions, much less interobserver agreement.

Again, I believe that all invasive melanomas should be treated with standard WLE's... LM can sometimes be problematic, however, and the micrographic technique can prove helpful if performed in conjunction with paraffin section confirmation. The 5mm margins that are commonly used for MIS will often prove inadequate for LM, so that should be the starting point at a bare minimum. I do not typically perform MOHS for LM -- I take the tumor out with a generous 6mm margin, map and stain as if I were preparing MOHS slides, and submit in cassettes for parafin sections. If linear repair is possible, reconstruction is performed immediately. If a flap or graft is required, the pathology is expeditied (overnight) and the patient is bandaged and scheduled for reconstruction within 48hrs pending margin determination.

 

[Neuronix]

so you'd have a few more, lower quality dermatologists which no one really wants.

Awwww, Derm would have to go from the top 1% of medical school classes to the top 5%? What a scary world that would be!

 

[sestamibi]

Awwww, Derm would have to go from the top 1% of medical school classes to the top 5%? What a scary world that would be!

That's the genius of whoever controls the number of spots in derm residencies.

They get to pick from the cream of the crop AND they don't oversaturate their own market.

 

[radslooking]

well, i do know its scientifically proven you can get in to see a dermie for a cosmetic procedure much sooner. maybe she would be better off if she needed restylane instead of a cancer workup.

 

[trauma_junky]

Seriously this is f*** up... It's bad enough to wait 1-2 weeks to see my PCP, but with dermatologist it's just ridiculous. Can you explain why the patient queues are so long?

If there is such a demand for dermatologists, and if the dermatology is so popular among medstudents, WHY ON EARTH WON'T ACGME INCREASE THE NUMBER OF DERM RESIDENCY SPOTS? I am usually not fond of conspiracy theories, but it seems that dermies are overprotective of their specialty, i.e. they are artificially keeping the # of new trainees low to keep the supply low... Please prove me wrong on this one...

Make an appointment for a Photofacial and you can be seen the next day. The Hippocratic oath is dead in dermatology!

 

[sestamibi]

Make an appointment for a Photofacial and you can be seen the next day. The Hippocratic oath is dead in dermatology!

Blame the system. Not the doctors.