White Coat Black Art26:30The early bird catches the derm
Roger Lang woke up at 3 a.m. on a September morning to drive 200 kilometres for a dermatology consultation.
He didn’t have an appointment, but the 80-year-old from Belleville, Ont., was hoping to be one of the 60-some early risers lined up outside the Avantderm rapid-access dermatology clinic in Toronto’s Distillery District to see Dr. Davindra Singh.
Lang has been waiting since July to see a dermatologist about a severe, itchy rash across his body. He had a dermatology referral from a family physician, but an appointment was a long way off.
“One of the doctors I saw said, ‘Oh, I see, you’ve been referred. Oh, good luck with that,'” Lang told Dr. Brian Goldman, host of White Coat, Black Art, outside the clinic.
“He said it could be up to two years.”
Wait times for dermatology referrals — for conditions from hair loss to rashes to potentially cancerous moles — have risen to the point that some patients in Toronto and beyond would sooner stand in line at 5:30 a.m. to be seen that morning than wait months for an appointment.
With a doctor’s referral, the rapid-access clinic visits are covered by the Ontario Health Insurance Plan (OHIP).
Dermatologists say a range of factors, including pressures added by the pandemic, have increased demand for care from a limited number of the skin specialists.
That morning, Victoria Jenkinson, from Hamilton, Ont., was making a third attempt to get into the clinic in hopes of getting an answer for her rapid hair loss. Ton and Mia Tran, a couple from north of Toronto, both took the day off work to have their pre-school aged daughter seen for a skin rash.
“Everybody that’s in that line is there because they feel their problem is important, it’s urgent, and there’s often a lot of anxiety surrounding it,” said Singh, who runs the clinic, in an interview with Goldman.
But, there’s a cap on the number of patients staff at Avantderm can see each day.
“We try to see as many as we can, but when we get to our limit, we just have to shut it off,” he said. That day Singh saw around 130 patients, including patients from the rapid-access clinic, pre-booked appointments and follow-up phone calls.
Thousands of melanomas removed
Adam Welton, 36, visited Avantderm the same day as Lang to have a suspicious mole checked out.
It’s not the first time the Toronto father has had a mole removed, and his family doctor recommended visiting the rapid-access clinic instead of waiting an estimated four months for an appointment.
“Both my wife and I’ve had little health things over the years,” he said outside the clinic. “So when you’re talking about something that can be really life changing, it doesn’t really seem to be that difficult to come and stand for a time.”
Once in, Singh asked Welton a series of questions: Do you tan or burn in the sun? Have you spent a lot of time in the sun? Is there a family history of cancer? — and examined the mark.
Ultimately, Singh decided the best course of action for Welton was to remove the mole the same day. Singh estimates in the clinic’s 13 years, he’s removed “thousands” of melanomas.
“I don’t think it’s cancer,” Singh told Welton. “But if we take it off, I’ll send it to the lab, I’ll analyze it, and then I’ll call you back and I’ll give you the results. It takes about four weeks now.”
Singh says a number of challenges have contributed to the expanding wait times.
As of 2021, Ontario has about 250 dermatologists, which is up 5.5 per cent from 2018 figures, according to figures from the provincial ministry of health. Nationally, per the Canadian Medical Association, there were around 630 practicing dermatologists in 2019.
That small number of specialists are taking on a greater number of referrals as family doctors see more patients virtually, and diagnose and treat fewer conditions in their own offices, dermatologists say.
Too many referrals, not enough specialists
Like many issues in the health-care system, Dr. Sam Hanna points to the pandemic as the starting point for the problems in dermatology.
“Up until the pandemic started, my waiting list was a month or, you know, a month and a half,” said Hanna, medical director of Dermatology on Bloor and a spokesperson for the Canadian Dermatology Association.
But now, he says family physicians are sending more patients his way — half or more of whom would have previously been triaged, given a provisional diagnosis and potentially treated at doctor’s offices for conditions like benign growths, warts, acne and mild eczema. So, it’s taking longer for dermatologists to get to patients with concerns like potentially cancerous moles, Hanna said.
“The solution can’t be, ‘OK, we’re going to take what the 15,000 [family] docs were doing and turn the pyramid on to the … dermatologists in Ontario,” Hanna said.
Featured VideoThe first three-year family medicine residency is slated to launch in 2027. Some are already sounding the alarm that an extra year of training could worsen Canada’s doctor shortages.
Compounding the problem is a growing number of dermatologists nearing retirement age, Singh said. Nearly 50 per cent of physicians are over 55, while only seven dermatologists are trained each year in Ontario.
And many incoming dermatologists, he says, are going into more lucrative cosmetic practices and offering treatments for wrinkles and sagging jowls.
“The thought of doing medical dermatology is just not attractive to them anymore, at least not as much as it used to be, and I think that’s a big problem,” he said.
“So we’ve got an issue with supply, we’ve got an issue with demand, and we’re getting squeezed in the middle.”
Engaging government, family docs necessary
Hanna, whose clinic offers both medical and cosmetic treatments, is skeptical that offering cosmetic dermatology is creating a wait time problem. Most dermatologists, including himself, still see patients with potentially harmful skin conditions, he says.
He says the problem lies in limited public funding for dermatology, which doesn’t train or fund enough of the specialists, and how referrals are made.
“What has evolved is a system where if everything is perfect and we don’t have a global pandemic, we can sort of squint our eyes and pretend that everything’s OK,” he said.
“As soon as you put a stressor on, you realize that … we were hoping for the best forever, and then we didn’t get the best.”
Hanna says that options like Avantderm’s rapid-access clinic, offering service for patients that don’t want to wait for referral appointments, can be a useful “bonus” solution to wait times in dermatology.
Where it breaks down is when that option becomes the primary path for seeing patients.
“As an overflow valve, it’s breaking,” he said. “When you kind of shift to all overflow, when the relief valve is under that much pressure, it just really speaks to the underlying system.”
Singh wants to better educate other providers — whether that’s family physicians or ER doctors — about best practices for dermatology referrals. Engaging governments is also critical, he said.
“I’m certainly willing to talk to anyone because I’ve got inside knowledge of all of this.”
‘If you have better ideas, just tell me’
Despite running his clinic for up to 12 hours a day, burnout is far in the rearview mirror for Singh.
“I think I passed that years ago,” he said. “I don’t know what keeps driving me, but I just keep doing this.
“But I don’t think I can do it forever.”
Lang, from Belleville, did manage to see Singh on one of those 12 hour days. He says the experience was efficient — like “an assembly line.” Jenkinson was also given a diagnosis and treatment for her unexpected hair loss.
But the Trans, despite taking the day off work and travelling two hours into downtown Toronto, arrived after the clinic’s cut-off time for walk-in appointments. They say they’ll be back.
“I have to, there’s no [other] way,” Ton told Goldman. “If you have any better ideas, just tell me.”