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Dangerous delays to see skin doctors

Hub patients wait longest, study says

Patients and doctors have complained for years about delays in getting appointments for treatment of acne and rashes and routine skin cancer screenings. Now, there is concern that patients can wait weeks to see a dermatologist even for potentially serious problems -- with the longest waits in the Boston area.

In a recent study, researchers posing as patients called 851 dermatologists in 12 cities, including Boston, to request an appointment for a "changing mole" -- a possible sign of skin cancer. The average wait was more than a month overall. Boston had the longest average wait -- 73 days -- though the city had the highest concentration of dermatologists, 4.3 per 100,000 residents.

For certain patients with aggressive skin cancers, doctors say it's possible that such a wait could allow the cancer to spread, making treatment more difficult, but others downplayed the risk.

"This study helped us confirm we really are dealing with an access problem," said Dr. Jack Resneck, a dermatology professor at the University of California San Francisco School of Medicine and coauthor of the study published last July in Journal of the American Academy of Dermatology.

Measures taken to reduce waits in Eastern Massachusetts, including hiring additional physicians at hospitals and group practices, work only temporarily, some doctors say, and in some cases waits have crept back up.

Physicians say that shortages of doctors in a number of specialties, particularly internal medicine and dermatology, create roadblocks for patients trying to find a new doctor. In dermatology, the waits are created both by patient demand and, some believe, by dermatologists' shifting their time to new, more lucrative or complex procedures. Public service campaigns have heightened fear of skin cancer, and melanoma cases are rising, meaning more people are seeking appointments.

At the same time, some dermatologists are devoting time to cosmetic procedures, or to skin cancer surgery that used to be done by general surgeons. Meanwhile, the federal government limits the number of residents hospitals can train, and hospitals would have to create more dermatology slots at the expense of other specialties. This means the number of dermatologists entering practice each year has remained flat, at about 300 nationally, making it difficult for practices to hire new doctors. Just as many have been retiring in the past five years.

"There is a very large consumer demand, and there's a mismatch between what patients want and the number of people available to give the services, said Dr. Richard Marshall, chief medical officer for Harvard Vanguard Medical Associates, a large physician group.

Dr. Karen Rothman, a dermatologist in Westborough, said the average wait not only has gotten longer in Central Massachusetts, but that waiting has become harder, because patients are more aware -- and scared -- that a suspicious mole could be melanoma.

"You look on the Internet and it sets a panic in you," said Shonda Schilling, wife of Red Sox pitcher Curt Schilling, who was diagnosed with melanoma in 2001. "How do you hold that panic down for three months?"

Beth Lauritsen, 53, who lives in Dudley, called her dermatologist in August 2004, when her husband noticed a darkening spot on her upper arm. Lauritsen, who is fair-skinned and grew up under the Long Island sun, was told the doctor couldn't see her until December that year. Two weeks before the appointment, she got a letter from the office saying the doctor wanted to go on vacation, and couldn't she reschedule until January. Lauritsen refused; her dermatologist tested her mole in December and it turned out to be stage two melanoma, which means it had grown more deeply into her skin, than if it had been caught at stage one. She had surgery to remove the mole and surrounding tissue, and now has check-ups every three months.

"I was very passive," she said. "I didn't want to annoy the girls at the desk; they're the gatekeepers. Now I know better; you need to go outside your comfort zone and be more pushy. I wonder if it might not have been stage two if I'd said December was unacceptable."

Resneck's study did not examine what happens if patients demand that a receptionist let them speak to a nurse, for example. And many dermatologists in Boston said they don't believe patients wait anywhere near 73 days if they insist on being seen sooner or, even better, if their primary care doctor calls the dermatologist to request an appointment. A doctor's or a nurse's referral can help because patients sometimes make appointments with dermatologists when it's not medically necessary, and at times even lie about having a worrisome mole to get in sooner, several dermatologists said. They said patients they have seen previously typically have shorter waits. And Resneck's study found that patients get in sooner if they're willing to see a nurse practitioner or physician assistant.

But melanoma specialists said they do hear complaints from skin cancer patients about having to wait, and although no studies have been done to determine whether delays worsen a patient's prognosis, melanoma can grow and spread rapidly.

"The real question is how much do these delays really contribute to poor outcomes in melanomas," said Dr. Donald Lawrence, clinical director of the melanoma program at Massachusetts General Hospital. "In some cases, delay leads to worse outcomes, but it's hard to know how often that happens. It certainly impacts a person psychologically, and I don't think that's acceptable as a general pattern of care."

One puzzling aspect of Resneck's study is that delays appeared to be worse in Boston despite a relatively large number of dermatologists; one-quarter of the state's 442 active dermatologists practice in Boston.

One reason could be the large number of dermatologists who work at teaching hospitals, where they divide their time among patient care, teaching, and research. Mass. General, for example, has 23 dermatologists, but on average they see medical patients about one-quarter of their time. In 2005 the hospital expanded its Laser & Cosmetics Center, hiring another dermatologist who mainly does cosmetic surgery and doubling its capacity.

Dr. Alexa Boer Kimball , who studies the dermatology workforce and works at Mass. General and Brigham and Women's Hospital, said that dermatologists nationally spend less than 10 percent of their time doing cosmetic procedures -- which are more lucrative because patients rather than insurance companies pay the fees. She said this average has changed little in recent years, but other doctors say the practice appears to be growing. A dermatologist in Harvard Vanguard's Wellesley center, for example, now spends a half-day a week doing Botox and other cosmetic treatments, but the number doing cosmetic procedures will probably soon expand to three or four dermatologists, out of 12.

"We need to make (cosmetic work) available partly so we can hire and keep dermatologists," Marshall said.

Medicare and insurers pay doctors roughly $45 to $65 for an office visit for a skin checkup, Resneck said. But patients can pay several hundred dollars for a simple cosmetic procedure.

At Brigham, patients face average waits of three and a half months for routine visits -- despite the addition of doctors. Office visits to dermatologists at the Brigham and Dana-Farber Cancer Institute's joint program grew to 35,000 last year, more than double five years ago. Other places, such as Harvard Vanguard, have added nurses to see patients for routine visits, while Lahey Clinic is training internal medicine residents to do basic dermatology.

"We've hired more people," said Dr. Thomas Kupper, chairman of dermatology at Brigham. "Our wait times did go down briefly, but now they're creeping back up to where they were. I don't think anyone is happy with the status quo of wait times. Everyone is trying to come up with ways to fix the problem. I think this is a problem that is going to face us for years to come."

Meanwhile, doctors say patients who are concerned about waiting should try to get their primary care doctor to advocate for them -- although many primary care doctors say they're stretched to the limit, too.

"When a primary care doctor sees someone at risk for cancer, they are responsible to make a referral happen," Harvard Vanguard's Marshall said. "If people have a mole that is changing, they should not take no for an answer."

Liz Kowalczyk can be reached at kowalczyk@globe.com.

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