By the time Carole McArthur was able to see a dermatologist for suspected skin cancer, she had to get layers of skin on her face carved out.
“I lost a chunk of my cheek, I lost the cartilage in my nose,” said the 67-year-old, who had basal cell carcinoma, the most common type of skin cancer.
McArthur was first diagnosed about 40 years ago and had to have skin on her nose removed. Since then, regular checkups kept her in the clear.
But in 2022, after her dermatologist retired and she moved from Owen Sound, Ont., to Ottawa, her face went unchecked. After noticing a concerning spot, she went to the hospital but said she was told there was no one she could be referred to.
Eight months later, McArthur got in to see a specialist, but by that time, the cancer had grown.
Even though she’s now considered cancer-free, she worries about recurrence and said she was recently told she’ll have to go to her family doctor for future skin checks.
“I feel like they are throwing me away and I don’t matter,” said McArthur, who is one of more than 80,000 Canadians who get diagnosed with skin cancer every year.
Across the country, Canadians are waiting months to get access to a dermatologist for medical purposes, including skin checks, mole removals, eczema and psoriasis.
These appointments typically require a referral from a family doctor or a nurse practitioner, which often adds another barrier for patients.
The most recent report from the Canadian Dermatology Association (CDA) finds the long wait is due to multiple factors, including a shortage of hundreds of dermatologists, complex conditions and increasing demand from an aging population.
And of the dermatologists who are practising, there’s something else occupying their time: out-of-pocket cosmetic procedures, like Botox or skin treatments, which don’t require a referral.
CBC News called half a dozen dermatology clinics in Toronto, Windsor, Ont., and Edmonton and found that while Botox appointments were available within a day or a few weeks, timely medical appointments were nearly impossible to secure.
One clinic said its medical appointments had reached full capacity, another said it wasn’t sure when it would be available and a third one said it would take at least a month to process the referral, with an actual appointment taking another three weeks.
Canada short more than 460 dermatologists
There are about 800 dermatologists practising in Canada, which equals 1.9 specialists per 100,000 people on average, according to the CDA.
But to meet a growing and aging population, and to keep pace with retirements, the association says the country needs another 465 dermatologists by 2033.
A shortage of dermatologists in Canada means patients can wait up to a year to get an appointment for critical care such as skin cancer screening, but cosmetic appointments such as Botox injections are readily available. Critics say it’s another symptom of for-profit care taking resources from the public system.
Dr. Mark Kirchhof, the CDA’s president, said one issue is the small number of dermatologist training spots across Canada. In 2023, there were only 29 first-year residency positions available, he said.
The system is also overwhelmed, Kirchhof said, because like other areas of medicine, they’re seeing an “exodus from public medicine into private medicine that’s more lucrative for some doctors.”
This could be due to a number of reasons, including financial pressures — dermatologists tend to make more money from cosmetic appointments — and physician burnout.
“A large percentage of our membership … are just trying to survive economically in the system that we live in. And so supplementing their medical work with cosmetic work is very common,” he said.
While Kirchhof said outdated provincial fees need to increase to help incentivize dermatologists, he also called into question doctors who “get their medical training subsidized by the public system and then end up just doing cosmetic dermatology for a private system for their entire career.”
In Canada, taxpayers partially fund medical students’ training with the goal being that they will end up servicing their communities. But if they’re stepping into for-profit care, that’s an ethical consideration, he said.
Based on member surveys, Kirchhof said a majority are still only practising medical dermatology, but about 30 to 40 per cent of members dedicate a large portion of their practices to cosmetics.
And he said it’s not just cosmetic services: There are also dermatologists who are charging a fee for virtual services to give patients quicker access. Often these services can include diagnosis and treatment of skin conditions, like acne and rosacea.
These services, Kirchhof said, bolster a two-tiered health-care system that threatens public care.
Across Canada, dermatologists receive about $80 to $90 for medical appointments with referrals, he said, noting that can vary depending on the service. In comparison, dermatologists can make a lot more money off cosmetic appointments, with consults starting at $200 to $400, Kirchhof said.
Toronto doctor trying to fill gap
In Toronto, Dr. Andrew Simone has spent the last 20 years opening his dermatology clinic at 4 a.m. on Saturdays to fit in patients who need biopsies or scans. He also doesn’t require a referral, which means he gets paid less per visit.
But for Simone, it’s not about the money. “We can save people’s lives if we diagnose malignant melanoma early,” he said.
And yet Simone said he knows that’s not happening. He’s had patients from different provinces come to his clinic, saying otherwise they would have had to wait.
“You have to understand the anxiety when a doctor says, ‘I think this is serious cancer.’ I don’t think any human would want to wait four months,” he said.
When asked whether it’s fair for dermatologists to focus on cosmetic procedures, Simone said he understands that some are under financial pressures and cosmetics is how they stay afloat.
Toronto resident Elizabeth Legge, who had been seeing her dermatologist for regular skin checks for about 20 years because of a family history of skin cancer, said she recently received an email saying her doctor was “fully retired from her medical practice” but would continue cosmetic appointments and “see her cosmetic patients medically.”
“I was just outraged,” Legge said. “I really don’t have much time for doctors who don’t even allocate a significant part of their practice to the thing they were trained to do.”
She added that her family doctor has told her that for now, there are no available dermatologists for her to be referred to.
What can help?
The Canadian Dermatology Association has proposed several ways to better meet demand.
Some of its solutions include:
- Increasing domestic training of dermatologists.
- Boosting international recruitment.
- Increasing medical appointment fees billed to provincial governments.
Kirchhof also said a return of service contract, which would require dermatologists to offer medical dermatology to communities in need, could help.
