EDITORIAL
Billing Disparities: Everyone Pays the Price he ratio of patients to dermatologists should be 65,000 to 1 according to the national benchmark set by the Royal College of Physicians and Surgeons of Canada.1 The Canada Skin Patient Alliance (CSPA) has set the acceptable wait time to see a dermatologist as 5 weeks.2 Unfortunately, we are meeting neither national benchmark for patient care. In terms of the doctor-to-patient ratio, we are missing the mark in 7 of 10 provinces, reported the CSPA in 2012.2 Meanwhile, the Canadian Dermatology Association reports that current wait times exceed 12 weeks.3 Why are we falling short? The simple answer is that there are not enough dermatologists in Canada, and the numbers are abysmally low in some parts of the country. But the reasons for this national shortage of skin care experts are multiple and complex. However, the issue of remuneration is certainly easy to pick off as a leading culprit. In fact, it ties in with other factors that influence how many physicians decide to specialize in dermatology, as well as how many stick with the profession. The crux of the problem is inequity. There are major disparities in remuneration across the provinces and territories, with British Columbia having the lowest compensation in the country and yet one of the highest costs of living. That makes it particularly challenging to recruit young dermatologists to that province or to keep them there. Some dermatologists leave for greener pastures, whereas others either grin and bear it or find alternative sources of income through nongovernment sources (eg, by doing procedural dermatology that is outside OHIP/MSP). For example, compared with the national average, New Brunswick is increasing recruitment and retention.2 Does remuneration have anything to do with it? A comparison might shed some light. The national average fee for a comprehensive consultation is $78.99. It costs $119.60 in Nova Scotia and $102.95 in New Brunswick, compared to $59.66 in British Columbia and $69.03 in Alberta.2 Whoever said ‘‘Go west, young man’’ (or woman, as the
T
DOI 10.2310/7750.2014.EDIT18.6 # 2014 Canadian Dermatology Association
case may be) was certainly not speaking to a dermatology resident. On the contrary, the advice for a dermatologist may very well be to head east. Nonetheless, the wait times in New Brunswick are surprisingly long despite a fuller complement of dermatologists. However, it is also notable that although most dermatologists in this eastern province are concentrated in three major centres, three-quarters of patients live in outlying areas. It is no huge surprise that, downstream, patient care is affected. Patients will be likely to complain, especially those waiting for an appointment or those forced to travel to major centres to visit one of the too few dermatologists who practice in their province or territory. There is an education component to the problem as well. Consider that it takes 5 years of training after completing medical school to become a dermatologist. Until recently, the number of training spots in Canada has also been limited; when I trained, there were four spots in Canada. Many dermatologists only see patients part-time due to other commitments. Many medical students choose dermatology as their speciality for the ‘‘right reasons’’: they see a need, and they want to help. But the reality is that theirs has to be a viable profession to justify staying in it. Students are abandoning the specialty as a choice, whereas practicing dermatologists are increasing their cosmetic procedure offerings to make ends meet, leaving the public system, or heading to different provinces. As a case in point, one Kamloops dermatologist flies to Newfoundland 2 weeks out of each month to boost his income.4 He now earns more as a part-time dermatologist than he did when he had a full-time practice in British Columbia. Another issue is that, given an average age of 55,5 many Canadian dermatologists are nearing retirement at a rate that far exceeds the increased demand for our services. According to the CSPA report card, we would need the number of full-time equivalent dermatologists to grow by 6.2% per year to keep up with retiring dermatologists and to meet rising future demands on our profession.2 As Dr. Evert Tuyp, president of the B.C. Section of Dermatology, recently commented in a newspaper interview, ‘‘Only if fees are increased well above the average in
Canadian Dermatology Association | Journal of Cutaneous Medicine and Surgery, Vol 18, No 6 (November/December), 2014: pp 365–366
365
Canada and resident numbers are doubled immediately will the number of dermatologists reach acceptable numbers, but it will take 20 years.’’6 Dermatology already makes a small medical community within Canada; we cannot afford for it to become a shrinking profession. By no means do the dwindling numbers in our field indicate a slowing trend or diminished need for dermatologic care; rather, they reflect a shortage of skin care specialists to handle patients now and into the future. In the meantime, dermatologists will need to continue to lobby for change to bring resolution to what can only be deemed an unfair and misguided policy that shortchanges both doctor and patient alike. In the end, everyone pays the price. Jason K. Rivers MD, FRCPC Editor-in-Chief
366
References 1. Royal College of Physicians and Surgeons of Canada. National specialty physician review. July 1988. 2. Canadian Skin Patient Alliance. Skin deep: a report card on access to dermatological care and treatment in Canada 2012. Available at: http://www.canadianskin.ca. 3. Kunimoto B. Fewer practitioners, longer wait times in B.C. Canadian Dermatology Association eBulletin 2013 Sept. Available at: http:// www.dermatology.ca/wp-content/uploads/2013/09/Editorial-BC-WaitTimes-Article-SEPT-2013-EN.pdf. 4. Fayerman P. B.C. suffers shortage of dermatologists. Vancouver Sun 2013 Nov 20. Available at: http://www.vancouversun.com/story_ print.html?id59192024&sponsor5true. 5. Chow EY, Searles GE. The amazing vanishing Canadian dermatologist: results from the 2006 Canadian Dermatology Association member survey. J Cutan Med Surg 2010;14:71–9. 6. Tuyp E. Only fair rates will keep doctors in BC. Nanaimo Daily News 2014 Jan 18. Available at: http://www.nanaimodailynews.com/onlyfair-rates-of-pay-will-keep-doctors-in-b-c-1.793883.
Canadian Dermatology Association | Journal of Cutaneous Medicine and Surgery, Vol 18, No 6 (November/December), 2014: pp 365–366
Billing Disparities: Everyone Pays the Price he ratio of patients to dermatologists should be 65,000 to 1 according to the national benchmark set by the Royal College of Physicians and Surgeons of Canada.1 The Canada Skin Patient Alliance (CSPA) has set the acceptable wait time to see a dermatologist as 5 weeks.2 Unfortunately, we are meeting neither national benchmark for patient care. In terms of the doctor-to-patient ratio, we are missing the mark in 7 of 10 provinces, reported the CSPA in 2012.2 Meanwhile, the Canadian Dermatology Association reports that current wait times exceed 12 weeks.3 Why are we falling short? The simple answer is that there are not enough dermatologists in Canada, and the numbers are abysmally low in some parts of the country. But the reasons for this national shortage of skin care experts are multiple and complex. However, the issue of remuneration is certainly easy to pick off as a leading culprit. In fact, it ties in with other factors that influence how many physicians decide to specialize in dermatology, as well as how many stick with the profession. The crux of the problem is inequity. There are major disparities in remuneration across the provinces and territories, with British Columbia having the lowest compensation in the country and yet one of the highest costs of living. That makes it particularly challenging to recruit young dermatologists to that province or to keep them there. Some dermatologists leave for greener pastures, whereas others either grin and bear it or find alternative sources of income through nongovernment sources (eg, by doing procedural dermatology that is outside OHIP/MSP). For example, compared with the national average, New Brunswick is increasing recruitment and retention.2 Does remuneration have anything to do with it? A comparison might shed some light. The national average fee for a comprehensive consultation is $78.99. It costs $119.60 in Nova Scotia and $102.95 in New Brunswick, compared to $59.66 in British Columbia and $69.03 in Alberta.2 Whoever said ‘‘Go west, young man’’ (or woman, as the
T
DOI 10.2310/7750.2014.EDIT18.6 # 2014 Canadian Dermatology Association
case may be) was certainly not speaking to a dermatology resident. On the contrary, the advice for a dermatologist may very well be to head east. Nonetheless, the wait times in New Brunswick are surprisingly long despite a fuller complement of dermatologists. However, it is also notable that although most dermatologists in this eastern province are concentrated in three major centres, three-quarters of patients live in outlying areas. It is no huge surprise that, downstream, patient care is affected. Patients will be likely to complain, especially those waiting for an appointment or those forced to travel to major centres to visit one of the too few dermatologists who practice in their province or territory. There is an education component to the problem as well. Consider that it takes 5 years of training after completing medical school to become a dermatologist. Until recently, the number of training spots in Canada has also been limited; when I trained, there were four spots in Canada. Many dermatologists only see patients part-time due to other commitments. Many medical students choose dermatology as their speciality for the ‘‘right reasons’’: they see a need, and they want to help. But the reality is that theirs has to be a viable profession to justify staying in it. Students are abandoning the specialty as a choice, whereas practicing dermatologists are increasing their cosmetic procedure offerings to make ends meet, leaving the public system, or heading to different provinces. As a case in point, one Kamloops dermatologist flies to Newfoundland 2 weeks out of each month to boost his income.4 He now earns more as a part-time dermatologist than he did when he had a full-time practice in British Columbia. Another issue is that, given an average age of 55,5 many Canadian dermatologists are nearing retirement at a rate that far exceeds the increased demand for our services. According to the CSPA report card, we would need the number of full-time equivalent dermatologists to grow by 6.2% per year to keep up with retiring dermatologists and to meet rising future demands on our profession.2 As Dr. Evert Tuyp, president of the B.C. Section of Dermatology, recently commented in a newspaper interview, ‘‘Only if fees are increased well above the average in
Canadian Dermatology Association | Journal of Cutaneous Medicine and Surgery, Vol 18, No 6 (November/December), 2014: pp 365–366
365
Canada and resident numbers are doubled immediately will the number of dermatologists reach acceptable numbers, but it will take 20 years.’’6 Dermatology already makes a small medical community within Canada; we cannot afford for it to become a shrinking profession. By no means do the dwindling numbers in our field indicate a slowing trend or diminished need for dermatologic care; rather, they reflect a shortage of skin care specialists to handle patients now and into the future. In the meantime, dermatologists will need to continue to lobby for change to bring resolution to what can only be deemed an unfair and misguided policy that shortchanges both doctor and patient alike. In the end, everyone pays the price. Jason K. Rivers MD, FRCPC Editor-in-Chief
366
References 1. Royal College of Physicians and Surgeons of Canada. National specialty physician review. July 1988. 2. Canadian Skin Patient Alliance. Skin deep: a report card on access to dermatological care and treatment in Canada 2012. Available at: http://www.canadianskin.ca. 3. Kunimoto B. Fewer practitioners, longer wait times in B.C. Canadian Dermatology Association eBulletin 2013 Sept. Available at: http:// www.dermatology.ca/wp-content/uploads/2013/09/Editorial-BC-WaitTimes-Article-SEPT-2013-EN.pdf. 4. Fayerman P. B.C. suffers shortage of dermatologists. Vancouver Sun 2013 Nov 20. Available at: http://www.vancouversun.com/story_ print.html?id59192024&sponsor5true. 5. Chow EY, Searles GE. The amazing vanishing Canadian dermatologist: results from the 2006 Canadian Dermatology Association member survey. J Cutan Med Surg 2010;14:71–9. 6. Tuyp E. Only fair rates will keep doctors in BC. Nanaimo Daily News 2014 Jan 18. Available at: http://www.nanaimodailynews.com/onlyfair-rates-of-pay-will-keep-doctors-in-b-c-1.793883.
Canadian Dermatology Association | Journal of Cutaneous Medicine and Surgery, Vol 18, No 6 (November/December), 2014: pp 365–366
