Dermatologist Chris Sladden leaves his young family in Kamloops for two weeks each month to work in Newfoundland.
In the coastal community of Corner Brook — population 20,000 — Sladden says he is paid almost double what he would earn in B.C. and has a hospital base, both of which allow him to do his best work for patients.
Sladden said he would have loved to practise in the community where his family is established.
“I can’t do it with the fee structure in B.C., and that’s such a shame,” Sladden said. “We clearly need to do more to retain people who want to do medical dermatology. The fees remain the worst in Canada.”
Relative to other provinces, B.C. pays the lowest fees for an initial consultation ($63.60) and an office followup ($27.10). Compare that to an initial visit in Nova Scotia which pays $125.84 or a followup visit in Prince Edward Island that pays $54.05.
“I made the decision [to work in Newfoundland] because I came to the realization I really couldn’t set up [an office] and practise the standard of medical dermatology I wanted to do in British Columbia — and I ended up being offered jobs right across Canada,” Sladden said.
“I can actually do everything better working out-of-province part-time than working in-province full-time,” Sladden said. He’s been doing it for three years.
Kamloops — the riding of B.C. Health Minister Terry Lake — is as an example of how hard it is to recruit and retain skin specialists in the province.
Theoretically, there are two dermatologists in Kamloops. But Sladden, in his early 50s, practises only in Newfoundland. His focus is complex skin cancers and complicated skin conditions.
The other dermatologist is Dr. Dick Lewis, 74, who by way of protest, de-enrolled from B.C.’s Medical Services Plan and runs a private practice.
Dermatologists deal with thousands of skin conditions, including skin cancer, inflammatory disorders, herpes, fungal infections and psoriasis.
There are 65 dermatologists in B.C. — 11 of them are on Vancouver Island (one in Courtenay, two in Nanaimo, and eight in Victoria). There are also job postings for 26 of the specialists in B.C.
In Greater Victoria, Dr. Mark Lupin devotes at least half of his practice to cosmetic surgery and Dr. Patrick Kenny focuses his entire practice on melanoma, the most deadly skin cancer.
There’s a need for four more dermatologists in Victoria and one in Duncan, said Dr. Evert Tuyp, president of the dermatology section of the Doctors of B.C. There’s also need for a Mohs surgeon, specially trained to remove skin cancer in sensitive areas — usually the nose, hands and genitals — by systematically removing then testing thin layers of cancerous tissue until the cancer is removed and as much healthy skin as possible is preserved.
The B.C. health minister said the province is aware of the shortage of dermatologists and wants it addressed but argues that, in the meantime, “there are many general practitioners who have a special interest in dermatology.
“Physicians are quite capable of dealing with skin problems and potential cancers and they can do biopsies,” Lake said. “It’s not limited to dermatologists.”
A patient with a suspected or confirmed melanoma is supposed to be fast-tracked to see a dermatologist or plastic surgeon.
Lake noted that the median wait-time to have a confirmed skin cancer surgically removed is 3.7 weeks. And, according to the Health Ministry, 90 per cent of patients receive the procedure within 7.1 weeks. Dermatologists dispute those statistics.
Sladden’s biggest concern is about patients never getting in to see a dermatologist for a diagnosis. Lack of access to dermatologists means people are walking around with undetected skin cancers, possibly life-threatening melanomas, he said.
“I saw a young girl, 32, came down this week to see me. She had a warty growth on her scalp but then she said, ‘Can I show you something on my leg? I’ve been told it’s nothing.’ And she had a melanoma,” Sladden said. When that happens, he doesn’t bother with a biopsy, but cuts the entire lesion out with a two-millimetre border.
“Some of these things can be notoriously difficult to diagnose. We all miss them — experts, people working in melanoma centres, miss them,” Sladden said. “But you’ve got to give patients the best chance and that’s by sending them to people trained to find them.”
He sees evidence of family doctors misdiagnosing basal and squamous cell cancers as “pre-cancers” and using cyrotherapy (the use of liquid nitrogen to remove superficial non-cancerous lesions, such as warts) on them. “I see it time and time and time again.”
Sladden, originally a family doctor, said before retraining as a specialist in Vancouver, he approached the Interior Health Authority and province for funding to cover expenses, such as travel between Kamloops and Vancouver, in return for a contractual obligation, after graduating as a dermatologist.
He delivered one letter in person and, “eight years later, I have yet to have a reply.”
“The shortage of dermatologists is a huge issue for the people of B.C.,” Sladden said.
“If the health minister or premier needed to see a dermatologist [because of a suspected skin cancer], I suspect a phone call would be made and they’d be seen at half past seven the next morning, privately,” Sladden said.
“I’d like to see [B.C. Health Minister] Terry Lake have the courage to step up to the plate and do something about this. I think he could. He’s not a stupid man. He knows there’s a problem. He also knows it’s not right, it’s just whether, politically, he can sort it out.”
In the latest physician master agreement with the province, the Doctors of B.C., formerly the B.C. Medical Association, got two evenly divided pots of money worth a total of $55 million to help compensate specialists.
Half, $27.5 million, will go toward the disparities between specialist groups within the province. The other half will top up the disparity between what specialists earn here compared to professionals in the same specialty in other provinces.
Dermatologists will make their case in June and compete with other specialists for money from both pots.
The government hopes the extra funding will attract more doctors here, maybe even bring some back from Alberta, the health minister said.
“I agree there is a challenge with the number of dermatologists we have and I’ve addressed this on many occasions,” Lake said.
“With the Doctors of B.C., we have created an opportunity to increase the compensation to dermatologists,” Lake said. “They have the opportunity … to make a case for increased compensation that would serve as a good recruitment and retention tool.”
Doctors of B.C. president Bill Cavers said the group is in the process of retaining a mediator who will settle the issue of payments to specialists.
But fees aren’t the only problem. The five-year dermatology program at the University of B.C. — the only such training program in the province — graduates just three dermatologists a year with no guarantee that any of those graduates will work in B.C. And that means many B.C. medical students who want to study dermatology can’t, Tuyp said.
Lake said the government worked hard with the university to increase the number of residency spaces from one to three in 2007. The number of residency positions is set by the University of B.C., but the Doctors of B.C. has a seat on the advisory committee, and has advised more training spots are needed, Cavers said.
Lake said the university is constrained by the fact there are not enough dermatologists to fill the supervisory roles needed for dermatology students.
The shortage of dermatologists is significant and the Doctors of B.C. is doing what it can do, Cavers said. Dealing with that shortage requires a multi-pronged approach that includes teledermatology — consulting with dertmatologists through photographs, video and phone, he said.
“Recognizing that it can take six months or more to get in to see a dermatologist, we are trying to improve the efficiency,” Cavers said.
“Does it address the shortage? No, it doesn’t. We know there is a shortage of dermatologists in B.C. and we know we are going to need to train more.”