Donald Hamon had worked construction all his life. Every weekday for about 45 years, he would wake up, grab his tool belt, and drive to a work site where he'd labor and sweat beneath the sun until it set. Then he'd return to his home in rural West Harrison, Indiana, to enjoy his children and eventually his grandchildren. It was on one of those evenings, in early 2005, while Hamon was wrestling around with his grandson on the living-room floor, that the 9-year-old made a discovery.
"Grandpa," said the boy, "you have a spot behind your ear."
Sure enough, as Hamon ran his finger behind his right ear, he could feel the tiny raw patch of skin. It was hidden, so he couldn't see it in the mirror. Nor could he remember ever feeling any pain. His wife confirmed the spot, no bigger than a punch hole, and told him he should have it looked at. So the 63-year-old Hamon did what many men do: He cleaned the wound, let it scab over, and promptly tried to forget about it.
Except the patch never healed. The scabs kept coming off, usually as Hamon slept. Almost a year went by. The spot grew to nearly the size of a nickel. Hamon couldn't wait any longer. He picked up the phone and called a dermatologist in Aurora, Indiana, about 17 miles south of his home.
The doctor booked him for an appointment the following week, and it was then that Hamon learned the patch was cancerous—an aggressive form of squamous-cell carcinoma that had spread to his parotids, the body's largest salivary glands. A team of doctors first removed almost a quarter of his right ear in an emergency surgery to head off the cancer. Later they took out his parotids, along with lymph nodes. Then began the radiation therapy. After 32 grueling treatments, Hamon was finally pronounced cancer-free.
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That should have been the end of the nightmare. But then, in May of 2010 as Hamon was mowing the lawn, a tree branch clipped his right ear. It started to ooze blood and never stopped. Having learned from his potentially fatal mistake 5 years earlier, Hamon phoned his dermatologist in Aurora and was told the doctor would be able to see him—in 4 to 6 months.
Four to 6 months? No, no. This was Donald Hamon, Ham-on, he told them. A former patient with a history of cancer in this very ear.
This was an emergency.
Sorry, they said. The doctor's appointment book was packed.
He called another dermatologist in the same building.
Four to 6 months.
He called a couple of specialists at the Western Hills campus of UC Health Dermatology, 19 miles away.
Six months or longer.
Cincinnati, 25 miles east?
Booked solid into next year.
Hamon went to his family practitioner, but all the doctor could do with his limited dermatological training was assist in trying to find a time, a cancellation, anything with an area dermatologist. Days became weeks that stacked into months without an opening. Hamon's physical state didn't improve. His mental state worsened. All he could envision was a tumor barnacled to his skull. He began to prepare himself for the idea that he might not be around much longer, that he was going to die in the distant, solitary waiting room his life had become.
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Hamon was lucky he didn't face a similar wait back in 2006. That same year, two researchers at the University of California at San Francisco's school of medicine decided to conduct an experiment. Posing as worried patients, they phoned 851 dermatologists across the country for an appointment to have a suspicious "changing mole" checked out. The average wait time: 38 days. In some cities, like Boston, the wait was as long as 73 days. That would have provided a 10-week head start for what could have been aggressive cancer.
One of the study's authors, Jack Resneck Jr., M.D., says the reasons behind the long wait are twofold. First, there are simply not enough skin specialists in the United States. According to Dr. Resneck, the nation has been producing roughly 300 new dermatologists a year for the past 30 to 40 years as the population has steadily grown, particularly the millions of baby boomers reaching retirement age. Second, those aging boomers, like Hamon, worked, played, and relaxed in the sun for decades, blissfully ignorant of the consequences.
"They grew up in an era before people really knew to use sunscreen," says Dr. Resneck.
"Many people were actually doing the opposite, and slathering themselves in baby oil and trying to get as fried as they could."
The result has been a huge spike in the incidence of skin cancer. Another recent study, released by the American Medical Association, recorded more than 2 million skin-cancer procedures in 2006—a 77 percent increase from 1992. Study coauthor Brett Coldiron, M.D., a dermatology specialist and surgeon in Cincinnati, says that today there are more than 3.5 million annual cases of skin cancer, making it the country's most common malignancy.
"That," he says, "is an epidemic."
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The obvious solution would be to convince more budding doctors to specialize in dermatology, a career move that in theory should be an easy sell, given the pay and the demand. And in fact, America's medical schools are filled with droves of hopefuls—there just aren't enough training spots for them all. Medicare funds a significant portion of medical-training costs, and in 1997, in order to wrangle federal spending, the government capped the number of residencies in hospitals across the country. (Hospitals can use their own resources to train more residents instead of relying on funds from Medicare, but they often choose not to, due to the high cost.) The result has been a plateau in the annual output of specialists in many fields, including dermatology. What's more, even if the Medicare funding were to increase today, Dr. Resneck points out that it would take years for those new dermatologists to enter the workforce.
One stopgap measure has been to bring on more nonphysician clinicians—either physician assistants or nurse practitioners—to see patients. In Dr. Resneck's study, 23 percent of the dermatologists contacted said they employed an "extender" who could perform scans and check out changing moles earlier than the doctor could. But not much earlier: The mean wait time to see one of these extenders was 28 days. Not only is that improvement marginal but, as Dr. Coldiron and Dr. Resneck both caution, these clinicians are not adequate replacements for dermatologists. "They are not as well trained," Dr. Coldiron says. "They could miss something during the scan."
Dr. Coldiron instead advocates an increased use of telemedicine—the transfer of medical information, including photos, by Internet—as a way to address more patients' concerns. With expanding technology able to provide a queue of detailed electronic pictures of suspicious moles and lesions, beleaguered dermatologists would be able to squeeze in a few telemedical consults in spare minutes between appointments.
But as Dr. Resneck points out, with so few dermatologists, spare time is limited. "Telemedicine is a helpful tool," he says, "but it won't fix the problem. If there were an easy answer, we would have fixed it already."
Erik Reis grew up along the rivers and beaches of coastal South Carolina. And although "sun" was a word that defined the days of his youth, "sunscreen" was not in his vocabulary. For Reis's mother, seeing her son come home with his fair skin singed lobster red just meant that he'd skipped school again. Blister, peel, repeat.
Reis's skin had always been riddled with moles. Spots of varying sizes and shades of brown were so commonplace he never gave them a second thought. Then one day, at the age of 37, he noticed a bump on the left side of his stomach that had grown to the size of a pea. Days later, it was as big as a grape. He brought the growth to the attention of his family doctor, who referred him to a local dermatologist. The receptionist told Reis that even with his referral, the next opening would be in a year to 18 months. So he called the other two dermatology practices in the region: same answer. Finally, he was able to book a date 6 months later in Charleston—almost 100 miles away.
After 6 months of futile phone calls to see if someone had canceled or if the doctor could squeeze him in earlier, Reis made the appointed 1 ½-hour trek to the city. The dermatologist informed him that the mole was basal-cell carcinoma and had to be removed.
Reis was fortunate. The cancer had not worsened significantly during his 6-month wait, and it was excised without much trouble. But there's no telling if that would have still been the case had he been unable to make the 100-mile trip but instead waited 12 to 18 months to see a specialist near his small hometown.
Reis's case highlights another aspect of the shortage: While a decided lack of dermatologists makes meeting the needs of major U.S. metropolises difficult, the dearth might be more acutely felt by people in small towns and less populous cities. "Like most specialties, dermatology practices tend to locate in more urban and suburban areas," says Dr. Resneck. "So you have lots of rural areas with extremely limited access, and some with no dermatologists."
In the large Diablo region of northern California, with the city of Walnut Creek near its center, medical providers have implemented a different approach to addressing the needs of an underserved population. Dermatologists in the Kaiser Permanente managed-care group have taken to the streets, using their cellphones to respond immediately to primary-care physicians in the region who have concerns about patients' skin. These roving dermatologists show up at doctors' offices to examine or even biopsy suspicious moles or lesions, giving treatment in a matter of hours instead of weeks.
"A lot of times a dermatologist can just determine right there that a lesion isn't worrisome," Dr. Resneck says of the rovers poking their heads into primary-care offices. "And you can reduce the number of referrals that way."
But Dr. Resneck says Kaiser is more of an integrated health-care system, in which the dermatologists and primary-care doctors are often located in the same building or complex, making it more feasible to hire a rover. "Kaiser can afford to pay the salary of a roving dermatologist, whose practice might save money in the end for the insurer but fail to generate enough visits to support a physician salary," says Dr. Resneck. "In the outside world, people would essentially be donating their time to provide such services."
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Perhaps a more practical short-term solution to lessen the demand on dermatologists' time is to better equip the gatekeepers—the family doctors and general practitioners who are forced to refer patients to specialists because of their own limited knowledge and experience with skin issues. Both Hamon and Reis had serious problems that required the attention of a dermatologist. But what about the glut of patients receiving routine skin checks and treatment for rashes and other less serious skin problems? What if these people who clog the system and keep the cancer-plagued men waiting could be cared for by someone else?
At Indiana University's school of medicine, Lawrence Mark, M.D., Ph.D., is working to make that happen by developing an expanded dermatological curriculum for all med students who plan to go into primary care. First-year med students at IU are now immediately introduced to melanomas through training modules, and their second year builds on that experience with the standard didactics. Third-year IU docs are put through another module that trains them to identify, biopsy, diagnose, and then surgically treat melanomas. And in the fourth year, a clinical skills exam requires students to interact with someone role-playing as a patient with a skin lesion.
Dr. Mark believes this curriculum is currently unique to Indiana University, but he says it could be tailored for launch at other medical schools. His goal is to put together a proposal for medical-school deans across the country. He also plans to upload it to the Web so that practicing primary-care physicians can sharpen their dermatological skills in order to intercept skin issues and possibly reduce the strain on specialists.
"Dermatologists do better skin exams because they have the training and see so much more skin than a primary-care physician does," Dr. Mark says. "But if those primary-care physicians receive better training, in all likelihood, fewer cases will fall through the cracks."
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Nonphysician clinicians, telemedicine, roving dermatologists, a better-prepared generation of family doctors—all of these are just bandages for the larger problem, a real solution for which, Dr. Resneck and Dr. Coldiron agree, is hard to see in the short term. Until the mountains of the federal government can be moved to increase Medicare funding and open up more training spots, the shortage will persist.
"We won't have enough dermatologists in the next few years to meet the demand," says Dr. Resneck. "The most important thing we can do is help educate patients about what the danger signs are, when they need to be seen quickly, and how to advocate for themselves."
Erik Reis knows now that it's up to him to save his own skin. After his encounter with the morphing mole, he now pays special attention to the spots that dot his body, and he's had several subsequent procedures to remove other lesions. He gives himself regular scans and has his wife check his back for suspicious marks. He's also scheduled annual skin exams years in advance. And, of course, Reis is correcting a mistake made in his own upbringing: He makes sure his 7-year-old boy wears sunscreen when he's out in the Carolina sun.
Dr. Resneck agrees that limiting sun exposure and applying a broad-spectrum SPF 30 sunscreen is still your best defense against cancer. But if you notice a changing mole or a suspicious lesion, he says, call a dermatologist immediately. Make it explicitly clear why you're concerned, and include any personal or family history of cancer. You may also need to recruit your primary-care physician to help you land an appointment.
Tragically, sometimes these strategies aren't enough—they weren't for Donald Hamon. Even after he and his primary-care physician explained to various receptionists that aggressive cancer had been in the very spot that was now bleeding, Hamon still had to wait 4 months to be examined. Worse, as soon as the dermatologist saw the nodule, he knew it was more than his office could handle. Hamon was referred to one of the best dermatologic surgeons in the area: Dr. Coldiron.
The wait had allowed the tumor to burrow so deep that Dr. Coldiron had to wield a hammer to literally chisel the malignancy from Hamon's skull. After three surgeries, initial biopsies of the area came back negative. For now, Hamon is in the clear.
"You have to be optimistic," he says today. "I think I have a fighting chance. But the wait, wait, wait... it was just terrible, especially knowing the possibilities."