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Bring Dermatology’s Focus Back to Practicing Medicine

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Why does it typically take over a month to get an appointment at the dermatologist’s office for a full body skin check to screen for melanoma, yet if you call the same office for a Botox appointment you can usually get an appointment within a couple of days?

Even though awareness of the seriousness of melanoma, and of the fact that it is often preventable, is spreading, these long wait times often deter people from getting checked.

Why does it take so long to get an appointment for a skin check?

If you are someone who does not have a lot of freckles, moles, or other pigmented areas on your body, chances are you will spend more time in the waiting room than you will actually getting screened for melanoma and other skin cancers. It doesn’t mean the doctor is not being thorough, it just means there’s nothing to report, and no news is good news.

But if you are someone who does have a large amount of freckles, moles, evident sun damaged-skin, and other higher-risk criteria, chances are you will be in there for a long time. The reason for this, which is also another reason why many people do not get regular skin checks, is that it is often necessary to have skin biopsies taken of any questionable mole or other lesion.

What is a skin biopsy?

A skin biopsy involves the removal of some or all of the suspicious lesion, and in some cases the surrounding skin or tissue. This sample is then sent off to be evaluated by a pathologist.

 

There are several different kinds of skin biopsies including:
Fine Needle Aspirate (FNA): technique in fluid is removed from the lesion in question.
Shave Biopsy: technique in which a shallow portion of a lesion is “shaved” off the surface of the skin using a scalpel or razor.
Punch Biopsy: technique in which a lesion as well as some of its surrounding tissue is cut out using a device that resembles a cookie cutter or hole punch. This is used to completely remove small lesions or to sample a portion of a larger lesion.
Incisional Biopsy: technique in which a lesion is removed from the skin by cutting out the affected area. This technique is often used to remove larger lesions.
Excisional Biopsy: technique in which a lesion is removed from the skin by cutting out the affected area as well as a portion of normal skin surrounding the lesion. This technique is also used to remove larger lesions.

Sound fun? It’s not. It can be time consuming, especially if there are several lesions to be removed; local anesthesia is often necessary, and there are post-biopsy home care instructions that need to be followed to prevent infection. Even if you follow the instructions exactly, chances are you will still wind up with a scar. This is another major factor that deters people from calling to make their annual skin check appointment.

Wouldn’t it be great if there was a way to test for melanoma without needles, pain, and scars?

There are ways. According to information I learned from my interview with Tim Turnham, executive director of the Melanoma Research Foundation, there are some non-invasive methods to test lesions without actually cutting them out. One test on the horizon is as simple and pain-free as sticking a piece of tape on the surface of the lesion, then removing it. When the tape is removed, a sample of the lesion’s DNA is removed with it. This sample is then sent to the lab to see if the DNA matches that of melanoma DNA.

Another method involves shining a certain type of light on the lesion. If it changes to a certain color, it may be melanoma which would warrant further study; if it does not, then it is likely to be benign. This type of test is a great time saver, since it could illuminate and reveal several lesions at a time.

Why don’t dermatologists use these pain-free and time-saving methods instead of biopsies?

There are two main barriers that stand in the way of these non-invasive tests becoming the standard for melanoma detection: technical barriers and cultural barriers. On the technical side there are still a few kinks to be ironed out. The tests have demonstrated a high level of sensitivity and accuracy, but are not yet available for clinical use, although they soon will be.

But even once they are available, Turnham does not see an immediate shift in testing methods happening anytime soon. This is the cultural barrier. It is very hard to tell a dermatologist who has been testing for and removing potentially cancerous lesions the same way for his or her entire career that guess what? All you need to do now is to stick a piece of tape on it or shine a light on it to tell you what once took much more time and effort to determine. Although change is good, many people tend to resist it.

The other problem has to do with capacity problems. Once these non-invasive tests are out and available for clinical use and the general public learns that they might not have to have their moles cut off and risk scarring, a typical dermatology practice’s patient load will increase significantly.

That’s good, though, right? What doctor doesn’t want more patients?

You think you have to wait a long time now for skin check appointments? Even though the new tests will take less time to perform, once the amount of people calling for these appointments doubles or triples, the waiting time will also increase. The reason for this is that there are not enough physicians practicing clinical dermatology to handle this kind of patient load. Many of the more experienced dermatologists have begun practicing cosmetic dermatology, because that’s where the most money is. Cosmetic dermatologists also do not have to deal with insurance companies as much as clinical dermatologists do, since many of them only accept payment in full from patients at the time of service. Many new medical school grads are more attracted to cosmetic dermatology as well for these exact reasons, and are foregoing joining clinical practices.

The priority needs to shift back to actually practicing medicine: diagnosing and treating skin diseases; not just pumping facial lines full of collagen. I was just at my dermatologist’s office and saw about eight different brochures for different cosmetic procedures and only two for skin cancer prevention/education.

Do these tests need to be performed by dermatologists?

Here’s the good part: no they don’t. Turnham indicated that these new non-invasive tests will be user-friendly enough that they can be performed by general practitioners during a regular physical examination. If the results come back positive or inconclusive for skin cancer, then the patient would be referred to the dermatologist for further testing.

Moving initial melanoma screenings into general practice would greatly free up the dermatologist’s schedules, as well as validate referrals to dermatology. People would only have to go to the dermatologist if there is a definite reason to. If a patient comes to the dermatologist after already receiving a positive test result, it greatly reduces the need for unnecessary biopsies (and the anxiety, pain and potential scars caused by them) and makes that patient’s care and diagnosis more efficient.

Will this change ever happen?

All I can say is I hope so, because melanoma statistics are not decreasing; and the longer people are reluctant to get screened for melanoma and other skin cancers (due to long waits for appointments or fear/anxiety associated with biopsies), the more cases there will be.

Regardless of if and when these tests become the standard in melanoma screening and testing, people still need to have annual full body skin checks. They’ll just have to be prepared to call for the appointment at least a couple of months before they actually want to be seen.

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About Rachael Pontillo

  • http://tribong-upos.xanga.com Ritche

    Well, this is good news, because as you said Rachael, more dermatologists are opting for the more profitable side of the profession that does not really involve telling people disheartening news. This new test, once available, would basically be saying, “Let the GP do the dirty job, and let the dermatologists continue its work making people feel good (after paying, of course) about themselves”

  • http://blogcritics.org/writers/rachael-pontillo/ Rachael Pontillo

    Yes it is good news…it’s just a matter of how long before this shift happens.