ENCORE: The early bird gets the derm
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Timely access to health care is a crucial issue in Canada, not just access to primary care providers, but specialists as well. So on this long weekend, we decided to re-air an episode about long waits for one specialist in particular. It aired back in October 2023, but the lineups are as lengthy as ever. If you want to see a dermatologist, at least in Ontario, you're probably looking at a minimum wait of many months. There just aren't enough of them.

Well, there's this clinic in downtown Toronto where you just might be able to score a same-day appointment with a skin doctor. But as we found out, you've got to line up very early. The clinic is called AvantDerm. It's been around since 2010. Me and senior producer Colleen Ross got here at 6 a.m. and already there's a lineup. And you have a chair. They're prepared. What's your name? Roger. Lang L-A-N-G. And where are you from? Belleville.

So that's a pretty long drive. A couple of hours. So how did you hear about this place? From a friend of mine who is a retired physician. And do you mind if I ask why you're here? I played golf with him and he saw me scratching. He said, I sent my patients to Advent Derm for years, but he said, you got to get there early. So he... So I finally got a referral and here I am. You have a rash? Bad. All over my body. Oh, really? Yeah.

And it's itchy? Oh, yes, very. Anything on it itches. Roger wears baggy shorts because long pants aggravate his itchy rash. The 80-year-old sits on a folding chair and tells me he's driven nearly 200 kilometers in the dead of night instead of waiting for a referral to a dermatologist closer to home. One of the doctors I saw said, oh, I see you've been referred. Oh, good luck with that.

Why were you told that? He said it could be up to two years. Two years? That's what he said. The rash might be gone by then. Maybe I'll be gone by then. I hope not. Me either. But here we are. So what time did you wake up to get here? Oh, three o'clock.

Wow. But the most sleep I've been getting since probably the 1st of August is maximum four hours at a time. What, because it's so itchy? Yeah. Oh, boy. Turnover, it itches, and I wake up. So here I am. You don't know if you have an appointment yet, and you don't know when you'll be seen? No, no idea. How do you feel about that? Typical of the Ontario medical system these days. For dermatology, there aren't very many dermatologists per population. What's the line-up?

While we chat with him, the lineup keeps growing. Soon it will number in the dozens. People of all ages from their 20s up to Roger's age and beyond. Each with a skin problem that should not wait months to get sorted out.

people like Adam. Good morning. Oh, there's more people with chairs. Chairs seem to have been a really good play. Leaning or standing was not necessarily a good strategy. So what's your name? My name is Adam Welton. And is this your first time at the clinic? So it is my first time here. My wife has come to the clinic before, so she was the one that sent me out early, made sure I got down here and knew kind of the

The strategy seems really crazy. Like the only thing I've ever lined up for like this, like the passport office. And Adam, how old are you? 36. I got an abdominal mole. I've had a couple removed like in adolescence. I lived in Australia in 2008, 2009, became very aware. And so went through family doctor. They recommended, hey, you could wait like four months if you want to get in for an appointment. You should probably go though and actually go to the clinic and wait in line. So here I am.

How worried are you about the mole? Yeah, like we had a child two years ago and, you know, you start to become a lot more aware about, like both my wife and I have had little health things over the years. And so when you're talking about something that like can be really life changing, it doesn't really seem to be that difficult to come and stand for the time.

Like my mother was an operating nurse for 40 years. And so my mom was tremendous at like navigating the medical system and having learned from her how to navigate the system, I think. Now, as I observe it, I find, I understand for a lot of people why it's just devastatingly complex. There's

There's lots of little details and ifs and buts about things. People get turned away if they don't have a paper referral in hand. So you had that, and then you had your wife who'd been here. Yeah. This is how you line up. I'm in a privileged position to understand this is the system. This is how things kind of work. Well, I hope it's not a melanoma. Yeah, I hope not. Either way, positive attitude. Positive attitude and word of mouth.

Adam's wife, who has also been here, told him the secret to getting a same-day appointment is to come as early as you can and certainly no later than around 8. Abdullah Dekhabi learnt that lesson the hard way by lining up too late.

It's my second time. I came here before. I came here like two weeks ago, but it was closed. They closed. They had to send me home and I had to come back today. My doctor sent me here, but he told me to come like 6 o'clock.

Like Abdullah, others in line have tried and failed to get in the door.

Some more times than others. Why don't you tell us your name? First and last name. Okay, Victoria Jenkinson. How early did you have to get up this morning to be here? Four o'clock. Four o'clock. Four o'clock, yeah. Do you have a chair? Yeah, I brought my chair because I was here about a week ago.

And I got here around 7.20 because the website says the rapid access clinic is open at 8 o'clock to 11. But the doors open for registration at 7.30. So I thought, okay, great. I'll show up at 7.20. I'm coming from Hamilton, by the way. So drive all the way here. I get in line around 7.20. By 8.20, a receptionist came out with a sign, four people ahead of me saying, that's it, we're done for the day.

How did you feel? Really freaked out because I'm having rapid hair loss. I saw my family doctor in Hamilton and she said, you really need to talk to a dermatologist. And you've got like six months to a year sometimes or eight months. So I actually tried to come out

A second time, and there was a traffic jam. I thought, okay, forget it. I'm not going to make it. So today, my husband drove me in again, and we showed up at like 6.15. And there was already people here. This is trip number three. This is trip number three, just to get the registration. How old are you? Well, 63. That's why I have the chair. And I was in the hospital like a couple of weeks ago for partial bowel obstruction. So it's like, I really don't want to have to stand this long, but what are you going to do?

Around 7.30 a.m., Victoria and the others in line have reason to feel hopeful. Hello, good morning. How are you guys doing? A member of the office staff unlocks the glass entrance to the clinic. I'm Jennifer.

Right now I'm just going to bring a few patients in because we only bring five at a time because we don't want to overfill the room. So as you register, we just ask them to stay because the doctors will be starting at 7.30. When we notice that the room is getting all filled up, we ask them to leave and they receive a text to come back when the doctor's ready for them. So this is what happens. I open the door. It's one of the doctors. Are you guys together, right? Inside, the waiting area is spacious with a high ceiling and lots of wood. Think industrial chic.

I count around 15 patients waiting indoors. Half are standing in line waiting for three office staff seated behind a glass barrier to check them in.

The rest are sitting on padded benches. These walk-ins have been given appointments. It's just a question of how long they have to wait this morning. The vibe here may be peaceful right now, but not so on busier days. A sign on the wall says, and I'm quoting, zero tolerance, physical or verbal abuse towards our staff will not be tolerated.

Some people who make it inside get turned away. For instance, if they don't come with a referral note from their doctor. You can imagine that some of those who wait in vain might get a little upset. The lineup is like about 60 patients. 60 patients? Yes. Can you give us your name, first and last name? Louisa Antebra. I'm a medical office administrator. And what's your job here?

So the first thing I'll do is review the schedule, check to see how many doctors we have in. Then I'll assess the lineup. So this is where we could determine how many patients will be seen in the morning for the walk-in clinic. Also, I do help with the lineup in terms of bringing the patients in, letting them complete intake forms while they'll complete their full registration in the front. And then also, as I'm doing this, I'm also communicating with the patients to let them know where we stand in the queue and if we have reached capacity for the day.

How many walk-ins do you usually see on a typical day? Typically from 67 to 78 patients. So around what time are you kind of stepping out the door and telling people that there aren't any more appointments for the day? Well, that day also depends on the day and then how many doctors we have in the clinic for the day. What's that like for you?

Well, in days like that, you just need to remain calm, right? So it's fine. So do you warn patients? Do you warn people? You say, you know what, you're getting close to the end of the line. You're welcome to wait, but I think you may be too late. Yeah, so this is during that I'm also communicating with them to let everyone know where they stand in the queue and if we are approaching capacity. Have people gotten really angry? No.

Yes, we do have situations like that. But for me, the best thing to do is remain calm, be that ear for them and just give them a solution and what I could do to help them out. Do you have security to help you? There has been time where security has been called. Yes. Are we approaching capacity yet? Not right now. Okay. You think we got another hour? Yes, we have another hour.

Adam Welton whom we met earlier in the lineup has been brought into a room. Hello. Hi Adam, how are you? I'm good. I'm Dr. Singh, nice to meet you. Nice to meet you too. Dr. Devendra Singh, the dermatologist who runs the Event Derm Clinic is going to check out Adam's skin mole. Now you're 36 and you're very healthy.

Yeah, for the most part. Good. And then you had a mole you wanted to show me. Yep. It's right on the abdominal here. Right there? Yeah. Okay, good. So that one in particular just looked very different from like others on the body and so that was the why we came in and had checked. Could I get you to stand up for me? Yep, no problem. I'm gonna take a good look at it with my light. Yeah, you're right. It looks a little bit funny. A couple of questions. In the sun,

Do you normally tan or burn? Tan. And have you had a lot of sun in your lifetime? I've definitely had some. Yeah? I've had a mole rooted on my back, which you can probably see like a scar from. I see one up here. Are there any other moles you're worried about? The only other thing was like I've got this sort of mark that's going on here. This one's nothing. It's like a little scar. Okay. Called a dermatophybroma. Yep. And last question. Does anyone in your family have skin cancer? No. Okay.

This mold here, I think we should remove it. Okay. So it might be something called the dysplastic mold. Okay. I don't think it's cancer. Okay. Okay. But if we take it off, I'll send it to the lab, I'll analyze it, and then I'll call you back, and I'll give you the results. All right. It takes about four weeks now. Okay, great. So I just go and we book a time to remove it? No, we'll remove it today. Oh, goodness. Okay. Yeah. Well, you've seen the line, right? Yeah. We try to get everything done the same day.

This is why you're here? Well, this is it. If we can identify melanoma this early, right, it makes a huge difference. So you found a suspicious lesion? Oh, yes. How often does that happen on a daily basis? Very often, yeah. A lot of people in that line will have moles that they're worried about. I'd say 90% of the time they're safe. But in this case, this one looks a little suspicious, so we'll take it off. Follow me out here. Adam is taken to the procedure room. Yeah, okay.

A short while later, Dr. Singh removes the mole. We just have to give you a little needle. Pain-wise, it's like a 2 out of 10. 2 out of 10? Yeah. Then you're frozen, and then I'll just take it off. And then you'll have a little scab there. Now, tiny pinch, okay? Ouch. Gonna burn a bit. That's it. Yeah, sounds about right. Not too bad, right? Okay, I'm just removing it right now. You want to see it? Sure. Oh, wow. Okay. It's all gone.

So we're just going to stop it from bleeding. And then Mesamine will put a bandaid on it. And then you just follow our instructions and help it heal. And then I'll phone you in four weeks. Sounds good. Okay? Yeah. All right. Bye-bye. So how are you feeling? Good. Yeah. I mean, that's like a, it's a very quick thing. We'll find out obviously in four weeks if I feel good about it or not. But it's pretty remarkable. I mean, when it works, it works pretty well. If you can get in, right? It's fast, but it's a necessary service. And if you didn't have it, where would you go?

And I don't know. You'd just be making a lot of phone calls trying to get in somewhere or just waiting and hoping that it's not a thing. All right. Thanks for speaking with us. And that is it. You take care. Thank you. Meanwhile, Roger Lang, one of the earliest patients to arrive this morning, has had his appointment. Have you been given treatment?

He's given me a prescription to take care of it with the instructions. And I'm going to take some time and read it when I get home. How do you feel about the whole experience? Oh, it's almost like an assembly line. Wonderful. You're glad you came? Oh, absolutely. It won't get any better until I try the subscription, but I've tried several others and nothing works, so I'm hopeful this will work. Well, thank you for speaking with me. No problem. Thank you. Have a nice drive back. Thank you. Bye-bye.

Victoria Jenkinson, the woman with unexplained hair loss who finally got an appointment on her third try, has also seen the dermatologist. So I know you're worried about hair loss. What did the issue turn out to be? Well, it's something called telogen effluvium and it happens because usually about several months after a stressful event and I was in the hospital in June and I had a very restricted diet and

I had some emotional stress as well. So we said, yeah, that can happen. Like your hair goes into a resting phase due to stress and it starts falling out two months later. But he said it's the best news because it will grow back. So anywhere from three months to a year. So he didn't prescribe any treatment? He just said if I wanted to use, there's a product that...

can encourage hair growth. So he said I could do that if I wanted to speed up the process. So how do you feel about the whole process? Third time lucky? Third time really lucky. Well, you know, I feel a lot better now. Like I finally have it. It was the not knowing. Like when I first came, I was just so disheartened and really worried. What would you do if a place like this wasn't available? Oh, I would feel very frustrated. I'd be going online and trying to figure out solutions and, you know, trying to deal with it myself, right? I would be very worried.

Avantdorm sounds like an oasis in a dermatology desert.

But even this clinic has its limits. That lineup had a cutoff point. Around 9:45 a.m., one of the office staff brought out an orange sign saying the clinic was full and could not accept any more patients that day. Even so, still more patients arrived including Thanh and Mia Tran, a couple who brought their preschool child. Trying to get to the line and they just closed. How do you feel about that?

Very bad. And it took us two hours to get here and now it's closed. Do you live in Toronto? In Woodbridge. It's a long way. Yeah. Who's supposed to see the dermatologist? This girl. Is she your daughter? Yes. Ivanka. Ivanka? Yeah. How old are you, Ivanka? She's shy. She's three years old. She's the oldest. Does she have a skin rash? Yes. You're missing work this morning. Yeah, both of us. Both of you are missing work and she'd be going to daycare? Yeah. That's inconvenient. Yeah.

How did you know to come here to the clinic? Oh, we got the referral from the hospital. From the hospital? From the emergency department? Yeah. So you haven't spoken to anybody yet? No, they just put a sign right there. You can see the sign. If you come back here at 6 o'clock in the morning, then you'll get seen, you know, within a couple of hours. We have to wake up around 3? What do you think of that? It's not fun. She's been for three weeks and she couldn't sleep at night. Very itchy. Like the eczema. So maybe you'll come back?

I have to. There's no way. Or if you have any better ideas, just tell me. It was over 30 years ago that Clifford Olson first called me. Secret phone calls from Canada's most notorious serial killer. I knew I was killing the children, but I couldn't stop myself. Now it's time to unearth the tapes. Because I believe there are still answers to be found.

I'm Arlene Bynum from CBC's Uncover. Calls from a killer. Available now. You're listening to White Coat Blackheart. This week, we're visiting one of the most unique clinics I've ever seen. One of few where, if you're prepared to line up very early...

you can get a same-day appointment with a dermatologist. AvantDerm has been operating for 13 years, but demand is skyrocketing amidst a crisis-level dearth of dermatologists. Just ask the doctor who runs the place. Did you have lunch or breakfast? No breakfast, but I did have lunch, a little bit, yeah.

That was a long time ago. Yeah, it was. 13 hours since Dr. Devendra Singh and a colleague started seeing patients earlier today. Hi, my name is Devendra Singh. I'm a dermatologist in Toronto. I also go up to Timmins to work. I'm the visiting dermatologist there. Before I did this, I used to be a family doctor and a merge doc in Iroquois Falls, which is near Timmins. And then I went back to do a residency in dermatology at the University of Toronto. And since then, I've opened this clinic.

So we were here at 6 a.m. It's been 13 hours, almost 13 hours since you started working. Was this an average day? This is an average day, yes. In fact, this was a little quieter than usual because I had an extra dermatologist working with me. How many patients did you see? Can you estimate? Probably around 130, including the phone calls.

And that's a mixture of the walk-ins and the people who had appointments. Yes. We try to see as many as we can, but when we get to our limit, we just have to shut it off. It must be hard for you. It's terribly difficult because we're here trying to help people. And turning them away, especially if they've been waiting for a long time or if they woke up early, it doesn't feel great. I met somebody about the second person in line who came all the way from Belleville. How typical is that?

Oh, that's extremely typical. So I'd say about 20% of the people we see are from Kitchener-Waterloo because the wait list to see a dermatologist is about 18 months. It might be up to 24 months now. So we'll see people from all over the province, not just from Toronto. We're coast to coast. We've had someone flying from Vancouver. Yes, we have. Yeah, from Vancouver. And we had someone just last week from Newfoundland. Yeah.

What kinds of problems are they coming in with? Everybody that's in that line is there because they feel their problem is important, it's urgent, and there's often a lot of anxiety surrounding it.

We see pretty much everything. It can range from skin cancer, melanoma, to severe inflammatory skin diseases. It could be psoriasis. It could be eczema. It could be drug reactions. It could be id reactions, all sorts of things. And then it could be acne. It could be warts. Many people just need reassurance. It could just be a pigmented lesion. It could be skin tags. We see it all.

That's things from your point of view. Let's turn to the patients themselves. How desperate are they when they come in? The one that made the biggest impact on me was when we first opened. And at that point, you know, we might have been seeing 10, 20 people a day kind of thing. And there was a person that came in and he had a pigmented lesion on the bottom of his foot.

And I just took one look at it. And dermatology is all pattern recognition. So I took one look at it and I said, listen, that's just blood under your foot. So I took my scalpel blade and I just paired it off and I showed him. And he started crying. And I'm like, okay, so this took me aback. I'm like, okay, what's going on here? So then I asked him and he said, you know what, I'm from Ottawa. I had an appointment in six months. I thought this was melanoma. And I was just thinking that I'm dying for six months. And then I found out about your clinic. I drove all the way from Ottawa. You just told me that and it was just like a release. So, you know, that really hit me.

You said you started seeing 10, 12 patients a day, and now you're up to 100. So what the heck happened in between? Well, I think there's two problems. I coined this, I'm coining this a dermatology crisis for acute care dermatology. And in a way, it's like the perfect squeeze. And the squeeze is between demand and supply. So if we talk about demand first, if we just look at Ontario, you know, our population increases by probably a million every year.

Primary care, family doctors, they're in a world of hurt right now. Overburdened with administrative work. That's taking away from their time to actually see patients. We're getting referrals from family doctors, nurse practitioners, physician assistants, emergency rooms, walk-in clinics.

If you look at those groups, the quality of the referrals gone down quite a bit as well, because sometimes patients aren't being seen, they're seen virtually. So a lot of this stuff that I feel used to be managed at primary care level and should be managed at the primary care level, like simple acne or a wart or a skin, you know, it's getting sent to us. The fastest way to get someone out of your emergency room, just refer them to here, especially if we're open the next day. So we're getting, you know, bombarded by referrals.

And then on the flip side, the supply is a problem. So here we are as dermatologists trying our best. And, you know, if you look at the statistics, there's only 250 of us in Ontario. If you look at the average age, so 47% of dermatologists are over 55. I'm 53, so I'm getting to that number too. They're looking to retire. There's a problem with how many dermatologists we train. Like we train basically five in Toronto and two in Ottawa, seven in all the province that stay in Ontario if they choose to stay.

That's not enough. And the newer dermatologists have a tendency to focus or be interested in cosmetic dermatology.

So the thought of doing medical dermatology is just not attractive to them anymore. And I think that's a big problem. And there aren't any places aside from this that are doing like acute care medical dermatology. Obviously, you see the lineup. There's a huge need for that. And you must shake your head every morning. They come in at 6 o'clock. Some of them come in before 6 a.m. I've never seen anything like it. Yeah, they used to line up like around 7.30. Now they line up at 5.30. We'll have people sleep overnight. And they wake up again in line. And sometimes they're not even first in line.

Yeah, it is. It's mind-boggling to see what's happening. I think it's a marker of a healthcare crisis. Do you have any idea how to fix it? Certainly, I think we need to make medical dermatology more attractive to the graduating dermatologists, somehow.

I think we need to graduate more dermatologists. And then we have to think about how do we help manage these patients at the primary care level. We have to start educating the, you know, referring providers in a better way. We need, like, health care policymakers. We need advocates. We need people at all levels of government to sit down and try to figure out how to solve this problem. How long can you keep doing this? I question that myself. Like, it's...

We talk about physician well-being and burnout. I think I passed that years ago, right? I don't know what keeps driving me, but I just keep doing this. But I don't think I can do it forever. So if I can't get help to do this, I think it would be a shame if I had to shut down the rapid access clinic. It would really hurt to do that. But I'm no good to anyone if I'm not healthy. You're obviously patient-centered. What do you think is at stake for patients if a place like this isn't open?

I think it's going to add to a lot of patient anxiety and worry and perhaps mental health issues if they have to sit there with skin disease that may not even be serious, but it's serious to them. I think we're going to certainly overburden walk-in clinics and emergency rooms, and they're not going to have a place to go. And I think that's going to filter down to the family docs because they'll take their frustration out on their primary care providers.

I just think it's going to make the whole system worse. And these aren't just inconveniences. How many melanomas do you think you've taken off here where you cured them and you wondered where they would have gone had no one looked at that melanoma and taken it off? It's hard to guess, but I think thousands, honestly. We've been doing this for 13 years. Yeah, it's almost like every day there's something. And a lot of those people are alive today because of you.

I don't think of it that way, but I'm just doing my part. But if we catch melanomas early, we're certainly making an impact on survival. Thank you for speaking with me. Oh, you're very welcome. Thank you.

Since this episode aired in October 2023, we went back to the Ontario Ministry of Health to ask how they're addressing the lack of dermatologists Dr. Singh talked about. A spokesperson said the government is adding hundreds of undergraduate and medical seats across the province with 40% of new residency seats specifically for specialties such as dermatology. They also said that last year, all of Ontario's medical residency spots were filled, including dermatology.

Tell that to the parents we met who arrived after the cutoff time. Or to Dr. Singh, whose walk-in derm clinic is hanging on by a thread. That's our show this week. This edition of White Coat Black Art was produced by senior producer Colleen Ross, with help from Jennifer Warren and Stephanie Dubois. Our digital producer is Ruby Buiza, and our digital writer is Jason Vermesh. I'm Brian Goldman, and I'm proud to bring you stories from the Canadian side of the gurney. Have a safe and happy holiday weekend. See you next week.

For more CBC Podcasts, go to cbc.ca slash podcasts.