As applications open for the next admissions to the Registrar of Dermatology, it is expected that medical students will try to land one of the 20-25 positions offered by the Australasian College of Dermatologists (ACD) across the country. With two in three Australians experiencing skin cancer at some point in their lives, those lucky enough to be accepted into the program will be conducting a significant public service to their patients for decades to come. Of course, assuming those patients live in a big city.
In almost all cases, as the distance between you and a larger city increases, the quality of your health care decreases. Compared to people living in major cities, rural residents are six times more likely to report not having a GP and almost ten times more likely to report not having a specialist nearby. A major area of study here concerns hospitalization for preventable diseases, with farsightedness being the best predictor of suffering in almost all cases.
Dermatology in particular deserves criticism because the conditions afflicting rural communities are incredibly dangerous, yet eminently treatable. For example, remote Aboriginal communities suffer the most from skin lesions worldwide, and when left untreated, they can progress to complications such as kidney failure or rheumatic heart disease, and can often be fatal. Huh. Scabies, an itchy and contagious rash that causes skin lesions, is found in 35% of children and 25% of adults in far northern Australia. If the patient is given proper treatment, then it can also be cured within two weeks. However, in many cases, Australians living in remote and rural areas are not able to access it.
The root cause of this is the relative concentration of dermatologists in urban areas. In Australia in 2021, only six out of 591 accredited dermatologists worked permanently in rural areas. Meanwhile, in Bondi Junction, nine dermatologists are working from the same building.
On March 6, the Grattan Institute released a report on healthcare spending, listing dermatology as a specialty of particular concern. This is because the structure of the Australian medical system effectively rewards dermatologists for going to lucrative private practices in major urban centres.
The report found that more than 60% of dermatologists charge more than double the $90 schedule fee. In Sydney, consultation costs regularly exceed three times the schedule fee. Of the 20 practices I contacted, the cheapest appointment was $240, the most expensive was $331, and the average was $290.
Of course, Australian citizens can access the public health system, but there is a waiting time of up to 600 days for those seeking regular first appointments. With government messages suggesting skin screenings every year, people at risk of skin cancer are essentially forced to switch to the private system. Likewise there are psoriasis (2.3-6.6% of Australians), severe cystic acne (~5%) and eczema (10-15%), for which effective treatment can only be legally prescribed by a dermatologist. Such skin diseases can be incurable and debilitating without lifelong treatment, leaving patients with no choice but to reluctantly bear the cost of private practice.
Underscoring the issues of unequal access and inflated prices is a more sinister social trend. In urban centers such as Sydney, dermatologists tend to focus more of their attention on less-serious cosmetic issues than the more debilitating ailments suffered by rural residents. While this thesis is difficult to maintain with anecdotal data, a survey of dermatologist clinic websites in rich areas is telling. As one of many examples, Complete Dermatology at Bondi devotes an entire section of its website to cosmetic treatments such as botox, face lifts, and anti-aging treatments. When compared to the struggle of rural residents to access specialist services for curable diseases, this focus on superficial cosmetic treatments appears to be in vain. As a public good, dermatologists like Bondi may be better served to help out in remote areas.
The problem is that for doctors who are more interested in profit than community service, dermatology has been corrupted by the marketing divisions of skin care companies with the intention of defining skin health as an aesthetic decision. , not skin that is disease free.
One such indicator that indicates increasing attention to aesthetic dermatology is the rise of cosmeceutical specialists. Cosmeceuticals are therapeutic products that are intended to have a beneficial effect on skin health and beauty, but their effectiveness is contested because they are unregulated. Across Australia, there are three times as many dermatologists interested in cosmeceuticals as there are in rural outreach clinics (use the “filter by specialty” tool to see for yourself).
A leading Australian dermatologist sells his own line of cosmeceutical products, which are advertised as ‘skin care backed by science’. One of her products — reportedly designed for skin care and acne treatment — is available on her website for $315. For a similar price, one can consult a dermatologist, get a prescription for isotretinoin (the most effective acne treatment) and pick it up from their local pharmacy. I hope this doctor never specifically recommends his products to his patients, as this may violate Section 3 of the ACD Professional Code of Conduct – “Clinical Judgment Not Affected by Personal Benefit” will be”.
Dermatology is not necessarily unique in that the concentration of wealth in urban centers is leaving rural residents without essential medical services. In fact, parallels can be drawn to the development of cosmetic surgery—another potentially lucrative industry that turns medical professionals away from doing the public good.
ACD is aware of unequal access to dermatologists, and has made changes in the hopes of revising training program selection criteria.
According to its website, ACD “encourages applicants who wish to practice in rural and regional areas to apply”. It also advertises routes for Aboriginal and Torres Strait Islander people to join the training program, although at the time of publication, the link to this route does not work.
Sydney medical student Daniel* feels that the current incentives for rural medical placements just don’t work for dermatology specialists. “Skin is different because it is not a hospital thing. There is a lot of demand for dermatologists, so patients will only come to you. The only people interested in working in rural areas are those who were born there,” he said.
As long as monetary incentives remain near urban centres, cosmetic and surgical procedures remain in place, it is difficult to imagine the disparity that dermatology will reduce in the near future. In its current form, the dermatological specialty is a blot on the Australian medical system.
*Note: Names have been changed.