Skin Cancer Report


You found an iffy mole. It might be cancerous–and could become deadly within weeks. Yet the dermatologist will not see you now, or possibly even for months. As melanoma rates skyrocket, a shocking derm shortage is putting millions of women’s lives at risk. But what’s more frightening, sinister even, is the underlying cause, one that’s being prioritized over your health: money.

By Melinda Wenner Moyer

A single black dot on her right breast, the size of the tip of a Sharpie marker. That’s what Amanda Greene noticed as she was getting out of the shower one morning in 2010. “I was standing about five feet away from the mirror and I thought, That’s weird—I don’t remember that being there before,” she recalls. Amanda, then 24, a radio host and producer in Pittston, Pennsylvania, had never had any skin problems. “It didn’t scare me or anything. I just went on with my life.”

But the mark grew bigger. Darker. So at her annual gyno checkup, Amanda showed it to her doctor, who insisted she see a dermatologist right away. Yet when she called a local derm’s office, explaining that her gynecologist recommended she be seen immediately for a changing mole, she was told that the first open appointment was in two months. Surely, if the problem were urgent, she thought, the derm would have squeezed her in.

That wasn’t the case. When Amanda finally saw the dermatologist, he biopsied her mole and diagnosed her with melanoma—the most serious form of skin cancer—scheduling her for surgery that very week. The doctor told Amanda that her cancer had already spread to two nearby lymph nodes, requiring a harder, and more invasive, operation, with more potential for recurrence. Though the surgeon was able to remove the cancer along with the affected lymph nodes, what can’t be erased are these shocking facts: Melanoma is the third leading cause of cancer death among women ages 25 to 39, and fast-growing types can become deadly in as little as several weeks. Getting an appointment quickly can be the difference between life and “there’s nothing we can do.”

Even though studies show the odds of a suspect mole being melanoma are quite low, if you do have melanoma, catching it early, stopping its spread, and getting treated right away is your best chance at survival. Had Amanda been seen even a month sooner, the cancer could have been removed before it reached her lymph nodes and threatened her life. The problem extends far beyond one dermatology office in northeastern Pennsylvania. Millions of Americans are being given months-long dermatologist wait times because of a critical shortage of skin doctors. There’s a national dearth of M.D.s in general, but the derm problem is particularly alarming: The U.S. has about 55,000 practicing pediatricians, 40,000 gynecologists, 38,000 psychiatrists—and a mere 10,845 dermatologists. Yet according to the American Academy of Dermatology (AAD), the country needs 22,000 dermatologists in order to treat everyone with skin issues in an appropriate amount of time.

A study published in February in the journal JAMA Dermatology explored this further. The report found that among areas of the country with at least one derm, three-quarters have fewer than four for every 100,000 people, the number needed for adequate care. What the text didn’t delve into were places with no derms at all. Only by combining the papers’ stats with our own research, then crunching the numbers, did Women’s Health unearth a more distressing statistic: One out of every five areas in the country has zero dermatologists.

If you’re in a big city, chances are there’s a derm near you. But many women in rural locations and medium-size towns alike are living in what WH has termed a “derm desert,” an area without a single dermatologist within 50 or even 100 miles, or one with a menacingly low number of these docs for the population.

And this is the fatal crux: Areas with fewer derms have more melanoma deaths. That’s a double whammy for women, because since the 1970s, melanoma rates among females ages 18 to 39 have skyrocketed by an astounding 800 percent.

So why are there so few skin doctors when there’s such a consequential need? In our six-month investigation, WH uncovered land mines within the health-care system, hospital community, and insurance companies, which we lay out on these pages. Our goal in exposing the many sides of the crisis is, ultimately, to help you protect your health. We hope it’s a start in changing a broken system that is blocking lifesaving care when you need it most.

Inside A WH Investigation

What started as a casual conversation with a family member turned into an examination involving 50 studies, dozens of derms, and thousands of calls and e-mails to uncover and corroborate facts.

1. In late fall of 2016, WH beauty director Maura Lynch learned her mother had to wait more than three months for the earliest appointment with her dermatologist in suburban Philadelphia. Around that time, another editor visited a pop-up skin clinic in an underserved community on a press trip with a beauty company. They brought up the issue to WH’s editor-in-chief, who wondered how widespread this shortage was and whether there was a correlation between melanoma rates and derm saturation. In January 2017, WH senior deputy editor Marina Khidekel began digging deeper.

2. Khidekel had already found statistics showing a national dearth of derms when, in February, the journal JAMA Dermatology released a report from a group of NYC dermatologists. They had analyzed the AAD’s national database, which lists virtually all practicing American derms, and cross-referenced that with U.S. Census population data to come up with the number of derms in each “section” of the country (as determined by a three-digit zip code). The study authors wrote: “Of the 712 section codes containing at least one dermatologist, 515 (72.3 percent) had fewer than four dermatologists per 100,000 persons.” Their findings included a top 10 list of what they referred to as the “least dermatologist-dense areas” in the U.S. But even in the number one (i.e., worst) area, the lowest number of derms was one. None of the listed areas had zero dermatologists.

3. This was perplexing, since in the report’s color map showing derm density, there were areas—represented as white splotches—indicating places with no derms (the only reference to those zero areas in the paper). We wondered: How many cities and towns had zero derms, which cities and towns were they, and why hadn’t they made the “least dermatologist-dense areas” list? When our writer, Melinda Wenner Moyer, reached out to the study’s lead author, he said those areas were too difficult to rank because it was hard to assess if there was a derm in an adjacent area—so he focused on areas that had at least one dermatologist instead. Then he referred us to the AAD.

4. WH asked the AAD for access to its raw data so we could pinpoint which specific cities were in the white areas. The organization told us this information was proprietary and pointed us to their online “Find a Dermatologist” tool. Following the JAMA Dermatology authors’ methodology, Moyer researched how many three-digit section codes there are total in the U.S.: 933 (a number she confirmed with the USPS). That means that if 712 areas—the number from the JAMA papers—have at least one derm, then 221 of the total 933 areas (23.7 percent) don’t have a single dermatologist. We located cities in the white areas with Google maps, then used the AAD’s tool to locate the closest derms—and found that in many places, the nearest one is nearly 100 miles away. Later, we’d learn that some of those practices were no longer even in business.

5. We kept reporting, which led us to truths about the derm shortage involving insurance money, hospital preferences, and something called “narrow networks”—plus what’s currently being done to deal with the problem.

Mapping Out the Problem

The worst derm deserts—where it’s impossible for many women to get even emergency skin care—are in rural areas, but in some cities, there aren’t enough derms to accommodate the large population. Urban derms are often affiliated with universities, splitting their days between patients and research, so wait times in cities and small towns are often almost the same, per a 2009 study. We plotted out specifics for a few of the deserts.*

Gallup, NM

Population: 22,469

Nearest derm: 111 miles away in Farmington, NM

Woodward, Oklahoma

Population: 12,963

Nearest derm: 76.5 miles away in Elk City, OK

La Grande, Oregon

Population: 13,026

Nearest derm: 84 miles away in Walla Walla, WA

Camden, Arkansas

Population: 11,569

Nearest derm: 84.6 miles away in Hot Springs, AR

Miles City, Montana

Population: 8,758

Nearest derm: 144 miles away in Billings, MT

Demopolis, Alabama

Population: 7,182

Nearest derm: 59 miles away in Sheridan, MS

El Paso, Texas

Population: 679,000

Though the city has 10 dermatologists, according to the four-derms-per-100,000-people rule, they should have nearly three times that many.

Jamaica, Queens, New York

Population: 217,000

One of the worst urban derm deserts in the U.S., Jamaica is a populous community in the NYC borough of Queens, and it has just two dermatologists. One of them is Jeffrey Weinberg, M.D., who opened up his office three years ago after hearing about the shortage from Jamaica residents he saw at his Manhattan office (an hour’s subway ride away). “A lot of them were waiting months,” he says. “The Jamaica office is now my busiest.” 


Population: 3 million

The entire state has only 22 derms—and claims the highest melanoma death rate in the country. To treat everyone there, they’d need 120 derms.

*All information current as of press time

Steep obstacles to lifesaving skin care: a bleak reality for millions

Why Can’t I Get an Appointment?

It’s not because dermatology is undesirable as a profession. The average income is $381,000—more than even anesthesiologists and emergency medicine docs make—and in a 2013 study ranking the desirability of 18 specialties, students placed dermatology number one in terms of “best lifestyle.” What’s really amiss?

More people need derms than ever before.

People are living longer. Skin conditions that once bore terminal diagnoses are now treatable. Both good things, but they’ve also contributed to the crisis. Sixty-eight percent of dermatology patients are 40 years old or older. Approximately 87,110 cases of invasive melanoma will be diagnosed in 2017 alone, and more new cases of skin cancer are detected every year than cases of breast, prostate, lung, and colon cancers combined. All that leaves patients jockeying for space on an already congested schedule. “It requires more output from physicians to treat a patient over a longer period, and [this field wasn’t] built for that war from a labor standpoint,” says Travis Singleton, senior vice president of physician recruitment firm Merritt Hawkins.

Hospital residency programs may keep derms away.

Aspiring derms face a hurdle: There aren’t enough training programs for them. In 2016, of the nearly 31,000 total residency spots available to graduating medical students in the U.S., only 420 were in dermatology (the top residency was internal medicine, which had 7,024 positions, followed by family medicine with 3,238 and pediatrics with 2,689).

Granted, all training programs at teaching hospitals are vulnerable because they depend largely on support from Medicare. “That funding stream for medical education has not seen meaningful growth in about two decades and, in fact, is often under threat,” says Jack Resneck, Jr., M.D., vice chair of the University of California at San Francisco (UCSF) department of dermatology and a health policy expert.

But hospitals do get to choose how much of the Medicare money they allocate to each specialty. And it’s not in a hospital’s best interest to bring on tons of would-be derms for training, because “dermatologists don’t admit many patients for hospital stays and don’t order a lot of expensive tests like CT scans,” says Cincinnati dermatologist Brett Coldiron, M.D., who served as president of the AAD in 2014 and 2015. In other words, derm residents don’t generate much revenue for hospitals, Coldiron says. A 2014 report published by the National Academy of Sciences—a nonprofit organization that advises the government on scientific issues—concluded that the financial benefit to hospitals of having on-call dermatology residents is “minimal,” while surgery residents provide considerable revenue. (The American Hospital Association and the American Association of Medical Colleges declined to comment about the issue for this story.)

Some insurance companies don’t want to pay dermatologists.

The irony: Derms don’t rack up enough bills for hospitals, but they rack up too many for insurance networks, way more than GPs do. And insurers, of course, have to reimburse those bills. So some insurance companies decide that “if they block a little bit of access to care by limiting the number of dermatologists on their plans, they’ll collect premiums from people but not have to pay out doctors, and they will see less loss,” explains NYC dermatologist Deborah Sarnoff, M.D., president of the nonprofit Skin Cancer Foundation. This results in “narrow networks,” in which fewer patients get care.

Another tangle in the web? Physicians’ contracts “are being terminated without cause,” according to a 2014 UCSF study. Trade publications, like Dermatology Times, have noted that the most expensive dermatologists—the Mohs surgeons—are frequently dropped from insurance networks. (Mohs surgery is the standard and most effective way to remove basal cell and squamous cell carcinomas—the two most common types of skin cancer­—and is increasingly used to treat melanoma.)

Resneck, too, is “concerned that some insurers may be removing those dermatologists from their networks who take care of the sickest or most vulnerable patients with the highest needs—and thus the highest costs—potentially driving those patients to select another insurer.” Coldiron, who has lobbied Congress about insurance issues, has seen this firsthand. “One insurance company went into a major city and said, ‘We’ll delist the 50 most expensive doctors,’” he says. “And the thing is, the delisted doctors generally perform more procedures. So they’ll delist the Mohs surgeons, or [those who see] the toughest psoriasis patients and prescribe expensive drugs.”

The American Academy of Dermatology Association (AADA)—the AAD’s sister organization that focuses on government affairs, health policy, and practice information—has been lobbying Congress since early 2014, when it says its members began receiving network termination notices. In a 2014 position statement, it made its stance clear: “The AADA is opposed to the practice in which health insurers reduce the size of their provider networks (i.e., engage in ‘network narrowing’) based on metrics related to cost.”

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More than half of U.S. states have created laws aimed at improving networks. In 2015, California passed the most comprehensive of the bunch, a statute that increases state oversight of insurance networks’ adequacy. But it’s not a federal solution. “We need some sort of minimum regulatory standard for ensuring that patients have access to the providers they need,” says Kevin Lucia, project director at Georgetown University’s Health Policy Institute.

WH reached out to America’s Health Insurance Plans (AHIP), the trade group that represents health insurance companies, for comment. Spokesperson Cathryn Donaldson denied the claim that insurers purposely remove dermatologists and pointed out that some derms themselves narrow the networks by choosing not to participate in plans. When asked why certain derms, including Mohs surgeons, have been dropped from plans seemingly without reason, she said, “Specific network configurations—including specialists in or out of network—will depend on the insurer, the plan, the region, and local market dynamics.”

The doctors in your insurance network may not even exist.

It’s smoke and mirrors: Some insurance companies continue to list the names of doctors who have retired, relocated, or died to make their networks look larger than they really are. According to the 2014 UCSF study, which investigated the accuracy of insurance plans’ dermatologist directories, only one out of four dermatologists listed as in-network in a popular nationwide health-care plan actually existed, accepted that plan, and offered appointments to new patients. Some had moved away or retired, some were duplicate listings, and others were totally mysterious—the researchers would call the phone number and a receptionist would answer and say they’d never heard of that doctor.

AHIP’s Donaldson acknowledges inaccurate physician directories are an issue, but says it’s unintentional and that her organization is taking steps to solve the problem, including by finding better ways to communicate with physicians to get updates. “Health plans depend on doctors to submit accurate and up-to-date information on details like provider and facility names, addresses, telephone numbers, and languages spoken. And it is critical that doctors reach out to health plans when their information changes and that health plans make the updates in a timely manner,” she says. The UCSF study noted another reason insurance companies give for erroneous listings: “last-minute changes to federal health-care plans.”

Yet multiple dermatologists we spoke to said on the record that they believe these mistakes on insurance networks’ lists are purposeful. Coldiron called the companies’ tactics “insidious”; W. Patrick Davey, M.D., a clinical professor of dermatology at the University of Kentucky in Lexington, used the word “deceptive.” Resneck lamented that at the same time insurers are terminating derms from their networks, they’re also “keeping bloated, inaccurate rosters.” Sarnoff minced no words: “It’s all about saving money. [Insurance companies] use [doctors’] names to entice the patients to sign on and purchase the policy but don’t keep [doctor lists] up to date.” And though medical trade magazines have covered the issue, “it’s not publicized enough for people to understand what’s going on,” Sarnoff says.

Cosmetic patients get choice appointments.

Patients with a possible melanoma wait more than three times as long for an appointment as those looking for younger-looking skin. So says a 2007 UCSF study in which researchers posing as patients called almost 900 dermatologists around the country. When they said they wanted wrinkle injections, they were given appointments within eight days—as opposed to an average of 26 days when they called complaining of a changing mole that fit the description of a melanoma.

And the appetite for cosmetic procedures has exploded. According to the American Society of Plastic Surgeons, facial injections have jumped 7,000 percent (not a typo) between 1997 and 2016. More pointedly: During the past few years, as injection rates have increased by 10 percent, Americans are waiting a very similar 12 percent longer for derm appointments, according to doctor recruitment firm Merritt Hawkins.

The issue isn’t the cosmetic treatments or injections themselves. It’s the old law of supply and demand—more people want cosmetic appointments, more people need medical appointments, and there just aren’t enough doctors to go around. Some experts point to money as a motive.

“Dermatologists may want to selectively improve access for these patients because of higher relative payments for cosmetic services,” the UCSF study authors write. As Bobby Buka, M.D., a New York City dermatologist, explains, “with cosmetic patients, dermatologists get paid up front by the patient directly, as opposed to medical visits, which involve insurance companies. The average time for a dermatologist to collect from insurance companies is 34 days, and oftentimes it can be a challenge to collect at all.”

There is a faction of derms who don’t think cosmetic appointments influence medical wait times at all. “I truly don’t believe that’s a reason,” says Sarnoff. “For the vast majority of derms doing cosmetic [work], it would be 10 percent or less of their practice. It’s important to note that [the UCSF research] is just one study and over a decade old.” But seven derms around the country—several of whom practice in or near deserts—told WHH that some dermatologists do prioritize cosmetic appointments over medical ones, and that most derms who offer cosmetic treatments now block off specific appointment slots for cosmetic versus medical patients. “Especially in slower economic times,” says Flint, Michigan, dermatologist Bishr Al Dabagh, M.D., “to stay competitive in cosmetics, a dermatologist must schedule a sooner appointment or risk losing that patient to a medi-spa or another practice.” (Al Dabagh himself does not offer cosmetic services.)

One dermatologist, who practices in the Northeast and asked to remain anonymous, noted that many derms are proactively trying to grow the cosmetic aspect of their practice even as medical appointments cannot be accommodated. One potential reason? “Many dermatologists can’t stay in business because they can’t manage all the government and health-insurance mandates. It’s become very cumbersome—the amount of things we have to report and document and follow,” says New York City dermatologist Doris Day, M.D. “Many dermatologists may need the aesthetic side to cover the medical side.” To wit, there’s almost a $100,000 difference in pay for doctors who do cosmetic procedures and those who don’t, “so it’s hard to blame them,” says Singleton of Merritt Hawkins.

The Weight of the Wait


The average wait time in a midsize city to get an appointment with a derm for a skin exam to detect a suspected melanoma. The average for large cities is 32 days.

Average wait times in specific cities for a skin exam to detect a suspected melanoma:


The time frame in which melanoma should be diagnosed and treated after being noticed by a patient to ensure the best survival. A U.K. study found a 20 percent higher chance that a person will be alive five years later if a melanoma is caught in this window.


How long 20 percent of Medicare patients with melanoma had to wait to get their melanoma removed, according to a 2015 study published in JAMA Dermatology. Eight percent had to wait more than three months.

Snapshot of a Derm Desert

Yes, There’s Some Good News

Five glimmers of hope for better skin care

Primary-care docs are getting dermatology training.

Continuing-ed classes in dermatology are drawing GPs in droves. Exhibit A: The dermatology course at the National Procedures Institute, an organization that trains GPs around then world in specialist medicine, “sells out at all of our Continuing Medical Education conferences,” says its program specialist Heather Osborne. Ask your primary-care doc about her training, but if she prefers that you see a dermatologist, she can provide an urgent referral to help secure a faster appointment.

Another training program that’s helping? Project ECHO. Since the first Project ECHO hub specializing in dermatology started in Columbia, Missouri, in 2015, GPs “have already found three early melanomas, so that’s three lives saved,” says dermatologist Edison, the Missouri hub’s team leader. One limitation: The doctors who have participated in Project ECHO can diagnose and treat many skin conditions, though the program doesn’t train docs in how to remove melanomas.

Teledermatology is on the rise.

With one new approach called “live interactive teledermatology,” patients stop in at a local hospital or community center, and the staff takes pictures of their affected skin and sends the photos (via a secure tablet app) to an off-site dermatologist. Minutes later, patients have a video-conference appointment with the derm. This approach won’t help everyone: These centers aren’t widespread, and if the doctor thinks you need a procedure, you still have to get an in-person appointment with a derm. It’s also hard to accurately diagnose skin issues this way, says dermatologist Davey, and not all telederm skin docs are board-certified by the AAD. Still, many derms say that this technology can help get skin care to people who need it. To find out if there is a teledermatology service near you, call your local hospital or community center.

More nurse practitioners and physicians’ assistants could cut down on wait times.

Between 2002 and 2008, derms made a 43 percent increase in these hires. “We have a nurse practitioner who handles more common things, and that leaves the doctors more available for the medical dermatology patients who really need our care,” Edison says. Generally, these nonphysician providers work closely with the doctors, ensuring they make the right diagnoses and treatment choices. That said, if you’re seeing an NP or PA and you’re not sure you’re getting the best care, “ask for a supervising physician in the practice to take a look,” says Kimball. (Because nonphysician providers do sometimes need a doctor’s assistance, avoid clinics that don’t have medical doctors on staff—because they can still call themselves “dermatology clinics” even without a single M.D.)

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A new bill could help.

In May 2017, Joseph Crowley (D-NY) and Ryan Costello (R-PA) introduced a bipartisan bill that would raise the number of overall medical residency positions by 3,000 each year between 2019 and 2023. (Bills have been introduced into Congress every year since 2009 to do this, but none have ever passed.) To help push through this attempt, call your U.S. representative (visit to find their contact info), give your name, and tell your rep you hope that he or she will support the Resident Physician Shortage Reduction Act because you’re worried about doctor—particularly dermatologist—shortages.

More nurse practitioners and physicians’ assistants could cut down on wait times.

Between 2002 and 2008, derms made a 43 percent increase in these hires. “We have a nurse practitioner who handles more common things, and that leaves the doctors more available for the medical dermatology patients who really need our care,” Edison says. Generally, these nonphysician providers work closely with the doctors, ensuring they make the right diagnoses and treatment choices. That said, if you’re seeing an NP or PA and you’re not sure you’re getting the best care, “ask for a supervising physician in the practice to take a look,” says Kimball. (Because nonphysician providers do sometimes need a doctor’s assistance, avoid clinics that don’t have medical doctors on staff—because they can still call themselves “dermatology clinics” even without a single M.D.)

Skin clinics are popping up.

Dozens of hospitals have opened urgent-care clinics for those worried about suspicious moles. The Cleveland Clinic has Growth of Concern and the University of Missouri in Columbia has What’s That Spot? Several organizations also sponsor traveling skin-cancer screening programs, where derms volunteer to check patients at no cost. Look for one near you: AAD’s SPOTme; The Skin Cancer Foundation’s Destination Healthy Skin; The Melanoma Research Foundation’s Mark the Spot!.

EXACTLY What to Say When You Call a Derm

We’ve established in this story that you’re up against tremendous barriers in getting an appointment, so when you call, every word matters. Rather than asking for a skin check, be specific and say to the receptionist: “I have a mole that’s changing/bleeding and I’m afraid that it’s melanoma.” This makes a big difference in how quickly you are seen. If that doesn’t work, demand to speak with a doctor or nurse. Still nothing? Offer to send a photo of your mark via e-mail.

These Derms WILL See You Now

WH enlisted dermatologists in or near deserts around the country to open their doors a little bit wider in an effort to help women who are desperate for care. The following M.D.s have pledged that if a reader calls their office worried about a suspicious mole during the time this issue is on newsstands—between August 8 and September 11—and mentions this article, they will see that patient (provided their insurance plans match or the patient pays outright) within two weeks to a month of receiving the call.

  • Bishr Al Dabagh (Flint, MI). 810-733-6050
  • Jeffrey Brackeen (Lubbock, TX). 806-701-5844
  • Jennifer Caudill (Clarkston, MI). 248-623-9700
  • Lisa Chipps (Encino, CA). 310-274-5372
  • Cathy Cole-Perez (Camp Wood, TX). 877-993-7549
  • W. Patrick Davey (Lexington, KY). 859-278-9492
  • Joshua L. Fox (Fresh Meadows, Queens, NY). 718-357-8200
  • Allison Jones, Emily Jones, and Sarah Smith (Memphis, TN). 901-866-8805
  • Sancy Leachman (Portland, OR). 503-418-3376
  • Garrett Lowe (Provo, UT). 801-354-7905
  • John Macke (Dayton, OH). 937-433-7536
  • Justin J. Marone (Owosso, MI). 989-725-8436
  • Letty Peterson (Vidalia, GA).912-538-9080
  • Amber Robbins (Sheridan, WY). 307-672-8941
  • John Roth and Clifton Smith (Lexington, London, and Richmond, KY). 859-276-1511
  • Eileen P. Smith (Walla Walla, WA). 509-525-9404
  • Jeffrey Weinberg (Jamaica, Queens, NY). 718-459-0900
  • Joshua Zeichner (New York, NY). 212-241-9728

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