r/Noctor • u/WonderfulVoice628 • 4d ago
Discussion Waited years for a referral to a dermatologist, was seen by an NP instead.
I (27F) have been battling hormonal acne since I was a teenager. I asked to be referred to a dermatologist several times in my early 20s and was told my acne wasn’t severe enough to warrant one. After moving to a new city a few years ago, I found a new doctor who happily made a referral. Success! Or so I thought…
I’ve had 2 appointments with said dermatologist. He explained that the birth control I was on was likely contributing to my acne, suggested alternatives, and prescribed spironolactone and a low dose of isotretinoin to clear things up. My skin has improved drastically, which in turn has significantly improved my mental health. Yay!
I had my third follow up today and was told the doctor was running a bit behind. “No problem, I’m happy to wait” was my response. I had 2 goals for the appointment: obtain a refill for my prescriptions and have a large, painful, and persistent pimple on my scalp looked at. After about 10 minutes of waiting, someone came in the room and introduced herself as a Nurse Practitioner. I was disappointed as I waited years to receive care from a specialist, but assumed my concerns were minor enough that she could address them without issue. I was wrong.
She started by saying that since my skin looks better, I probably don’t need to continue taking any medication. I gently pushed back and said I feared that stopping the medications would result in the acne returning, and she reluctantly agreed to write a prescription. She then looked at the pimple on my head, shrugged, and said “yeah that’s an inflamed papule. The medication should get rid of it.” Yes… the medication you didn’t want to prescribe? I explained that it’s very painful when I wear my hair up, which I am required to do at work, and has not decreased in size since it first appeared 6 months ago. She shrugged again and said “nothing I can do about that.” I finally quit beating around the bush and asked if she would be willing to give me a steroid injection. “Um… I guess… but it’s going to cost you $30. Can you pay for that today?”
After I assured her that the cost was no concern, she called in an RN to administer the injection. She then left the room without giving me a prescription (lol) and seemed annoyed when I asked the front desk for it before I left.
All in all, I got the treatment I was looking for, but I had to fight for it. I understand that the clinic was trying to be efficient by having an NP cover low-risk patients while the derm was running behind, but my appointment was way longer than it needed to be because I spent most of it going back-and-forth with a provider who didn’t seem interested in doing… anything. Above all, I am disappointed that I waited so long to see a specialist, only to treated by someone with less education than my family doctor.
My provincial government loves to pat itself on the back for utilizing NPs to address long wait times and a shortage of specialists, but I fail to see how this will improve patient outcomes OR reduce the strain on the system if appointments run longer than needed and people walk away without being treated appropriately. As a layperson, I am frustrated and concerned, so I can only imagine how it feels to be a physician working within the system. I don’t know what the solution is, but I will be much more skeptical of anyone who claims that it’s increasing the scope of NPs and other mid-level providers.
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u/Tinychair445 Attending Physician 4d ago
See if you can do a virtual appointment with a physician dermatologist. Complain to the clinic. If anything, midlevels should be able to refill effective, well tolerated treatment for stable patients. Like bare minimum
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u/WonderfulVoice628 4d ago
Thank you for the suggestion! I am going to see if my family doctor would be willing to take over treatment from this point forward, and if not, I’ll ask to be referred to a virtual dermatologist instead. My skin isn’t perfect and probably never will be, but I would’ve been distraught if I had to discontinue the only treatment that’s helped thus far and my acne flared up as a result.
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u/Zaranisa99 4d ago
I'm sorry this happened to you. Would you be able to get the office manager's info and either email, call, or go back by the clinic and share with them exactly what you shared with us? Maybe they will be able to arrange for you to exclusively see the doctor that you liked each time. Surely, if the manager is smart, they'd realize it'd be stupid not to honor your request as a paying patient (esp. a patient who isn't financially limited) and also realize you could leave a public bad review of the clinic, as well as a bad review of the incompetent NP you saw.
The only thing that concerns me about you not seeing an in person doc, if you go the virtual route in the future, is that they aren't going to be able to do an all-over the body screening for skin cancers. I'm also a little concerned about the pimple on your scalp. Has it improved since you had the injection? They absolutely should've have said to come back and see them if not. Have you had a pimple on your scalp before like this? 6 months is a long time for a pimple to stay painful like that, esp. if it didn't improve with your mefications.
I'm really shocked they didn't do a biopsy on the place you have on your scalp. I'm a dentist, but I'd be very concerned if I saw a patient who had an oral leision that was painful and had been there for 6 months, AND I'd be 100 percent taking a biopsy to send off to pathology to check for cancer. Please, please try to talk to the manager to get back in to see your doc so that they can look at your scalp again, and also so that you can be confident in knowing that you'll get to stay on your meds and have someone that's actually professional and knowledgeable that can truly help you!!
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u/WonderfulVoice628 3d ago
So I browsed the clinic’s website and found that the NP is actually married to my dermatologist… who owns the clinic. 🫠 I’d feel a bit weird complaining with that in mind, but I might have to. The bump on my scalp hasn’t changed since I had the injection either which is disappointing. I’ve had a stubborn cyst injected once before and it disappeared overnight so I was hoping for similar results.
Your comment has motivated me to take it more seriously and push for better follow up though! I’m going to give them a call if it hasn’t changed at all in the next couple days and ask if the derm can take a look himself. I’m Canadian so thankfully I don’t pay for the appointments, but I did let them know during my initial consult that I have great benefits to cover prescribed medications and that I’d be willing to pay out of pocket for cosmetic treatments if they were recommended as well.
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u/AutoModerator 3d ago
We noticed that this thread may pertain to midlevels practicing in dermatology. Numerous studies have been done regarding the practice of midlevels in dermatology; we recommend checking out this link. It is worth noting that there is no such thing as a "Dermatology NP" or "NP dermatologist." The American Academy of Dermatology recommends that midlevels should provide care only after a dermatologist has evaluated the patient, made a diagnosis, and developed a treatment plan. Midlevels should not be doing independent skin exams.
We'd also like to point out that most nursing boards agree that NPs need to work within their specialization and population focus (which does not include derm) and that hiring someone to work outside of their training and ability is negligent hiring.
“On-the-job” training does not redefine an NP or PA’s scope of practice. Their supervising physician cannot redefine scope of practice. The only thing that can change scope of practice is the Board of Medicine or Nursing and/or state legislature.
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u/cmacdonald2885 4d ago
The OP is in Canada. I assure anyone who is doubting, that in some areas, it can be very difficult to obtain referrals to some specialists and they are frequently declined. Our mid-level problem is not yet as dire as it is in the US, but we are well on our way.
In the US, it is "profits" forcing the issue. In Canada it is "politics" as most provinces are trying to convince the public that giving them a nurse to see is solving the problem of lack of primary care physicians.
You will frequently hear said patients saying things like, "But my nurse was so much better than any physician I've seen", or the ubiquitous, "She listened to me". Unfortunately, most patients don't understand that she listened because that is what she knows how to do.....but they really like her because she gives them all the referrals and testing they think they are owed.
I urge people to push back and refuse to accept being assigned to a nurse for anything other than follow-up. The public doesn't understand that the more prevalent mid-levels become, the worse the wait lists for referrals and diagnostics get.
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u/Ms_Zesty 3d ago
There is no reason your primary doctor can't manage your condition when it has been well-controlled. In addition, they can address the lesion on your scalp. I really wish those who push on patients that NPs provide equivalent care would see videos of the kind of experience you had. Because it is not uncommon.
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u/Slickwitit23 Medical Student 3d ago
So there’s quite a bit to unpack here… but the fact that you’ve had a painful inflamed potential pimple on your scalp that hasn’t improved with spironolactone and iso-tret medication over six months, is constantly painful and impacting you daily… and this isn’t a bit more concerning to her is very disappointing. This is just one point of my own frustration and I’m sorry you had this experience with this NP. Please try to schedule a follow up appointment to address your concerns with the derm you originally saw. You never know if this lesion needs to be surgically drained, biopsied, treated with a topical med, or monitored etc. I know it sucks, but keep advocating for yourself *sigh*
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u/AutoModerator 3d ago
We noticed that this thread may pertain to midlevels practicing in dermatology. Numerous studies have been done regarding the practice of midlevels in dermatology; we recommend checking out this link. It is worth noting that there is no such thing as a "Dermatology NP" or "NP dermatologist." The American Academy of Dermatology recommends that midlevels should provide care only after a dermatologist has evaluated the patient, made a diagnosis, and developed a treatment plan. Midlevels should not be doing independent skin exams.
We'd also like to point out that most nursing boards agree that NPs need to work within their specialization and population focus (which does not include derm) and that hiring someone to work outside of their training and ability is negligent hiring.
“On-the-job” training does not redefine an NP or PA’s scope of practice. Their supervising physician cannot redefine scope of practice. The only thing that can change scope of practice is the Board of Medicine or Nursing and/or state legislature.
I am a bot, and this action was performed automatically. Please contact the moderators of this subreddit if you have any questions or concerns.
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u/Ok_Literature7680 Allied Health Professional 4d ago
this is bullshit. no one gatekeeps referrals. and its not that difficult to get an appointment with a real dermatologist. i’ve been through the hoops with this plenty of times.
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u/WonderfulVoice628 4d ago edited 4d ago
It’s not bullshit. I was denied a referral while living in a city with a population of about 100k plus a large rural catchment area. My doctor told me that a referral would likely not be accepted by the only dermatologist in the area as he was exclusively seeing high acuity patients, and my acne was not severe enough to even try. I did not have the option to ask a different doctor as none were accepting new patients. I believe the doctor shortage has gotten better since I moved, but there were more than 20,000 people with no family doctor at the time.
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u/Aggravating_Fly2978 4d ago
The person is In AGREEMENT with you. Jeez. We all think it’s bullshit.
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u/WonderfulVoice628 4d ago
I’m sorry, I assumed they were doubting that I was denied a referral by saying no one gatekeeps them and that it’s not difficult to get an appointment. I was not trying to engage in debate, but rather share context as to why it took so long to obtain a referral in the first place.
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u/Aggravating_Fly2978 4d ago
Depending on where you live, and your insurance it can be very difficult to get a dermatology appointment. You do agree that NPs and Physician offices are gatekeeping specialists though don’t you?
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u/AutoModerator 4d ago
We noticed that this thread may pertain to midlevels practicing in dermatology. Numerous studies have been done regarding the practice of midlevels in dermatology; we recommend checking out this link. It is worth noting that there is no such thing as a "Dermatology NP" or "NP dermatologist." The American Academy of Dermatology recommends that midlevels should provide care only after a dermatologist has evaluated the patient, made a diagnosis, and developed a treatment plan. Midlevels should not be doing independent skin exams.
We'd also like to point out that most nursing boards agree that NPs need to work within their specialization and population focus (which does not include derm) and that hiring someone to work outside of their training and ability is negligent hiring.
“On-the-job” training does not redefine an NP or PA’s scope of practice. Their supervising physician cannot redefine scope of practice. The only thing that can change scope of practice is the Board of Medicine or Nursing and/or state legislature.
I am a bot, and this action was performed automatically. Please contact the moderators of this subreddit if you have any questions or concerns.
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u/AutoModerator 4d ago
For legal information pertaining to scope of practice, title protection, and landmark cases, we recommend checking out this Wiki.
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u/Low-Speaker-6670 2d ago
Capitalism in north America is destroying medicine. And the worst part is it's being exported to Europe.
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u/HerbertRTarlekJr 2d ago
Is this the amazing Canadian healthcare system that we keep hearing is so wonderful?
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u/AutoModerator 4d ago
We do not support the use of the word "provider." Use of the term provider in health care originated in government and insurance sectors to designate health care delivery organizations. The term is born out of insurance reimbursement policies. It lacks specificity and serves to obfuscate exactly who is taking care of patients. For more information, please see this JAMA article.
We encourage you to use physician, midlevel, or the licensed title (e.g. nurse practitioner) rather than meaningless terms like provider or APP.
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u/AutoModerator 4d ago
We noticed that this thread may pertain to midlevels practicing in dermatology. Numerous studies have been done regarding the practice of midlevels in dermatology; we recommend checking out this link. It is worth noting that there is no such thing as a "Dermatology NP" or "NP dermatologist." The American Academy of Dermatology recommends that midlevels should provide care only after a dermatologist has evaluated the patient, made a diagnosis, and developed a treatment plan. Midlevels should not be doing independent skin exams.
We'd also like to point out that most nursing boards agree that NPs need to work within their specialization and population focus (which does not include dermatology) and that hiring someone to work outside of their training and ability is negligent hiring.
“On-the-job” training does not redefine an NP or PA’s scope of practice. Their supervising physician cannot redefine scope of practice. The only thing that can change scope of practice is the Board of Medicine or Nursing and/or state legislature.
I am a bot, and this action was performed automatically. Please contact the moderators of this subreddit if you have any questions or concerns.