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Time needed to schedule dermatological consultations in Brazil*

BACKGROUND It is not clear what the population's demand for dermatologists is, nor how many professionals are needed in order to provide adequate care in this area of expertise. Knowledge of the flow of patients at dermatological clinics throughout the country allows for the formation of expansion and distribution policies regarding professionals, and provides backing for the decision to increase medical residency places. OBJECTIVES To evaluate the time it takes to schedule a private dermatological consultation in Brazil, and other factors concerning consultations. METHODS Survey with a random sample of 14% of Brazilian dermatologists, simulating the scheduling of emergency clinical and cosmetic consultations, and botulinum toxin procedures. Also, details relating to cost and professionals, were studied. Data were adjusted for each region of the country. RESULTS A total of 873 dermatologists were evaluated. Full SBD members represented 85%, and 66% were women. The median time to schedule a consultation ranged from 6 (out-of-pocket payment) to 7 (medical insurance) consecutive working days. Times varied depending on the region. A multivariate analysis showed that out-of-pocket consultations and procedures were scheduled sooner than with medical insurance, regardless of whether they were clinical or cosmetic. CONCLUSION The characteristics of dermatologists are varied throughout regions of the country. Private consultations and procedures are scheduled sooner than with insurance companies.


INTRODUCTION
It is not clear what the demand for dermatological services is among the Brazilian population, nor how many professionals are needed to provide adequate care in this domain. 1 The Brazilian Ministry of Health has deemed that there should be one dermatologist for every 80,000 citizens for dermatological and leprosy care, provided by the SUS (Unified Health System, the Brazilian public health system). 2 In countries with hierarchically organized health systems, such as the UK, the expected number is one dermatologist for every 100,00 citizens. 3 On the other hand, in metropolitan areas with spontaneous demand for medical care, like in the US, there can be up to one dermatologist for every 20,000 patients. 1,4,5 The Brazilian Dermatological Society (SBD) is the second largest dermatological society in the world, with 6,053 registered members (data from 2011), averaging one dermatologist for every 32,000 citizens. However, distribution throughout the country and the states is irregular, being concentrated in metropolitan areas. 6,7 Further, the SBD has grown by 400-500 members per year (6-8%), at a faster rate than the Brazilian population (1-1.5%), during the last decade. [6][7][8] Knowledge of the flow of patients at dermatological consultations throughout the country allows for the formation of expansion and distribution policies regarding professionals, and provides backing for the decision to increase medical residency places.
The authors seek to estimate the time taken to arrange dermatological consultations in the private system in different regions of the country and, as a secondary aim, to examine matters regarding dermatologists, the cost of consultations, and differences linked to particular types of cutaneous issues.

METHODS
The article adopts a cross-sectional method of inquiry, involving a random sample (stratified into regions of the country) of dermatologists, drawing on SBD membership data as per the website (http://www.sbd.org.br), between February 21 st and August 8 th , 2011. Sampling involved a table of random numbers, corresponding to the dimensioning for each stratum, applied according to the alphabetical order of the names listed on the SBD website.
A couple of trained actors, in accordance with the randomization, called the clinics of every professional to try and arrange cosmetic (actress) and clinical (actor), consultations. They inquired about insurance agreements, private consultations and aesthetic procedures (Chart 1).
Values (median and interquartile deviations) for the number of consecutive working days for scheduling are discussed in relation to regional characteristics, city population, age, gender, type of member, type of consultation (insurance or private), cost of consultation, type of issue (clinical or cosmetic) and procedure (botulinum toxin).
Proportions among regions were compared using the chi-squared test and residue analysis (standardized and adjusted) of the contingency table. A bivariate comparison was undertaken of the cost of private consultations throughout the regions using a generalized linear model (distribution range), as well as the times for scheduling, using a counting model (negative binomial regression). The multivariate analysis of the times for scheduling consultations was carried out on the basis of a mixed-effects counting model (negative binomial regression). 9 The significant, two-tailed value of p<0,05, was adopted. Data were analyzed using the SPSS 20 software. 10 The sample size was determined via a pre-test of 50 dermatologists, taking into account a standard error of ±3,0%, an alpha of 0,05, and power of 0,8, corrected for the finite universe of each region (Table 1). 11

RESULTS
1756 telephone calls were made to 873 Brazilian dermatological clinics (14,4%), SBD members, and inquiries were made regarding scheduling times for clinical (urgent), cosmetic and botulinum toxin consultations. Table 1 outlines the various densities of dermatologists in different Brazilian states. Table 2 shows demographic data and scheduling times for dermatological consultations and procedures in different regions of the country, noting regional differences with regard to all the variables studied.
Over 40% of the dermatologists were under 40. Women and full members represented the youngest age group, even when broken down by region (p<0,01) (Graph 1).
Most of the medical consultations varied in price from R$150 to R$250, involving considerable regional variation, as the higher prices were generally in the southeast and southwest regions ( Table 2). The cost distribution of the medical consultations sampled is outlined in graph 2. Higher consultation costs were associated with dermatologists who were full SBD members, operating in cities with higher populations, offering exclusive, private care, from a higher age bracket, and who carried out botulinum toxin procedures (p<0,01).
Over half the bookings took place between 2 to 15 working days, involving significant regional variation, with shorter waiting times in the north and northeast, in accordance with the type of service in question (Table 2 and   Wait for the secretary to say whether they accept insurance agreements, which ones and the date of the cosmetic appointment through insurance.
-What about a private consultation?
Wait for the secretary to determine the appointment date.
-What if I wanted to do a "BOTOX" procedure?
Wait for the secretary to determine the available date for the botulinum toxin procedure.
-Is this doctor young? How old are they roughly?
Wait for the secretary to say what the dermatologist's age bracket is.
-Thanks, I will speak to my husband and see If he can take me on that day, I will call back in a minute.

Male character: man aged 25 -Clinical consultation
Good morning/afternoon.
-I'm worried about a black spot on my back that has swollen up and I would like a consultation with Dr. Fulano, does he/she accept insurance?
Wait for the secretary to say whether they accept insurance agreements, which ones and the date of the clinical appointment through insurance.
-What about a private consultation?
-How much would the consultation cost? -Thanks, I will speak to my brother and see if he can come with me on that day, I will call back in a minute.
Discarding dermatologists who dealt exclusively with clinical matters (10.8%), and making adjustments in relation to the regions of the country, the scheduling times for private appointments did not differ between clinical and cosmetic consultations (p=0,41), nor between the procedures (botulinum toxin) and private clinical consultations (p=0,21). In the same way, scheduling times for clinical and cosmetic consultations were the same if both were arranged via insurance coverage (p=0,43).
Dermatologists who work exclusively with private consultations reflect a different distribution pattern throughout the country's regions, carry out more botulinum toxin procedures (88.9%), and have a preference for more populous cities (median: 1 million inhabitants). Their consultations are more expensive (median: R$250) and their waiting times are shorter (median: 3 days) (p<0,05) ( Table 2).

DISCUSSION
The study outlined waiting times for scheduling private dermatological consultations in Brazil in 2011. Discrepancies emerged between waiting times, and factors relating to the medical consultations and dermatologists in different regions of the country.
The territorial area considered and the variability in demographic, ethnic and cultural density are not the only elements that explain the disparities in private dermatological cover. With irregular distribution of dermatologists, concentrated in metropolitan areas, economic realities in particular states might explain the greater purchasing power of individuals and thus, the larger market for private dermatological care. The fact that there are smaller densities of dermatologists in less developed states such as Acre, Amapá, Roraima, Rondônia, Maranhão and Piauí, in contrast to the great densities of the Federal District, São Paulo, Espírito Santo and Rio de Janeiro, adds weight to this argument. [6][7] In the US, there is also a metropolitan distribution of professionals, with a lack of dermatologists in rural areas, which intensifies the discussion on what the right amount is to provide care for the population and the reasons for the poor distribution of professionals. 4,5,12 The expansion of operations in terms of surgeries, laser and cosmetic treatments, has been identified as the main reason for the increased demand for dermatological services, leading to variation in state averages of 20 to 73 days for scheduling consultations. 4,[13][14][15] In the same way, waiting times to book consultations are shorter in places with higher population densities. The number of dermatologists who perform cosmetic care is also higher in these cities. 13 Long waiting periods for booking consultations was the main factor some authors highlighted for the involvement of non-dermatologists in the domain, even leading to the hiring of professionals to undertake joint work in dermatological clinics in the US. 4,16 Nevertheless, the desire to qualify other medical professionals for the purposes of undertaking strictly cosmetic operations should be viewed as a desire to promote courses that are not SBD-certified and the invasion of professionals into dermatological practice. This insufficient training poses a potential risk to society. In Japan, over half the dermatological procedures have been delegated to non-dermatologists. 17 It is beyond the scope of this study to gauge directly the impact of non-dermatologists but the reduction in waiting times for scheduling consultations is directly linked to this competition.
It is estimated that a waiting time of up to two weeks is appropriate for dermatological appointments and most of the consultations examined in this study fell within this period. 13,15 However, there are examples among the sampled cities in provincial areas of average waiting times of over 20 working days, which demonstrates not the surplus of dermatologists but rather the irregular distribution across the territory, provoking a shortage in care for a significant proportion of the population.
In Canada, there are fewer than 1,000 dermatologists and, along with progressive urbanization, there are concerns over the lack of cover for retiring dermatologists, despite the impetus to hire foreign doctors. The time for scheduling a dermatological consultation is 5 to 10 weeks. 15 Some governments have adopted teledermatology assistance programs and training of generalists as ways to address the gap. 18,19 Scheduling times vary greatly in Brazil but data show that private consultations and procedures are arranged quickly in comparison with appointments made via insurance, particularly those involving botulinum toxin procedures. These elements suggest that there is a difference between payment from medical insurance companies for consultations, and for procedures, which is why professionals opt for private appointments. North American studies have shown that scheduling times for botulinum toxin procedures, which are not covered by insurance, are on average half as long as for conventional appointments. There are also regional variations and relative differences in relation to the type of health insurance, in terms of waiting periods for scheduling consultations. 20,21 The developments noted in the new generation of dermatologists, like the greater proportion of female professionals holding the title of specialist, can help bring changes to the domain of dermatological coverage. There has been a reduction in the number of weekly clinical appointments, while recommended procedures have become more common, which could poten-tially widen the jobs market in the coming years. 22 The methodology applied here does not allow for examination of the states' specificities or comparison between metropolitan and provincial regions. However, it paves the way for the widening of the sample to investigate local realities.
Equally, this study did not discuss public outpatient dermatological care (offered by SUS), which, even though it represents a smaller proportion of dermatological operations in the country, should be studied using a particular methodology, so as to gauge the need for dermatologists in a country with endemic areas of infectious dermatoses and that has seen a rise in basal cell carcinoma, melanoma and syphilis. [23][24][25][26][27] The Brazilian Dermatology Society and its teaching committee should pay attention to the registration of residency places and work experience in areas with high concentrations of dermatologists, or that have shorter scheduling times for consultations, in order to preserve the members' jobs market and guarantee adequate care for the population.
Further, excellent accredited dermatological services could promote insurance agreements with teaching institutions in regions that lack professionals, in order to provide residency places for students of the domain.

CONCLUSIONS
There is great variation as regards dermatologists and scheduling times throughout the regions of the country. Private consultations and procedures are scheduled more quickly than with insurance. The SBD should focus on the span of the market and care for the population, in policies geared towards increasing the number of professionals and their distribution. ❑