The range of error in clinical as opposed to microscopic diagnosis can be as high as 50 percent, according to professional liability insurance statistics for claims involving malignant melanomas.
In view of the apparent increase in mortality statistics and a very real increase in substantial claims involving pigmented skin lesions, The Doctors Company recommends the following guidelines:
- Avoid electrocoagulation and/or desiccation of a pigmented lesion until microscopic examination excludes a melanoma diagnosis.
- Submit each lesion for pathological examination in a separate container. Do not combine lesions from different sites in the same container. This practice is as senseless as it is dangerous.
- Assist the pathologist by orienting the lesion with a stitch and a description of its location (e.g., "stitch at 12 o’clock"). A better orientation of the lesion would include the stitch with an accompanying sketch and explanation. In large lesions with involved margins, this information is essential in guiding a re-excision.
- Describe the specimen’s location, and include a very brief history; do not merely document it as a skin lesion or mole.
- Keep a log that includes the date of submission, the number of specimens, and a description of their precise location. Include a check-off box to record the return of pathology reports.
- Initial each pathology report before filing. Instruct office personnel not to file any report until the treating physician has seen it, even if someone else removes the sutures or subsequently follows the patient.
- Place valid informed consent documentation in the patient’s record. Resist the temptation to remove a lesion incidental to some other procedure. Claims have been filed because of impromptu decisions to perform procedures that the patient has not specifically authorized.
- Send all specimens to a pathologist for diagnosis.
- Hold a thorough and frank discussion with the patient and family if a pathological examination shows the lesion to be malignant. This is often useful after consultation with other specialists.
- Inform the patient when any indicated re-excision would be disfiguring and/or when radical ablative procedures (with or without lymph node dissection) are indicated. Explain treatment alternatives and what complications might result from them. The law in all jurisdictions is specific on the point that it is the patient, not the physician, who must ultimately make the decision about where his or her best interests lie. Your records must reflect that the patient was given sufficient information with which to make that decision.
- Document refusals of your treatment recommendations most carefully. The patient has the right to refuse treatment recommendations, but be sure to document that you have explained the consequences of failure to heed your warnings.
- Weigh difficult ethical questions with possible legal consequences. For example: The patient asks you for a straight answer but directs you not to inform his or her family. Distasteful as it may be, if you have accurate signed and witnessed documentation, you are probably safe in complying with the patient’s wishes. The family suspects the answer and asks you not to inform the patient. In whatever manner you deem most appropriate, you are legally duty-bound to disclose the gravity of a prognosis to the patient.
- When faced with a difficult or complex lesion, consider preoperative consultation with a pathologist who will assist with defining margins.
Other Malignant Skin Lesions
The Doctors Company has recently documented an increase in skin cancers—especially those appearing on sun-exposed areas of the head and neck. Early diagnosis and treatment are particularly important when these lesions occur close to the vital structures of the face, such as the eyelids, nose, mouth, and ear canal. Complete surgical excision with pathological examination of the margins for adequacy of the excision is preferable to shave biopsy or desiccation.
When considering treatment for any pigmented skin lesion, your index of suspicion should be elevated. Regardless of your level of clinical expertise, however, there is no substitute for accurate microscopic pathological confirmation prior to definitive treatment. In the interest of moderating claims relating to pigmented skin lesions, The Doctors Company strongly urges your conformance with these guidelines.
Updated: May 2000
Originally published: April 1990