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Patients’ (mis)understanding of their skin cancer diagnosis


DII small banner By Warren R. Heymann, MD
Sept. 26, 2016

“If names be not correct, language is not in accordance with the truth of things.” — Confucius

Occasionally a patient’s misunderstanding of their dermatologic diagnosis can elicit a smile. How can you not chuckle when someone says that they suffer from “hanky-panky” (lichen planus) or that they have been plagued with acme since high school? In cases of skin cancer, the consequences of inaccuracy may not be so amusing.
 
Sommer et al* performed a study to determine the accuracy of self-reported diagnosis versus true histopathologic diagnosis of patients with skin cancer for patients who called their dermatologic surgery center to schedule Mohs surgery. Of the 290 patients who met their criteria for the project (121 BCC, 88 SCC, and 81 MM), 19% (n = 55) were unable to accurately report their skin cancer diagnosis (CI: 14.6%–24%). Most of the patients (97%, n = 280) had a previous history of skin cancer. Patients with MM were more likely to accurately report their diagnosis (90%) than patients with NMSC. This was significantly more accurate when compared with SCC (67%, p < .001) but not significantly more accurate when compared with patients with BCC (85.1%, p = .298). Most importantly, 10% of patients with MM [malignant melanoma] could not accurately recall the diagnosis. Potentially, this could have resulted in delayed scheduling and treatment. The authors concluded that a significant number of patients are not aware of their precise diagnosis, and state that this “should prompt physicians to consider how patients receive biopsy information and what, if any, additional education and counseling in regard to diagnosis and disease process of skin cancer can be provided.” (1)

Communicating results focuses much more on speed today; as noted by Choudhry et al, “Patient preference has shifted from face-to-face visit to discussion over the telephone because of a desire for rapid notification. Experience with online portal delivery of results favorably inclined patients toward that modality.” (2) As millennials increasingly have cutaneous malignancies, texting may become the preferred method.

Simionescu et al classified six categories of error regarding melanoma: 1) clinical diagnostic errors; 2) primary surgical errors; 3) pathology errors; 4) sentinel lymph node biopsy errors; 5) staging errors; and 6) treatment or management errors (3). I would add a seventh — communication errors.

A couple of years ago, I saw a patient that I had biopsied demonstrating extensive Bowen disease of the vertex; I suggested that Mohs surgery was optimal for his lesion, and wrote on the biopsy report for my staff to refer him. When I saw him a year later, the lesion was still present, and I asked him why he did not have the surgery. “Because your nurse told me it was benign,” he exclaimed. I was livid (the medical assistant had already been let go for other reasons). I apologized profusely and subsequently changed the way I practice. Any patient referred for Mohs or excisional surgery receives their biopsy results directly from me. Period. I briefly explain the procedure, why I’m recommending it, and ask if they have any further concerns or questions. While that does not guarantee that they have processed what was communicated, I know what they were told was accurate.

*This paper is from the Section of Dermatologic Surgery in our Division of Dermatology at Cooper Medical School of Rowan University. Undoubtedly, some of the 290 patients are mine.

1. Sommer LL, Eminger LA, Lawrence N. Tbe accuracy of self-reported skin cancer diagnosis: Room for improvement. Dermatol Surg 2016; 42: 1110-1.
2. Choudhry A, et al. Patients’ preferences for biopsy result notification in an era of electronic messaging methods. JAMA Dermatol 2015; 151: 513-21.
3. Simionescu O, et al. Learning from mistakes: Errors in approaches to melanoma and the urgent need for updated national guidelines. Int J Dermatol 2016; 55: 970-6.

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