In response to Dermatology Lab Referrals: Cash Cow or Ethical Trap?
The dilemma facing the fictitious Metro Dermatology Group in this vignette has been created by external forces, which have essentially reshaped the way that health care is provided in the United States. These external forces have caused physicians to work harder; that is, to see more patients in a given time frame with reduced compensation. The usual response of any prudent physician responsible for management of a practice is to seek ways to reduce expenses and ethically maximize income.
In states where labs and other service providers are not allowed to bill their clients—the dermatologist in this case—they must bill patients or the patients’ insurance carriers directly. In states where client billing is allowed, physicians can pay the medical service provider—in this case the pathology laboratory—directly and submit a claim for payment to the patient or, most commonly, to the patient’s insurance carrier. Client billing creates an incentive to seek out the lowest-cost provider. While this practice, where permitted, is not unethical, it could have an effect on a physician’s judgment. All physicians must always keep in mind the cardinal ethical principle which is sacred to medicine: primum non nocere, first (or above all) do no harm.
In the vignette, Dr. Vinaver is concerned about the group’s contracting with a “giant out-of-state lab.” The concern is reasonable because he doesn’t know anything about the pathologists who would be interpreting his patient’s biopsies. All clinicians, and especially dermatologists, should have a comfort level with the pathologist(s) who interpret the biopsy samples that they submit. Dermatologists are especially sensitive to this issue because of differences in terminology and philosophy among dermatologists and dermatopathologists. This comfort level or feeling of trust is established by knowing that the pathologist is well trained and qualified. Understanding terminology used, especially with pigmented skin lesions, and being able to communicate easily, effectively and in a timely manner are other requisites for a feeling of trust. The local lab and its pathologists are a known entity, and the large, remote, out-of-state lab is not—a reasonable concern for any physician who cares about the well-being of his or her patients.
I practiced in a community hospital for 15 years. For the last 22 years, my practice setting has been in a large commercial laboratory—Quest Diagnostics. Commercial laboratories offer the same high quality services as hospital or smaller pathology group labs, usually at lower cost. The lower cost is made possible by operational efficiencies, increased purchasing power and economies of scale, to mention the more apparent reasons. The trust level mentioned above may be harder to establish in some cases because of geographical separation. In today’s world, this lack of closeness can be overcome by a personal visit, if feasible, and telephone or e-mail communication. If a dermatologist is considering using the services of another laboratory, it is appropriate to interview the dermatopathologist(s) who will be responsible for interpreting his or her patient’s biopsies.
The following are some specific questions that should be asked and answered:
- What agency inspects and accredits your laboratory for CMS?
- What criteria does your laboratory use to employ dermatopathologists?
- Where did you train? How long have you been practicing? Are you certified by the American or Osteopathic Board of Pathology or Dermatology? May I have a copy of your curriculum vitae?
- What terminology do you use for pigmented skin lesions? What do you mean when you say…?
The following exercise is often helpful in determining if you and the dermatopathologist are on the same page and can communicate effectively.
- Describe your laboratory’s quality assurance process. Do you get second or consensus opinions from your colleagues in the laboratory? Can I get second opinions on cases when I request it?
- Will you notify me directly about malignant interpretations and problematic and delayed reports?
- May I see some copies of your reports with patient identification removed?
- How are your reports delivered?
- How can I contact you directly if I need to?
The questions noted above should be explored in as much detail as needed to establish a level of comfort or discomfort. In my practice setting, the questions can easily be answered to any reasonable physician’s satisfaction.
Additionally, quality anatomic pathology laboratories should require a pre-employment slide test before considering a pathologist for employment. Biannual credential verification, similar to the systems used for granting hospital privileges, is also a sign of a quality-oriented laboratory.
Ongoing monitoring of a pathologist’s performance is difficult because each interpretation represents individual value judgments based on experience, training and ongoing continuing medical education. An effective quality monitoring system, focused on error reduction and patient safety, should use random and targeted case review to monitor an individual pathologist’s performance. An ethical quality-oriented laboratory will not restrict pathologists from ordering additional slides, special stains or immunohistochemical stains when indicated. Pathologists should work at a speed or volume that is consistent with accurate interpretation.
The decision to use a large commercial laboratory should be made with the same care as selecting a physician to care for you or your family.