Position Statement on Physician Choice of Consultant for Interpretation of Skin Biopsy Speciments

Position Statement on Physician Choice of Consultant for Interpretation of Skin Biopsy Speciments

(Approved by the Board of Directors February 1995)
(Approved by the American Society of Dermatopathology December 1994)

The American Academy of Dermatology and the American Society of Dermatopathology strongly support the rights of patient access to care and choice of a physician. As an extension of these rights, physicians have the responsibility to choose consultants in the best interests of their patients. Specifically this requires that clinicians choose a physician with expertise in dermatopathology or cutaneous immunopathology to interpret skin biopsy specimens taken from their patients. Dermatologists and pathologists are trained in the interpretation of skin biopsy specimens and many have maintained competency in this field through continued education and practical experience. The Residency Review Committees for both Dermatology and Pathology require that residency training programs emphasize dermatopathology in their curricula. A dermatology residency program devotes approximately 25% of its curriculum to dermatopathology and an equal percentage of the dermatology certifying examination evaluates proficiency in dermatopathology. This level of expertise is recognized at the Federal level as evidenced by the most recent CLIA regulations published in the February 28, 1992 Federal Register (Vol. 57, No. 40, page 7179 (1) (2) (B) (3)), which attest to the qualifications of dermatologists for interpretation of dermatopathology tests.

Many dermatologists prefer to refer skin biopsy specimens obtained from their patients to specialized dermatopathology laboratories directed and staffed by dermatologists and/or pathologists with special expertise in dermatopathology and immunopathology. Besides the education obtained during residency training, these physicians have acquired specific training leading to certification of special qualification in dermatopathology by the American Board of Dermatology and the American Board of Pathology. This additional training is a one year program approved by the Accreditation Council for Graduate Medical Education. Also included under the general category of dermatopathology are physicians with further training leading to special certification in cutaneous immunopathology.

Dermatopathology is a professional or consultation service rather than a quantitative laboratory test. Dermatopathologic interpretation is an integral part of a dermatologists service to his or her patients. Accurate interpretation of skin biopsies requires an ability to recognize and record the details of the specimen, and to synthesize these findings with the clinical situation. Failure to interpret skin biopsy specimens correctly can mislead the clinician, can interfere with institution of appropriate medical or surgical therapy, and may thus potentially cause harm to the patient. Certain managed care programs mandate that the treating physician send skin biopsy specimens to laboratories with exclusive contracts for pathology. These laboratories may lack a physician, or lack sufficient numbers of physicians, with a high level of training and experience in dermatopathology or immunopathology. Sometimes the treating physician must send skin biopsy specimens to multiple different laboratories in multiple locations, depending upon the mandates of various insurance plans. This dissemination of specimens results in interpretations by a variety of individuals whose expertise may be unknown to the treating physician, and whose terminology may be unfamiliar to the treating physician. Often no working relationship has been established between the clinician and the managed care pathologist. This subjects the patient to a likelihood of having the skin biopsy specimen misinterpreted.

Quality medical care demands that physicians have the right and responsibility to use an acknowledged expert in the histopathologic diagnosis of skin diseases. Sometimes this expert will be the treating physician. In other cases the treating physician will choose a local or regional expert. Patients deserve routine access to this expertise, especially when the physician highly trained in dermatopathology is willing to accept a competitive reimbursement.

In summary, the American Academy of Dermatology and the American Society of Dermatopathology support the principles of freedom of choice of consultants, free access to any qualified physician, and the right of any qualified physician to negotiate a competitive reimbursement.