When to Refer/Mohs Surgery

Published on 26/02/2015 by admin

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37 When to Refer/Mohs Surgery

John L. Pfenninger, MD, and Richard P. Usatine, MD

The primary care clinician handles a multitude of problems and each person has his or her own level of comfort and expertise. There are no hard-and-fast guidelines to determine when a consultation/referral should be obtained. Some clinicians will feel very comfortable performing extensive flaps, whereas others will be anxious about doing a fairly straightforward skin biopsy. This chapter provides some general guidelines to help gauge when, and if, the expertise of another clinician is needed.

When to Refer

In general, a referral means that the patient is being turned over to another physician for care. A consult asks for direction, but the patient remains under the care of the consulting physician. In practice, these two terms are often used interchangeably. The term verbal consult is often used to relay the fact that the case was discussed with someone else for input and direction as to proper care but not referred formally. Although discouraged on a legal basis, it is commonly done and for simple questions such as “What should the margins of the excision be?” it functionally works well.

Medical-legal considerations are important. Hospitals may limit privileges and require that a referral be made for performing certain procedures in hospital-owned facilities. In such cases, it may not be a matter of expertise, but rather of legal restriction as to what may be done.

HMOs and insurance companies may also limit the ability of a clinician to employ the full use of his or her skills. Some restrict payment to certain specialties only. It is not a matter of competence (despite the insurers’ claims), but rather a matter of rules, regulations, and “protecting turf.”

It is important for clinicians to always provide complete disclosure to patients about their background and training. Patients must not be misled into thinking that the physician assistant, nurse practitioner, family physician, or internist is a dermatologist or plastic surgeon. The simplest procedure for professionals may appear to be very complex to the patient and can be a fearful ordeal. It is always appropriate to mention that a dermatologist, plastic surgeon, or referral to some other center is readily available should the patient so desire. A statement such as “This is a common procedure that has few complications. I perform it frequently and I would be happy to do it for you. However, if you’d like to see someone else, I understand and can easily arrange a referral” goes a long way toward putting the patient at ease. Do not forget the family members in the equation. Some may be extremely concerned about a scar, even though it involves an elderly parent. These issues need to be discussed and dealt with prior to performing any procedure. If the patient or the family appears to be hesitant, it is prudent to make a referral.

No clinician will ever feel totally comfortable in every situation that he or she will encounter. Sometimes, too, a straightforward diagnosis and planned treatment becomes more complicated than expected. It is important to have lines of communication open with other specialists so that when these “complications” do arise, the clinician has support. Whether this consultant is a plastic surgeon, dermatologist, general surgeon, or another colleague who performs the same procedure, it is important to have the backup. Immediate complications will most likely involve bleeding or the inability to close a large, gaping wound; wound dehiscence; or nonhealing of a treated site. Rarely, a nerve may be transected or the repair may leave the surrounding structures distorted. Long-term complications include scarring, missing a diagnosis, or recurrence.

Clinicians should not be hesitant to perform a skin biopsy. Multiple methods are available (see Chapters 8 through 11). Complications are so rare, and the benefits are so great, that all clinicians, especially those in primary care, should consider mastering this skill. If one wants to limit procedural acumen solely to skin biopsies, then referral would be necessary for many findings. However, the average primary care clinician should be able to evaluate and treat 95% of all dermatologic conditions that come into the office using the techniques described in this text. Cryotherapy, electrosurgery, injection techniques, laceration repair, and simple incisions/excisions will be adequate to treat the majority of conditions. When the excisions become larger and more complicated, it is then that many patients may need to be referred.

Keeping in mind all of the considerations noted above, the clinician will individually define when a referral is indicated. As expertise increases with training and experience, fewer consultations and referrals will be needed. General guidelines for when to consult and when to refer include the following:

1. Lack of experience with the method needed for diagnosis and/or treatment.

2. Significant cosmetic concerns with the skills for removal being beyond the practitioner’s comfort level.

3. Large lesions, whether benign or malignant. These often need to be referred to a specialist. “Large” is relative and depends on the practitioner’s expertise and the nature of the lesion (benign or malignant, location, new or recurrent, etc.).

4. Request by the patient or the family for a referral.

5. A poor or questionable patient–doctor relationship.

6. An uncooperative patient.

7. Medical-legal or insurance requirements/regulations.

8. Advanced and/or complicated disease. In general, the major considerations for aggressiveness of a tumor are histologic type, size, and location of the lesion.

All factors should be considered when deciding whether or not to make a referral. The skin cancers that cause the most concern for all of us can be categorized as follows by histologic type (from least to most aggressive):

Basal Cell Carcinoma (BCC)

• Superficial