A Question of Standards
As health maintenance organizations (HMO’s) acquire market share, standards become
an important issue. Webster’s Dictionary defines a standard as something established
by authority, custom or general consent as a model or example. For the practice of
medicine, standards are often based upon what the majority of physicians would do in a
certain situation. If dermatology is to survive as a specialty, we must be sure that our
standards of diagnosing and treating cutaneous pathology are superior to our other
colleagues practicing medicine.
When I perform a biopsy on a family member, such as the atypical mole that I removed from
my brother’s back several years ago, I sent my specimen to a dermatopathologist who
had a superb reputation because I wanted to be absolutely sure that my brother did not
have a malignant melanoma. When I received the results of the pathology, I wanted to feel
comfortable with the interpretation provided by the dermatopathologist. I have set the
same standard for all of my patients, sending all of my specimens to the same
dermatopathologist. It is often difficult to decide in the day-to-day practice of
dermatology what standard one should hold oneself to. It is often easy to compromise the
standard of care based on a particular patient’s situation. I have heard another
dermatologist remark that it doesn’t matter if I send my pathology for one patient to
the regular lab because he has Medicaid or is an "HMO patient," while sending
another specimen to a dermatopathologist because the patient is an attorney or the
hospital administrator. I have found the easiest standard for me to follow is to ask
myself what I would do if this were a family member. One can argue that if one is treating
a member of one’s own family, emotional involvement can overshadow one’s ability
to make an objective decision. I think that this is a reasonable argument when it comes to
patient management decisions. However, I think this is a useful standard when one is
deciding where to send a pathology specimen or when a patient asks me the name of a doctor
that I would recommend. I would be very uncomfortable telling a patient to see a doctor
that I would not want my brother to see or to use a laboratory that I would not send my
mother’s pathology specimen to.
I think a very important aspect of the specialty of dermatology is the fact that we are
associated with dermatopathologists. There is no doubt that a dermatopathologist provides
a higher quality reading of a cutaneous specimen than that of a general pathologist. Using
a dermatopathologist makes me a better dermatologist. This not only benefits me in
providing patient care, but it certainly benefits the patients by providing a more
accurate diagnosis and treatment tailored to the correct diagnosis. The patient who
receives an incorrect diagnosis is often better off if he or she never came to the
physician in the first place. Our patients fully understand that substandard care is no
better than no care at all.
A pernicious trend is occurring in this country in which HMO’s are dictating the
standard of care. I think that HMO dominance in our healthcare system is a fact of life
and is something that we have to live with. Despite this, we must preserve our standards
as a specialty in order to survive. We must not sign contracts with HMO’s that
dictate where our cutaneous specimens are interpreted and processed. When faced with one
of these monoliths threatening to send our patients elsewhere, we need not truckle to
their unreasonable demands. We fight trenchantly and we adamantly hold to our standards.
Several HMO’s have attempted to force me to use a particular pathologist. Thus far, I
have been successful in my attempts to insist to these HMO’s that I will only send my
specimens to one particular dermatopathologist because I consider this dermatopathologist
to be the best in the world. I was put in a position with one HMO of having to use a
particular laboratory and we were forced to terminate our contract with this HMO. The HMO
said they were sending the patients to a different dermatologist, one without our
standards. I wrote letters to Senator Biden and Senator Roth (U.S. Senators for the State
of Delaware) and other elected officials explaining that my dispute with this HMO was one
of quality and not one of personal reimbursement. These elected officials were successful
in pressuring the HMO to reconsider in my favor. I was fully prepared to go to the
newspapers, as I explained to this HMO. My fight with this HMO was time consuming, but in
the end, a positive result certainly made it worthwhile. Several patients who are members
of this HMO have unusual diagnoses and they are very grateful for the excellent
dermatopathological interpretation which they have received. I was fortunate that one of
these people turned out to be very influential and is putting further pressure on the HMO
on my behalf. Other battles lie ahead. One must rise to the challenge when others are
attempting to compromise our standards.
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