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Total body skin exams (TBSEs): Saving lives or wasting time?
Total body skin exams (TBSEs): Saving lives or wasting time? Jane M. Grant-Kels, MD,a and Benjamin Stoff, MD, MABb Farmington, Connecticut, and Atlanta, Georgia
CASE SCENARIO Dr Young recently completed his dermatology residency and joined a well-respected dermatology practice. Initially, the partners allow him to see the number of patients per day with which he is comfortable. However, over time, they pressure him to increase his patient volume. When Dr Young reports to the partners that, because of the increased volume, he can no longer perform total body skin exams (TBSEs) on every new patient or at routine screening visits for established patients at risk for skin cancer, the senior partner informs him that none of the other partners standardly perform full skin exams. Typically, they only examine sun-exposed skin (face, chest, and arms) and any specific lesions the patients are concerned about. Dr Young should: A. Only offer lesion-directed skin examinations. B. Continue to perform TBSEs on all new patients and at routine screening visits for established patients at risk for skin cancer because these exams detect more skin cancers. C. Modify his TBSE by eliminating the exam of acral, genital, and buttock skin, along with scalp and nail examinations. D. Offer a TBSE to all new patients, at routine screening visits for established patients at risk for skin cancer, and on those patients who request it.
DISCUSSION The central ethical issue raised by this scenario is whether it is morally obligatory to perform TBSEs, or at least offer them, to all new dermatology patients and at routine screening visits for patients at risk for skin cancer. Those supporting TBSEs make claims that the practice increases detection of skin cancer (general beneficence or utility), represents a professional duty to patients (deontology), and upholds patient preferences (autonomy). Those supporting lesion-directed exams over TBSEs suggest that the time saved from more focused exams permits seeing more patients while only making a small sacrifice in skin cancer detection, a utilitarian claim. Greater access to dermatologic care is, they claim, preferred by patients and therefore respects autonomy. This From the Dermatology Departments at the University of Connecticut Health Centera and Emory University, Atlanta.b Funding sources: None. Conflicts of interest: None declared. Correspondence to: Jane M. Grant-Kels, MD, Dermatology Department, University of Connecticut, 21 South Rd, Farmington, CT 06032. E-mail: [email protected].
article will consider the ethical merits of both sides of this debate. Supporters of lesion-directed skin exams claim that limiting evaluation to only concerning lesions is more efficient than TBSEs, permitting evaluation of a greater number of patients while only making a small tradeoff in detecting skin cancer. A recent study from Belgium compared TBSEs with lesion-directed skin exams.1 Among 1982 total patients screened, a greater absolute number of skin cancers were detected in the TBSE group compared with the lesion-directed exam group (39 vs 8).1 However, skin cancer detection rates were not statistically different and lesion-directed exams were 5.6-fold less time-consuming.1 Given the limitations in patient access to dermatologic care, the authors J Am Acad Dermatol 2017;76:183-5. 0190-9622/$36.00 Ó 2016 by the American Academy of Dermatology, Inc. http://dx.doi.org/10.1016/j.jaad.2016.06.024
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conclude, lesion-directed exams provide a reasonable alternative to TBSEs because they potentially permit access for a greater number of patients to dermatologic care. Therefore, the moral claim is that lesion-directed exams enhances health-related utility because it does the most good for the most patients. Proponents of lesion-directed exams assume that patients can perform examinations of their own skin, detect potentially harmful lesions, and access dermatologic care for definitive diagnosis and treatment. A recent study demonstrated that up to 72% of 176 patients with melanoma reported doing skin selfexams.2 However, only 14% of these patients examined all parts of their body, 13% always used full-length mirror, 12% used a hand-held mirror, and 9% always had someone help them do the exam. When queried why their compliance was so poor, respondents reported that they either didn’t think of it, didn’t know what to look for, didn’t know that they should, were never told by their doctor to do it, or did not see the need as they receive regular exams from their doctor.2 Lesion-directed exams diagnose skin cancers that patients are aware of and enhance efficiency. However, they fail to detect lesions that patients with skin cancers are not aware of and that are covered by clothing not removed at a lesion-directed exam. For example, at a Department of Veterans Affairs (VA) hospital, routine TBSEs by dermatologists on almost 17,200 patients demonstrated that 5% to 13% of these patients had incidental lesions not noticed by patients that were concerning enough to biopsy. Of those lesions biopsied, over 50% were malignant.3 Furthermore, over one third of melanomas are detected as incidental lesions not noticed by patients on complete skin exams. A recent publication stated: ‘‘Thorough dermatologic examination, regardless of reason for consultation, is essential for early identification of melanoma. More than one third (37.7%) of melanomas. were detected incidentally and would have otherwise been missed without an in-person skin examination by a dermatologist.’’4 In addition, incidental melanomas have been shown to be thinner at diagnosis than those diagnosed after patients have become aware of the lesion and brought it to the attention of their physician.5
ANALYSIS OF CASE SCENARIO Option A is not ethically ideal. Although there are data supporting lesion-directed skin examinations, we argue that there are circumstances in which a TBSE should be performed,
J AM ACAD DERMATOL
JANUARY 2017
Despite the potential benefits of lesion-directed exams to public health resulting from the capacity to evaluate more patients, individual patients should maintain the autonomous right to a comprehensive skin exam if they desire it, especially at an initial visit. We argue that, in individual cases, respect for autonomy may override health-related utility. If a new patient makes a reasonable request for a TBSE then the dermatologist should respect that request. So, what are general patient preferences about TBSEs by dermatologists? In a survey study of 251 patients at the VA, 83% of responders expressed a preference for regular TBSEs by their dermatologists and only 4% did not desire regular TBSEs (the remaining 13% were neutral).6 The bioethical principle of beneficence suggests that health care providers should do good for patients, both individually and in aggregate. General beneficence represents the ideal of promoting the wellbeing of all patients and is reflected in public health interventions. As to whether there is greater utility in TBSEs or lesion-directed exams remains an ongoing debate. We argue here that there may be a specific beneficence claim to the individual patient to perform TBSE in some cases, particularly in new patients and in patients at high risk for skin cancer as a matter of professional duty. Further, if a patient requests a TBSE, it is reasonable to comply to respect patient autonomy. A more difficult scenario arises when a patient declines a TBSE, particularly when the dermatologist believes it is in the patients’ best health interests to have one. There is no uniform approach to cases like this and the dermatologist is left to weigh patient autonomy against specific beneficence. Further research is needed to determine the reasons patients may decline TBSEs when recommended by their dermatologists. Interestingly, patient embarrassment appears to play only a minor role. In the patient preference study of patients at the VA, only 8% reported embarrassment about a TBSE.6 Finally, the financial well-being of the dermatology practice, and related issues of fairness in distribution of the workload, must be considered in this scenario. A senior partner of a practice has a right to address the need for another provider to care for an adequate number of patients to ensure financial viability and just distribution of work and compensation.
including when a patient requests it and in new patients or those at high risk. Option B is reasonable, as TBSEs do seem to detect more skin cancers than lesion-directed exams, based on limited data. However, there may be
J AM ACAD DERMATOL VOLUME 76, NUMBER 1
situations in which a TBSE is clearly not appropriate, such as when a patient at low risk does not want a TBSE or the patient is following up for an inflammatory dermatosis to assess symptomatic improvement. Further, insisting on TBSEs for all patients leads to more time-consuming and, potentially, costly visits for patients. A modified TBSE, as in choice C, may seem like a reasonable compromise
BOTTOM LINE Some dermatologists argue (verbally, not in writing) that TBSEs are boring and not good use of a dermatologist’s time. They recommend that others, including physician extenders (eg, nurse practitioners and physician assistants) and family physicians, should be trained to perform these exams. We would contend that performing a thorough TBSE is a critical skill and part of our profession. Who is better trained to recognize an early skin cancer than a trained dermatologist with a dermatoscope? As dermatologists we are responsible for the cutaneous health of our patients. Although we hope that other health care providers, such as primary care physicians and physician extenders, perform TBSEs as part of their patient encounters, a TBSE by a dermatologist is, in many if not most cases, in the best interest of the health of our patients. In addition, young physicians should be allowed to practice dermatology in the manner in which they were trained and in a style that makes them comfortable as long as it is not detrimental to the well-being
Grant-Kels and Stoff 185
between lesion-directed exams and full TBSEs. However, this still does not fully account for the possibility of incidental findings or patient preferences. In our opinion, choice D, offering a TBSE to all new patients and on established patients at risk for skin cancer, allowing preferences to determine whether one is actually performed, strikes the best balance between beneficence and autonomy in this context.
of their patients and the financial viability of the practice. REFERENCES 1. Hoorens I, Vossaert K, Pil L, et al. Total-body examination vs lesion-directed skin cancer screening. JAMA Dermatol. 2016;152:27-34. 2. Coups EJ, Manne SL, Stapleton JL, Tatum KL, Goydos JS. Skin self-examination behaviors among individuals diagnosed with melanoma. Melanoma Res. 2016;26:71-76. 3. Kingsley-Loso JL, Grey KR, Hanson JL, et al. Incidental lesions found in veterans referred to dermatology: the value of a dermatologic examination. J Am Acad Dermatol. 2015;72:651-655. 4. Aldridge RB, Naysmith L, Ooi ET, Murray CS, Rees JL. The importance of a full clinical examination: assessment of index lesions referred to a skin cancer clinic without a total body skin examination would miss one in three melanomas. Acta Derm Venereol. 2013;93:689-692. 5. Hanson JL, Kingsley-Loso JL, Grey KR. Incidental melanomas detected in veterans referred to dermatology. J Am Acad Dermatol. 2016;74:462-469. 6. Federman DG, Kravetz JD, Tobin DG, Ma F, Kirsner RS. Fullbody skin examinations: the patient’s perspective. Arch Dermatol. 2004;140:530-534.
CASE SCENARIO Dr Young recently completed his dermatology residency and joined a well-respected dermatology practice. Initially, the partners allow him to see the number of patients per day with which he is comfortable. However, over time, they pressure him to increase his patient volume. When Dr Young reports to the partners that, because of the increased volume, he can no longer perform total body skin exams (TBSEs) on every new patient or at routine screening visits for established patients at risk for skin cancer, the senior partner informs him that none of the other partners standardly perform full skin exams. Typically, they only examine sun-exposed skin (face, chest, and arms) and any specific lesions the patients are concerned about. Dr Young should: A. Only offer lesion-directed skin examinations. B. Continue to perform TBSEs on all new patients and at routine screening visits for established patients at risk for skin cancer because these exams detect more skin cancers. C. Modify his TBSE by eliminating the exam of acral, genital, and buttock skin, along with scalp and nail examinations. D. Offer a TBSE to all new patients, at routine screening visits for established patients at risk for skin cancer, and on those patients who request it.
DISCUSSION The central ethical issue raised by this scenario is whether it is morally obligatory to perform TBSEs, or at least offer them, to all new dermatology patients and at routine screening visits for patients at risk for skin cancer. Those supporting TBSEs make claims that the practice increases detection of skin cancer (general beneficence or utility), represents a professional duty to patients (deontology), and upholds patient preferences (autonomy). Those supporting lesion-directed exams over TBSEs suggest that the time saved from more focused exams permits seeing more patients while only making a small sacrifice in skin cancer detection, a utilitarian claim. Greater access to dermatologic care is, they claim, preferred by patients and therefore respects autonomy. This From the Dermatology Departments at the University of Connecticut Health Centera and Emory University, Atlanta.b Funding sources: None. Conflicts of interest: None declared. Correspondence to: Jane M. Grant-Kels, MD, Dermatology Department, University of Connecticut, 21 South Rd, Farmington, CT 06032. E-mail: [email protected].
article will consider the ethical merits of both sides of this debate. Supporters of lesion-directed skin exams claim that limiting evaluation to only concerning lesions is more efficient than TBSEs, permitting evaluation of a greater number of patients while only making a small tradeoff in detecting skin cancer. A recent study from Belgium compared TBSEs with lesion-directed skin exams.1 Among 1982 total patients screened, a greater absolute number of skin cancers were detected in the TBSE group compared with the lesion-directed exam group (39 vs 8).1 However, skin cancer detection rates were not statistically different and lesion-directed exams were 5.6-fold less time-consuming.1 Given the limitations in patient access to dermatologic care, the authors J Am Acad Dermatol 2017;76:183-5. 0190-9622/$36.00 Ó 2016 by the American Academy of Dermatology, Inc. http://dx.doi.org/10.1016/j.jaad.2016.06.024
183
184 Grant-Kels and Stoff
conclude, lesion-directed exams provide a reasonable alternative to TBSEs because they potentially permit access for a greater number of patients to dermatologic care. Therefore, the moral claim is that lesion-directed exams enhances health-related utility because it does the most good for the most patients. Proponents of lesion-directed exams assume that patients can perform examinations of their own skin, detect potentially harmful lesions, and access dermatologic care for definitive diagnosis and treatment. A recent study demonstrated that up to 72% of 176 patients with melanoma reported doing skin selfexams.2 However, only 14% of these patients examined all parts of their body, 13% always used full-length mirror, 12% used a hand-held mirror, and 9% always had someone help them do the exam. When queried why their compliance was so poor, respondents reported that they either didn’t think of it, didn’t know what to look for, didn’t know that they should, were never told by their doctor to do it, or did not see the need as they receive regular exams from their doctor.2 Lesion-directed exams diagnose skin cancers that patients are aware of and enhance efficiency. However, they fail to detect lesions that patients with skin cancers are not aware of and that are covered by clothing not removed at a lesion-directed exam. For example, at a Department of Veterans Affairs (VA) hospital, routine TBSEs by dermatologists on almost 17,200 patients demonstrated that 5% to 13% of these patients had incidental lesions not noticed by patients that were concerning enough to biopsy. Of those lesions biopsied, over 50% were malignant.3 Furthermore, over one third of melanomas are detected as incidental lesions not noticed by patients on complete skin exams. A recent publication stated: ‘‘Thorough dermatologic examination, regardless of reason for consultation, is essential for early identification of melanoma. More than one third (37.7%) of melanomas. were detected incidentally and would have otherwise been missed without an in-person skin examination by a dermatologist.’’4 In addition, incidental melanomas have been shown to be thinner at diagnosis than those diagnosed after patients have become aware of the lesion and brought it to the attention of their physician.5
ANALYSIS OF CASE SCENARIO Option A is not ethically ideal. Although there are data supporting lesion-directed skin examinations, we argue that there are circumstances in which a TBSE should be performed,
J AM ACAD DERMATOL
JANUARY 2017
Despite the potential benefits of lesion-directed exams to public health resulting from the capacity to evaluate more patients, individual patients should maintain the autonomous right to a comprehensive skin exam if they desire it, especially at an initial visit. We argue that, in individual cases, respect for autonomy may override health-related utility. If a new patient makes a reasonable request for a TBSE then the dermatologist should respect that request. So, what are general patient preferences about TBSEs by dermatologists? In a survey study of 251 patients at the VA, 83% of responders expressed a preference for regular TBSEs by their dermatologists and only 4% did not desire regular TBSEs (the remaining 13% were neutral).6 The bioethical principle of beneficence suggests that health care providers should do good for patients, both individually and in aggregate. General beneficence represents the ideal of promoting the wellbeing of all patients and is reflected in public health interventions. As to whether there is greater utility in TBSEs or lesion-directed exams remains an ongoing debate. We argue here that there may be a specific beneficence claim to the individual patient to perform TBSE in some cases, particularly in new patients and in patients at high risk for skin cancer as a matter of professional duty. Further, if a patient requests a TBSE, it is reasonable to comply to respect patient autonomy. A more difficult scenario arises when a patient declines a TBSE, particularly when the dermatologist believes it is in the patients’ best health interests to have one. There is no uniform approach to cases like this and the dermatologist is left to weigh patient autonomy against specific beneficence. Further research is needed to determine the reasons patients may decline TBSEs when recommended by their dermatologists. Interestingly, patient embarrassment appears to play only a minor role. In the patient preference study of patients at the VA, only 8% reported embarrassment about a TBSE.6 Finally, the financial well-being of the dermatology practice, and related issues of fairness in distribution of the workload, must be considered in this scenario. A senior partner of a practice has a right to address the need for another provider to care for an adequate number of patients to ensure financial viability and just distribution of work and compensation.
including when a patient requests it and in new patients or those at high risk. Option B is reasonable, as TBSEs do seem to detect more skin cancers than lesion-directed exams, based on limited data. However, there may be
J AM ACAD DERMATOL VOLUME 76, NUMBER 1
situations in which a TBSE is clearly not appropriate, such as when a patient at low risk does not want a TBSE or the patient is following up for an inflammatory dermatosis to assess symptomatic improvement. Further, insisting on TBSEs for all patients leads to more time-consuming and, potentially, costly visits for patients. A modified TBSE, as in choice C, may seem like a reasonable compromise
BOTTOM LINE Some dermatologists argue (verbally, not in writing) that TBSEs are boring and not good use of a dermatologist’s time. They recommend that others, including physician extenders (eg, nurse practitioners and physician assistants) and family physicians, should be trained to perform these exams. We would contend that performing a thorough TBSE is a critical skill and part of our profession. Who is better trained to recognize an early skin cancer than a trained dermatologist with a dermatoscope? As dermatologists we are responsible for the cutaneous health of our patients. Although we hope that other health care providers, such as primary care physicians and physician extenders, perform TBSEs as part of their patient encounters, a TBSE by a dermatologist is, in many if not most cases, in the best interest of the health of our patients. In addition, young physicians should be allowed to practice dermatology in the manner in which they were trained and in a style that makes them comfortable as long as it is not detrimental to the well-being
Grant-Kels and Stoff 185
between lesion-directed exams and full TBSEs. However, this still does not fully account for the possibility of incidental findings or patient preferences. In our opinion, choice D, offering a TBSE to all new patients and on established patients at risk for skin cancer, allowing preferences to determine whether one is actually performed, strikes the best balance between beneficence and autonomy in this context.
of their patients and the financial viability of the practice. REFERENCES 1. Hoorens I, Vossaert K, Pil L, et al. Total-body examination vs lesion-directed skin cancer screening. JAMA Dermatol. 2016;152:27-34. 2. Coups EJ, Manne SL, Stapleton JL, Tatum KL, Goydos JS. Skin self-examination behaviors among individuals diagnosed with melanoma. Melanoma Res. 2016;26:71-76. 3. Kingsley-Loso JL, Grey KR, Hanson JL, et al. Incidental lesions found in veterans referred to dermatology: the value of a dermatologic examination. J Am Acad Dermatol. 2015;72:651-655. 4. Aldridge RB, Naysmith L, Ooi ET, Murray CS, Rees JL. The importance of a full clinical examination: assessment of index lesions referred to a skin cancer clinic without a total body skin examination would miss one in three melanomas. Acta Derm Venereol. 2013;93:689-692. 5. Hanson JL, Kingsley-Loso JL, Grey KR. Incidental melanomas detected in veterans referred to dermatology. J Am Acad Dermatol. 2016;74:462-469. 6. Federman DG, Kravetz JD, Tobin DG, Ma F, Kirsner RS. Fullbody skin examinations: the patient’s perspective. Arch Dermatol. 2004;140:530-534.