In dermatology, a particularly common ethical dilemma can arise when the skin lesions of bystanders are inadvertently viewed in public settings. Dermatology is a unique field, where a person’s organ of interest is readily visible to others. When lesions are suspicious for skin disease, unsolicited medical opinions may or may not be given depending on several factors. This study examined the actions and attitudes of dermatologists with different levels of experience through the use of case scenarios with various settings and skin lesions. © 2017, Dermatology Online Journal. All rights reserved

Keller, Matthew S.

Korta, Dorota Z.

Wang, Jordan

Zachary, Christopher B.

English

Jefferson Digital Commons

Thomas Jefferson UniversityJefferson Digital CommonsDepartment of Dermatology and CutaneousBiology Faculty PapersDepartment of Dermatology and CutaneousBiology10-2017Trends in unsolicited dermatologic opinions: Anational surveyJordan WangThomas Jefferson University, jordan.wang@jefferson.eduDorota Z. KortaUniversity of California, IrvineChristopher B. ZacharyUniversity of California, IrvineMatthew S. KellerThomas Jefferson University, matthew.keller@jefferson.eduLet us know how access to this document benefits youFollow this and additional works at: https://jdc.jefferson.edu/dcbfpPart of the Dermatology CommonsThis Article is brought to you for free and open access by the Jefferson Digital Commons. The Jefferson Digital Commons is a service of ThomasJefferson University's Center for Teaching and Learning (CTL). The Commons is a showcase for Jefferson books and journals, peer-reviewed scholarlypublications, unique historical collections from the University archives, and teaching tools. The Jefferson Digital Commons allows researchers andinterested readers anywhere in the world to learn about and keep up to date with Jefferson scholarship. This article has been accepted for inclusion inDepartment of Dermatology and Cutaneous Biology Faculty Papers by an authorized administrator of the Jefferson Digital Commons. For moreinformation, please contact: JeffersonDigitalCommons@jefferson.edu.Recommended CitationWang, Jordan; Korta, Dorota Z.; Zachary, Christopher B.; and Keller, Matthew S., "Trends inunsolicited dermatologic opinions: A national survey" (2017). Department of Dermatology andCutaneous Biology Faculty Papers. Paper 82.https://jdc.jefferson.edu/dcbfp/82UC DavisDermatology Online JournalTitleTrends in unsolicited dermatologic opinions: a national surveyPermalinkhttps://escholarship.org/uc/item/9521562sJournalDermatology Online Journal, 23(10)AuthorsWang, Jordan VKorta, Dorota ZZachary, Christopher Bet al.Publication Date2017-01-01LicenseCC BY-NC-ND 4.0eScholarship.org Powered by the California Digital LibraryUniversity of CaliforniaVolume 23 Number 10 | October 2017 23 (10): 20- 1 - Dermatology Online Journal  ||  LetterJordan V Wang1 MD MBE, Dorota Z Korta2 MD PhD, Christopher B Zachary2 MBBS FRCP, Matthew Keller1 MDAffiliations: 1Department of Dermatology and Cutaneous Biology, Thomas Jefferson University, Philadelphia, Pennsylvania; 2Department of Dermatology, University of California, Irvine, CaliforniaCorresponding Author: Jordan V Wang MD, MBE, c/o Matthew Keller MD, Department of Dermatology and Cutaneous Biology, Thomas Jefferson University, 833 Chestnut Street, Suite 740, Philadelphia, PA, 19107, Tel: (610) 202-9030, Fax: (215) 503-3333, Email: jordan.wang@jefferson.eduTrends in unsolicited dermatologic opinions: a national surveyKeywords: bioethics, dermatology, residency, medical education, unsolicited diagnosisIntroduction:Unlike other organs, a person’s skin is often readily visible to the public. Therefore, dermatologists may inadvertently and unintentionally view lesions suspicious for skin disease. The subject of whether physicians should offer their unsolicited medical opinions has continued to garner interest in the recent dermatologic literature [1-4]. As a clear ethical dilemma, many factors must be acknowledged before approaching a bystander who is thought to have an abnormal skin condition. Key considerations include the potential for privacy, the location of the encounter, and the type, severity, and certainty of the potential diagnosis. Options available to the physician range from disregarding any signs of disease to performing an impromptu examination. The aim of this study was to examine the attitudes of dermatologists at different levels of experience toward giving unsolicited dermatologic opinions using various settings and skin lesions.MethodsAn optional 16-item online survey was sent in September 2016 to dermatology residency program coordinators to be forwarded to residents and program directors. Program directors served as the physicians with greater experience. The survey asked for demographic data, length of training specific to dermatology, and questions related to various hypothetical scenarios pertaining to approaching bystanders with unsolicited medical opinions. The scenarios specifically focused on healthcare and non-healthcare settings. In addition, consideration was given for differences in approach to lesions suspicious for melanoma, squamous cell carcinoma (SCC), basal cell carcinoma (BCC), and actinic keratosis (AK). Top-box scoring was utilized and chi-squared test was performed.ResultsA total of 34 of 121 (28.1%) program directors and 76 of 1358 (5.6%) residents completed the survey. Unsurprisingly, program directors possessed greater length of training in years than residents (20.1 vs. 2.0, p<0.00001). In each non-healthcare and healthcare setting, program directors were more comfortable than residents approaching bystanders with unsolicited medical opinions (6.9% vs. 2.2%, p=0.037; 91.2% vs. 71.1%, p=0.021). There were no significant differences in physician confidence in each setting respectively (18.6% vs. 19.7%; 58.8% vs. 51.3%).AbstractIn dermatology, a particularly common ethical dilemma can arise when the skin lesions of bystanders are inadvertently viewed in public settings. Dermatology is a unique field, where a person’s organ of interest is readily visible to others. When lesions are suspicious for skin disease, unsolicited medical opinions may or may not be given depending on several factors. This study examined the actions and attitudes of dermatologists with different levels of experience through the use of case scenarios with various settings and skin lesions.Volume 23 Number 10 | October 2017 23 (10): 20- 2 - Dermatology Online Journal  ||  LetterTable I. Approach rates (%) of skin lesions.Skin Lesion Healthcare Setting (Y/N)Program Directors (%) Residents (%) p-valueBCC Y 100 96.1Melanoma N 94.1 77.6 p=0.035SCC N 41.2 32.9AK N 2.9 5.3Program directors were more likely to approach bystanders with lesions suspicious for melanoma (94.1% vs. 77.6%, p=0.035). There were no significant differences in rates of approach for other skin lesions including BCC (100.0% vs. 96.1%) in healthcare setting, and SCC (41.2% vs. 32.9%) and AK (2.9% vs. 5.3%) in non-healthcare settings. (Table I)Conclusion: Experienced dermatologists were generally more comfortable approaching bystanders both in public surroundings and also in healthcare environments. They were also more likely to approach bystanders with high-risk lesions suspicious for melanoma. The visualization of all other skin lesions, including BCC, SCC, and AK, showed no differences in bystander approach. However, there was a trend toward increased rates of approach for more severe lesions in non-healthcare settings. Additional studies are needed to further examine other factors influencing unsolicited dermatologic opinions.References:1. Bercovitch L. “Excuse me…”: Unsolicited dermatologic opinions: Ethical, moral, and legal issues. In: Bercovitch L, Perlis C, editors. Dermatoethics: Contemporary ethics and professionalism in dermatology. London: Springer; 2012. 3-7.2. Bercovitch L. Should one offer an unsolicited dermatologic opinion? Ethics for the locker-room dermatologist. J Am Acad Dermatol 2011;65:134-6. [PMID: 21536344].3. Grant-Kels JM, Anderson JK, Kels BD. The unsolicited ominous diagnosis: Legal, moral, and ethical considerations. J Am Acad Dermatol 2012;66:985-7. [PMID: 22583709].4. Wolz MM, Drage LA. The unscheduled and incidental bystander: Legal, moral, and ethical considerations in the office. J Am Acad Dermatol 2013;68:332-4. [PMID: 23317971].Survey1.Are you a resident or program director? Resident Program Director2.How many years have you been practicing in dermatology, including residency training?__________3.Do you participate in an in-patient hospital consultation service? Yes No4.If you are a current resident, do you participate in a resident-run clinic? Yes No Not A Current Resident5.Scenario 1: You are changing your clothes in the communal locker room at your nearest gym. Standing next to your locker is someone who is unknown to you. While putting away your clothes, you inadvertently view what appears to be an irregularly hyperpigmented lesion on this person’s arm. This is suspicious for a possible melanoma.a.Would you approach the bystander regarding this Volume 23 Number 10 | October 2017 23 (10): 20- 3 - Dermatology Online Journal  ||  Letterpotential diagnosis? Yes Nob.How comfortable do you feel approaching the bystander in this location? 1 (Extremely Comfortable) 2 (Very Comfortable) 3 (Comfortable) 4 (Somewhat Comfortable) 5 (Not Comfortable)c.How confident are you in making the diagnosis? 1 (Extremely Confident) 2 (Very Confident) 3 (Confident) 4 (Somewhat Confident) 5 (Not Confident)6.Scenario 2: You are visiting your nearest beach town for the weekend. While walking along the ocean, there is another person walking in the opposite direction toward you. When this person passes you by, you inadvertently view an erythematous and hyperkeratotic papule on this person’s ear. This is suspicious for a possible squamous cell carcinoma.a.Would you approach the bystander regarding this potential diagnosis? Yes Nob.How comfortable do you feel approaching the bystander in this location? 1 (Extremely Comfortable) 2 (Very Comfortable) 3 (Comfortable) 4 (Somewhat Comfortable) 5 (Not Comfortable)c. How confident are you in making the diagnosis? 1 (Extremely Confident) 2 (Very Confident) 3 (Confident) 4 (Somewhat Confident) 5 (Not Confident)7. Scenario 3: You are shopping at a clothing store in your nearest mall. Next to the clothing rack that you are browsing through are a couple of chairs for shoppers to sit. An older gentleman walks toward one of these chairs. When this person bends over to sit down, you inadvertently view several thick and hyperkeratotic papules on this person’s scalp. These are suspicious for possible actinic keratoses.a. Would you approach the bystander regarding this potential diagnosis? Yes Nob. How comfortable do you feel approaching the bystander in this location? 1 (Extremely Comfortable) 2 (Very Comfortable) 3 (Comfortable) 4 (Somewhat Comfortable)Volume 23 Number 10 | October 2017 23 (10): 20- 4 - Dermatology Online Journal  ||  Letter 5 (Not Comfortable)c. How confident are you in making the diagnosis? 1 (Extremely Confident) 2 (Very Confident) 3 (Confident) 4 (Somewhat Confident) 5 (Not Confident)8. Scenario 4: You are participating in an in-patient hospital consultation service. You were consulted to evaluate a patient for a possible drug reaction. However, when examining this patient, you also view a pearly nodule on this patient’s outer cheek. This is suspicious for a possible basal cell carcinoma.a. Would you approach the patient regarding this potential diagnosis that is unrelated to the consult? Yes Nob. How comfortable do you feel approaching the patient about this potential diagnosis that is unrelated to the consult? 1 (Extremely Comfortable) 2 (Very Comfortable) 3 (Comfortable) 4 (Somewhat Comfortable) 5 (Not Comfortable)c. How confident are you in making the diagnosis? 1 (Extremely Confident) 2 (Very Confident) 3 (Confident) 4 (Somewhat Confident) 5 (Not Confident)

Trends in unsolicited dermatologic opinions: A national survey

Name not available

In dermatology, a particularly common ethical dilemma can arise when the skin lesions of bystanders are inadvertently viewed in public settings. Dermatology is a unique field, where a person’s organ of interest is readily visible to others. When lesions are suspicious for skin disease, unsolicited medical opinions may or may not be given depending on several factors. This study examined the actions and attitudes of dermatologists with different levels of experience through the use of case scenarios with various settings and skin lesions

Wang, Jordan V

Korta, Dorota Z

Zachary, Christopher B

Keller, Matthew

eScholarship - University of California

UC DavisDermatology Online JournalTitleTrends in unsolicited dermatologic opinions: a national surveyPermalinkhttps://escholarship.org/uc/item/9521562sJournalDermatology Online Journal, 23(10)AuthorsWang, Jordan VKorta, Dorota ZZachary, Christopher Bet al.Publication Date2017DOI10.5070/D32310037011Copyright InformationCopyright 2017 by the author(s).This work is made available under the terms of a Creative Commons Attribution-NonCommercial-NoDerivatives License, available at https://creativecommons.org/licenses/by-nc-nd/4.0/eScholarship.org Powered by the California Digital LibraryUniversity of CaliforniaVolume 23 Number 10 | October 2017 23 (10): 20- 1 - Dermatology Online Journal  ||  LetterJordan V Wang1 MD MBE, Dorota Z Korta2 MD PhD, Christopher B Zachary2 MBBS FRCP, Matthew Keller1 MDAffiliations: 1Department of Dermatology and Cutaneous Biology, Thomas Jefferson University, Philadelphia, Pennsylvania; 2Department of Dermatology, University of California, Irvine, CaliforniaCorresponding Author: Jordan V Wang MD, MBE, c/o Matthew Keller MD, Department of Dermatology and Cutaneous Biology, Thomas Jefferson University, 833 Chestnut Street, Suite 740, Philadelphia, PA, 19107, Tel: (610) 202-9030, Fax: (215) 503-3333, Email: jordan.wang@jefferson.eduTrends in unsolicited dermatologic opinions: a national surveyKeywords: bioethics, dermatology, residency, medical education, unsolicited diagnosisIntroduction:Unlike other organs, a person’s skin is often readily visible to the public. Therefore, dermatologists may inadvertently and unintentionally view lesions suspicious for skin disease. The subject of whether physicians should offer their unsolicited medical opinions has continued to garner interest in the recent dermatologic literature [1-4]. As a clear ethical dilemma, many factors must be acknowledged before approaching a bystander who is thought to have an abnormal skin condition. Key considerations include the potential for privacy, the location of the encounter, and the type, severity, and certainty of the potential diagnosis. Options available to the physician range from disregarding any signs of disease to performing an impromptu examination. The aim of this study was to examine the attitudes of dermatologists at different levels of experience toward giving unsolicited dermatologic opinions using various settings and skin lesions.MethodsAn optional 16-item online survey was sent in September 2016 to dermatology residency program coordinators to be forwarded to residents and program directors. Program directors served as the physicians with greater experience. The survey asked for demographic data, length of training specific to dermatology, and questions related to various hypothetical scenarios pertaining to approaching bystanders with unsolicited medical opinions. The scenarios specifically focused on healthcare and non-healthcare settings. In addition, consideration was given for differences in approach to lesions suspicious for melanoma, squamous cell carcinoma (SCC), basal cell carcinoma (BCC), and actinic keratosis (AK). Top-box scoring was utilized and chi-squared test was performed.ResultsA total of 34 of 121 (28.1%) program directors and 76 of 1358 (5.6%) residents completed the survey. Unsurprisingly, program directors possessed greater length of training in years than residents (20.1 vs. 2.0, p<0.00001). In each non-healthcare and healthcare setting, program directors were more comfortable than residents approaching bystanders with unsolicited medical opinions (6.9% vs. 2.2%, p=0.037; 91.2% vs. 71.1%, p=0.021). There were no significant differences in physician confidence in each setting respectively (18.6% vs. 19.7%; 58.8% vs. 51.3%).AbstractIn dermatology, a particularly common ethical dilemma can arise when the skin lesions of bystanders are inadvertently viewed in public settings. Dermatology is a unique field, where a person’s organ of interest is readily visible to others. When lesions are suspicious for skin disease, unsolicited medical opinions may or may not be given depending on several factors. This study examined the actions and attitudes of dermatologists with different levels of experience through the use of case scenarios with various settings and skin lesions.Volume 23 Number 10 | October 2017 23 (10): 20- 2 - Dermatology Online Journal  ||  LetterTable I. Approach rates (%) of skin lesions.Skin Lesion Healthcare Setting (Y/N)Program Directors (%) Residents (%) p-valueBCC Y 100 96.1Melanoma N 94.1 77.6 p=0.035SCC N 41.2 32.9AK N 2.9 5.3Program directors were more likely to approach bystanders with lesions suspicious for melanoma (94.1% vs. 77.6%, p=0.035). There were no significant differences in rates of approach for other skin lesions including BCC (100.0% vs. 96.1%) in healthcare setting, and SCC (41.2% vs. 32.9%) and AK (2.9% vs. 5.3%) in non-healthcare settings. (Table I)Conclusion: Experienced dermatologists were generally more comfortable approaching bystanders both in public surroundings and also in healthcare environments. They were also more likely to approach bystanders with high-risk lesions suspicious for melanoma. The visualization of all other skin lesions, including BCC, SCC, and AK, showed no differences in bystander approach. However, there was a trend toward increased rates of approach for more severe lesions in non-healthcare settings. Additional studies are needed to further examine other factors influencing unsolicited dermatologic opinions.References:1. Bercovitch L. “Excuse me…”: Unsolicited dermatologic opinions: Ethical, moral, and legal issues. In: Bercovitch L, Perlis C, editors. Dermatoethics: Contemporary ethics and professionalism in dermatology. London: Springer; 2012. 3-7.2. Bercovitch L. Should one offer an unsolicited dermatologic opinion? Ethics for the locker-room dermatologist. J Am Acad Dermatol 2011;65:134-6. [PMID: 21536344].3. Grant-Kels JM, Anderson JK, Kels BD. The unsolicited ominous diagnosis: Legal, moral, and ethical considerations. J Am Acad Dermatol 2012;66:985-7. [PMID: 22583709].4. Wolz MM, Drage LA. The unscheduled and incidental bystander: Legal, moral, and ethical considerations in the office. J Am Acad Dermatol 2013;68:332-4. [PMID: 23317971].Survey1.Are you a resident or program director? Resident Program Director2.How many years have you been practicing in dermatology, including residency training?__________3.Do you participate in an in-patient hospital consultation service? Yes No4.If you are a current resident, do you participate in a resident-run clinic? Yes No Not A Current Resident5.Scenario 1: You are changing your clothes in the communal locker room at your nearest gym. Standing next to your locker is someone who is unknown to you. While putting away your clothes, you inadvertently view what appears to be an irregularly hyperpigmented lesion on this person’s arm. This is suspicious for a possible melanoma.a.Would you approach the bystander regarding this Volume 23 Number 10 | October 2017 23 (10): 20- 3 - Dermatology Online Journal  ||  Letterpotential diagnosis? Yes Nob.How comfortable do you feel approaching the bystander in this location? 1 (Extremely Comfortable) 2 (Very Comfortable) 3 (Comfortable) 4 (Somewhat Comfortable) 5 (Not Comfortable)c.How confident are you in making the diagnosis? 1 (Extremely Confident) 2 (Very Confident) 3 (Confident) 4 (Somewhat Confident) 5 (Not Confident)6.Scenario 2: You are visiting your nearest beach town for the weekend. While walking along the ocean, there is another person walking in the opposite direction toward you. When this person passes you by, you inadvertently view an erythematous and hyperkeratotic papule on this person’s ear. This is suspicious for a possible squamous cell carcinoma.a.Would you approach the bystander regarding this potential diagnosis? Yes Nob.How comfortable do you feel approaching the bystander in this location? 1 (Extremely Comfortable) 2 (Very Comfortable) 3 (Comfortable) 4 (Somewhat Comfortable) 5 (Not Comfortable)c. How confident are you in making the diagnosis? 1 (Extremely Confident) 2 (Very Confident) 3 (Confident) 4 (Somewhat Confident) 5 (Not Confident)7. Scenario 3: You are shopping at a clothing store in your nearest mall. Next to the clothing rack that you are browsing through are a couple of chairs for shoppers to sit. An older gentleman walks toward one of these chairs. When this person bends over to sit down, you inadvertently view several thick and hyperkeratotic papules on this person’s scalp. These are suspicious for possible actinic keratoses.a. Would you approach the bystander regarding this potential diagnosis? Yes Nob. How comfortable do you feel approaching the bystander in this location? 1 (Extremely Comfortable) 2 (Very Comfortable) 3 (Comfortable) 4 (Somewhat Comfortable)Volume 23 Number 10 | October 2017 23 (10): 20- 4 - Dermatology Online Journal  ||  Letter 5 (Not Comfortable)c. How confident are you in making the diagnosis? 1 (Extremely Confident) 2 (Very Confident) 3 (Confident) 4 (Somewhat Confident) 5 (Not Confident)8. Scenario 4: You are participating in an in-patient hospital consultation service. You were consulted to evaluate a patient for a possible drug reaction. However, when examining this patient, you also view a pearly nodule on this patient’s outer cheek. This is suspicious for a possible basal cell carcinoma.a. Would you approach the patient regarding this potential diagnosis that is unrelated to the consult? Yes Nob. How comfortable do you feel approaching the patient about this potential diagnosis that is unrelated to the consult? 1 (Extremely Comfortable) 2 (Very Comfortable) 3 (Comfortable) 4 (Somewhat Comfortable) 5 (Not Comfortable)c. How confident are you in making the diagnosis? 1 (Extremely Confident) 2 (Very Confident) 3 (Confident) 4 (Somewhat Confident) 5 (Not Confident)

Trends in unsolicited dermatologic opinions: a national survey

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Trends in unsolicited dermatologic opinions: A national survey

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