It can be confusing these days when so many different types of doctors evaluate and treat skin cancer to some degree. The skin, after all, is easily accessible for most physicians during routine exams, and it’s not uncommon to get varying opinions about a spot of concern. Sometimes, a physician may point out a suspicious spot on a patient’s skin, while other times, the patient may ask the doctor about an area of concern. In either case, the responsibility ultimately rests with the patient, who alone has to evaluate the reliability of the doctor’s opinion. Therefore, a patient’s expectations should partially depend upon the nature and expertise of a given doctor’s practice.

While many things on one’s skin may be easily recognizable to many general physicians, depending on their level of interest and education, it is also important to realize that many skin problems present with more subtle warning signs that are not easily identified by the unaided eye of a general practitioner. Of course, many doctors are generalists in their routine practice of some broad field of medicine or surgery. These doctors, while extremely prevalent and valuable to our communities, are often less specialized and probably deal with skin cancers or pre-cancers on an infrequent basis.

At the opposite end of the spectrum, a board certified dermatologist is typically recognized as the expert in the evaluation and treatment of all diseases of the skin. There are also dermatologists who further specialize and limit their practice to the evaluation and treatment of skin cancer. It is these relatively few dermatologists who are considered by some as “sub-specialists,” in that they are considered as specialists within the specialty of dermatology. By virtue of their time, extra training, and cumulative experience with a focused group of problems, it stands to reason that sub-specialists would develop an even greater degree of expertise in treating a more specific problem, such as skin cancer.

What a Patient Should Expect From a Skin Cancer Sub-Specialist

1. Attention to detail and a willingness to provide a total body examination

2. A total body exam at least once a year for high-risk patients who have a personal or family history of melanoma

3. The use of typical visual aids, such as lighting and magnification devices

4. The use of technologically advanced visual aids, such as digital photography (to follow spots of concern over time) and dermoscopy (see details in section on Dermoscopy)

What a Patient Should Expect at a Doctor’s Office

Each patient deserves the undivided attention of the physician. If a doctor is popular or well established, there will always be a time crunch in the ever-challenging realm of patient scheduling. However, in my opinion, each patient’s visit merits time to accurately and completely evaluate the patient’s problems.

While the patient should not always expect to have every question thoroughly answered during the time allotted for one visit, the doctor should listen to and note a patient’s concerns. If you feel that your doctor is not giving you enough focused time and attention and that he is rushing to clear a waiting room full of patients, this should give you a hint that the doctor could be overlooking something important in the haste to keep things moving along.

What a Patient Needs to Know Prior to an Examination

A well-trained dermatologist who is conducting a skin cancer screening does not always follow a patient’s list of concerns in the order in which the patient presents them. This is not to say that your spots of concern should not or will not be examined. Oftentimes, the doctor may have a systematic methodology that he follows in order to ensure that he inspects all areas of your body for skin problems; then, the doctor may focus on the spots or lesions that he feels are of most potential concern or suspicion for cancer.

If you want to ensure that you don’t forget to ask the doctor about your particular concerns, feel free to draw a circle around specific spots to ensure that they are seen. This will serve as a reminder to you and as an area of focus for your doctor.

It is best to remove make up from your face prior to the examination so that nothing is hidden. You may choose to bring make up with you to put back on prior to leaving the office and returning to your daily routine.

Finally, if you have a sense that your doctor has not taken an adequate amount of time to possibly screen your skin or address your primary concerns, perhaps a second opinion is warranted. You should trust your instincts and not assume that the doctor couldn’t possibly miss something of importance.

“Red Flag” Warnings

1. If you get a sense that your doctor routinely double- and triple-books the appointment schedule and that the amount of time spent with you tends to leave you a little unsettled, be concerned! Look elsewhere for a second opinion.

2. If your doctor doesn’t give you at least a couple of different treatment options, be concerned! Not everything is all that “black and white.” Each way of treating a problem generally involves varying levels of risk and requires different levels of expertise from the doctor. It is to your benefit when the doctor has more than one method whereby a problem can be approached or treated.

3. If your doctor rarely gives you options but consistently treats your problems the same way, be concerned! This could mean that the doctor is generating large bills for multiple quick procedures, and this is not in your best interest! For example, treating a skin problem with a common approach, such as spraying with liquid nitrogen, may be to your detriment because this approach only treats the surface of what could be a deeply rooted skin cancer. In the course of multiple surface treatments, the real problem—a more serious skin cancer—could persist and worsen. If a specific spot or skin lesion is treated but persists or worsens, seek a second opinion.

Problems I Have Seen During My Years of Practice

1. A doctor is too conservative and fails to get to the root of the problem or is so afraid of missing something that he rarely uses a more conservative method of removal, such as liquid nitrogen. I would like to believe that most doctors strive to keep the patient’s best interest at the forefront of their practice. However, in our increasingly litigious society, there may be times when some doctors feel pressure to do extra tests or procedures in order to avoid missing something of potential importance. This practice of defensive medicine only contributes to the problem of rising healthcare costs.

2. Increasing governmental regulation takes a toll on treatment. The alarming trend toward greater regulation typically equates to a continued increase in cost and practice overhead. At the same time, the reimbursement rates for most medical services are slowly going down. With each passing year, it seems that a physician generally has to do more in less time, simply to keep up and to maintain an acceptable balance in the income/overhead ratio.

3. The best doctors must weigh in the balance many factors with regard to the treatment of their patients. With the demands for specialists in small communities, the demands of insurance companies, and the sheer time involved in maintaining a practice, this balance is sometimes difficult to achieve. We must continually monitor ourselves in light of our expertise and limitations. Above all, we must remember the Hippocratic Oath: to first and foremost do no harm.