Coordinating Care
To Refer or Not to Refer

T he disciplines of dermatology and plastic surgery overlap in several areas, including that of skin cancer treatment. As dermatologists, you can take care of the majority of skin cancers seen in your practices, but some special situations may require you to coordinate your patient’s care with care from a plastic surgeon. The tips offered in this article are designed to aid you in making the decision to refer part or all of a patient’s cancer treatment to a plastic surgeon when necessary. It will also provide you with ideas for the best ways to effectively deal with plastic surgeons. When To Think About Referring When trying to decide if you need to refer a patient to another specialist, keep in mind that just as each person is unique, you must consider each case individually. What worked for one patient may not work for another. Likewise, though you may have been able to successfully treat one patient on your own, another may require the expertise of a plastic surgeon. That said, you might find yourself in a situation where you’re not sure if you should continue treating a patient or if you should refer him or her to another physician. You’re not alone in this dilemma. That’s why I’ve illustrated some common examples of patient cases in which you should seriously consider bringing in the expertise of a plastic surgeon. For example, if you have a patient who has a lesion with an excision defect too large to leave open and too large to close primarily, you should definitely consider referring him or her to a surgeon. Sometimes you can use a skin graft in this scenario, but it’s often less cosmetically desirable than closure with local or distant flaps. This is especially true when dealing with lesions of the face, neck and hands, when patients will be more worried about visual scars from the procedure. Keep in mind that even a small excision in a “cosmetically sensitive” area such as the eyelid, nose, auricle or lip can produce a noticeable deformity. Reconstruction may involve complex plastic surgical techniques that transpose skin and soft tissue from other sites. These techniques are beneficial to the patient for cosmetic reasons and they’re extremely important for restoring and maintaining function. Another scenario in which you may consider referring a patient is if he or she has an aggressive cancer type that may also require lymph node biopsy or neck dissection. You’ll also want to think about referring a patient who insists on having a plastic surgeon operate on his or her face. While you know that you’re perfectly qualified and experienced to perform the procedure, a patient who’s insistent from the get-go is probably critical and demanding with everything. These types of patients can be very difficult to deal with and may not be happy with the end result no matter how good of a job you do. Once a patient is set on wanting a plastic surgeon to perform an operation, it can be difficult to convince them that it’s not necessary. In this case, referring the patient is most likely in your best interest as well as his or hers. A patient who has wound-healing problems caused by arterial or venous insufficiency, diabetes mellitus, heavy smoking, immune deficiency or other causes is another instance in which you’ll want to consider a referral to a plastic surgeon. Skin cancer excision in these patients may require special techniques that you’re not familiar or experienced with to produce optimum healing and a satisfactory result. When There’s no Question About It In this section, we’ll take a look at scenarios where there should be no question in your mind whether to keep a patient in your care or to refer him or her to a surgeon. For example, if you plan to do an excision, whether standard or Mohs’ fresh tissue chemosurgery technique, and you think you may need a plastic surgeon to perform the closure, it’s often preferable to send the patient for a consultation before the excision. This consultation helps to ease your patient’s fears and it allows the surgeon to assess the situation and plan accordingly. On more than one occasion I’ve had only 5 minutes’ notice before a dermatologist sent a patient to my office with a large leg or cheek defect to close. This creates a stressful circumstance for the patient and sometimes causes the surgeon to have to scramble to schedule time for the closure. For certain types and locations of tumors, a plastic surgeon may prefer to perform the excision as well as the closure. Typical scenarios include the requirement of wide margins, such as in the case of melanoma, or a functionally important area such as the lip or nose, or in an area where immediate closure is desirable, such as when cartilage or bone is exposed. There’s nothing wrong with delaying the closure of most skin cancer defects for a few days. In fact, this is common practice in the case of Mohs’ surgery, which is usually performed at a different outpatient location than where the closure is performed. In some cases, this delay is even preferable, as when waiting for definitive microscopic confirmation of margins. However, make sure you tell the patient to keep his or her open wound covered and the base moist to make débridement easier before the repair. Who Do You Turn To? Once you’ve decided to refer your patient to a plastic surgeon, you next have to figure out which surgeon to choose. That’s why it’s a good idea to have one or more plastic surgeons whom you can refer patients to. Be sure to choose one who has a special interest in cancer reconstruction. Some surgeons who concentrate on cosmetic procedures also like to do these types of cases, so just ask. It’s also helpful for your patients if you refer him or her to a surgeon who’s a covered provider for his or her insurance plan, but understand that this isn’t always possible. Work with plastic surgeons who are easily accessible and who communicate effectively with you. You should expect him or her to keep you updated regarding treatment, pathology reports and the patient’s healing progress. Ideally, the surgeon should refer the patient back to you for ongoing follow up care and cancer screening. Listen to your patients. If you hear good reports and see good results, continue to refer to those plastic surgeons. You’ll have happier patients and you’ll build and strengthen your referral network. Cooperation’s the Name of the Game Unfortunately, in today’s high-stress and lower-profits medical marketplace, conflicts between specialists are common. Dermatologists and plastic surgeons are no exception. The area of skin cancer reconstruction is a common ground between these physician groups. Optimal results for patients can best be achieved through appropriate, timely referrals and coordination of care. If you’re unsure of how to proceed with a patient’s care, refer back to this article for a better idea of whether to continue treating him or her yourself or to refer him or her on to someone else for better care. Your patients will appreciate your time in assessing their situations. If you keep the best interests of your patients in mind, they’ll appreciate you for it and you’ll retain patients and patient referrals.