MrsPA2u Posted July 15, 2017 Share Posted July 15, 2017 Here's the update (and ongoing issue). My supervising physician and I quote is "not a fan of shave biopsies" and as it stands requests that his mid levels avoid them entirely (his reasoning was "I personally don't like them"). He doesn't even want them being offered as an option that exists. His personal preference are punch biopsies or full excisions. So, his protocol essentially is, all pigmended lesions need to be automatically scheduled for full excision to be performed by him and anything else can be sampled by me via punch biopsy. This problem is...his surgical outcomes are quite unsightly and more often than not, the "lesion of concern" ends up being benign. Quick side note: I am the ONLY full time provider (M-F 830-4pm) in my office. My SP comes in once a month for surgical cases only. The main issue(s) that arise are the constant complaints I get from patients during follow up regarding the cosmetic outcome of the post surgical scarring on a lesion that is ultimately proven to be benign. I am the one spending countless moments listening to unsatisfied patients, reviewing wound care, injecting hypertrophic scars with Kenalog, or addressing other problems since I'm the sole provider on site at all times. My alternative to this have been shave biopsies. This allows for smaller sample size to be taken, which results to a less visible scar that typically heals flush with the skin. I use a dermablade so I am able to get adequate margins at the time of biopsy and the path reports confirms free margins more often than not. Then on those instances when margins aren't free, they then get scheduled for an excision with my SP to remove any remaining atypical cells. SOOOOOOO MANY PATIENTS have expressed satisfaction with this approach. However, I am now faced with the decision of defying the requests of my SP or choosing what's best for the patient. Unfortunately the obvious answer isn't so obvious, help! Link to comment Share on other sites More sharing options...
thepaplatform Posted July 21, 2017 Share Posted July 21, 2017 I think this is where your autonomy as a PA comes in. I was working with one provider who wanted me to do everything exactly like she did, despite my training, so ultimately we had to have a conversation about what was best for the patients and how my plans were not clinically wrong, but just occasionally different than what she would have done. It sounds like you need to have an honest conversation with your SP. My pathologist prefers shave biopsies for pigmented lesions because it is more difficult for them to make an accurate diagnosis with just a piece of the lesion. I only do punch biopsies on lesions <8 mm that I'm fairly certain are atypical and that I think I can clear w/ biopsy (but I do shaves much more often) or inflammatory rashes. Sorry you've been put in that position! Link to comment Share on other sites More sharing options...
Soulfari Posted September 9, 2017 Share Posted September 9, 2017 does he take 5mm margins on the primary EXC of all clinically atypical pigmented lesions? Link to comment Share on other sites More sharing options...
MrsPA2u Posted November 25, 2017 Author Share Posted November 25, 2017 On 9/9/2017 at 1:23 PM, Soulfari said: does he take 5mm margins on the primary EXC of all clinically atypical pigmented lesions? Yes Link to comment Share on other sites More sharing options...
paapp123 Posted December 22, 2017 Share Posted December 22, 2017 This seems like malpractice? And upcoding... Link to comment Share on other sites More sharing options...
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