•Lawsuit process takes 3–5 years. Dig in and be in honest communication with your attorney.

•Do contact your malpractice carrier early and, if no response in few days, send a certified letter since many carriers require prompt notification. Also, there is a time limit to responding to complaints, and certain states can move to a default judgment if you wait too long.

•Do not change the medical record, speak to the plaintiff’s attorney, or discuss details of the case with others, including your colleagues.

•Malpractice carrier will likely ask you to choose from a panel of pre-selected lawyers. The carrier may also honor choice of an alternate attorney.

•Choose an attorney by word of mouth or hospital list ahead of time. Assess the attorney’s willingness to listen to you.

•Options for a malpractice case: (1) case is dropped plaintiff, (2) case goes to trial, (3) case is settled using indemnity funds, (4) plaintiff’s attorney is reimbursed for costs, without using indemnity funds. (Indemnity funds, like adverse judgments, are reportable.)

•If consent clause is present in your malpractice policy (check your policy now), the malpractice carrier cannot settle out of court without your approval.

Summary: Conclusion

•It is important to understand the components of medical malpractice and take measures to mitigate risk, acting with the best interest of the patient in mind.

46.7Conclusion

It goes without saying that this chapter can only chip away at what is a very important part of a Mohs surgery practice. If a lawsuit is initiated against a physician, the best action a physician can take is to consult with his attorney and malpractice carrier. This chapter is not intended to provide a substitute for guidance or advice in that regard. Nevertheless, knowledge is power, and understanding the process and issues presented here can help the physician through this difficult ordeal. It is information that is at once, important,

interesting, tedious, frustrating, and anxiety provoking, but can also be reassuring. Much of its value will depend on how the practitioner approaches it. Regardless, what is critical is that the information be addressed before any legal action occurs. Hopefully, the lessons therein will be incorporated into a Mohs surgery practice to help both patients and physicians alike.

References

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1991. p. 525–34.

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Summary: Introduction

¥It is essential to recognize that Mohs surgery can have positive or negative psychological effects on patients.

M.M. Heller (*) ¥ T. Bhutani ¥ E.S. Lee ¥ J. Koo Department of Dermatology,

UCSF Psoriasis and Skin Treatment Center, San Francisco, CA, USA

e-mail: misha.max.heller@gmail.com

47.1Introduction

Understanding the psychological impact of Mohs surgery is a crucial aspect of managing patient care. Unfortunately, however, this topic has been largely neglected in the literature. As far as we are aware, there are only two published studies that speciÞcally examine the psychosocial issues of Mohs surgery [1, 2]. Both of these studies seem to focus only on the psychological beneÞts of Mohs surgery. While it is important to recognize how patients undergoing Mohs surgery can improve overall quality of life, it is just as

important to acknowledge the potential for severe psychological problems because of disÞgurement. SigniÞcant disÞgurement is a possible outcome following treatment of cutaneous neoplasms with Mohs surgery. Consequently, patients are at risk of developing signiÞcant psychiatric morbidity secondary to the postsurgical disÞgurement. This may manifest, for example, as social phobia, generalized anxiety, or depression.

It is essential to identify patients who have psychiatric problems as a result of surgical disÞgurement, since many of these patients can be helped by seeking professional help. Unlike patients with chronic psychiatric disorders, many of these patients have reasonable premorbid psychological adaptation levels. If treatment is provided through the crisis period, these patients can overcome the many difÞculties of disÞgurement and become fully functional in society once again.

In the following discussion, we will elaborate on the psychological beneÞt, as well as detrimental psychological impact of patients following Mohs surgery. We will explain how Mohs surgery can result in signiÞcant disÞgurement and why such disÞgurement can cause severe psychiatric problems. Finally, we hope to provide the Mohs surgeon with practical guidelines to help diagnose and manage these patients.

Summary: The Psychological Benefits

of Mohs Surgery

¥It seems almost intuitive to assume that Mohs surgery can offer many beneÞcial psychosocial effects. Mohs surgery has long been considered the gold standard for the excision of cutaneous tumors because it can maximize cure rates and minimize the loss of normal surrounding tissue. Mohs surgery is typically performed for tumor resection in aesthetically important anatomic locations [3, 4]. Such locations include the ears, periauricular region, temporal region, periocular region, nasal tip, nasal ala, melolabial sulcus, and upper lip (also known as, the ÒH-zoneÓ of the face) [5]. Surgical excision scars following Mohs surgery are generally small, can be inconspicuous, and are often hidden in natural facial

creases. Thus, Mohs surgery is considered to be a superior surgical technique in its abilities to offer deÞnitive tumor excision and cure rate, with minimal functional disability and good cosmetic outcomes [6Ð10].

¥In general, patients are satisÞed with the cosmetic results following Mohs surgery and are left with an added sense of relief that their cancer has been successfully resected. In the following section, potential areas of psychological and behavioral beneÞts experienced by patients following Mohs surgery will be discussed.

47.2The Psychological Benefits of Mohs Surgery

47.2.1Improvement in Quality of Life and Sun-Protection Behavior

The two published studies that investigated the impact of Mohs surgery found that post-Mohs surgery patients appear to improve quality-of-life outcomes [1] and change-sun protection behavior [2]. To be speciÞc, the study by Chren et al. [1] examined qual- ity-of-life outcomes following treatment for cutaneous basal cell carcinoma and squamous cell carcinoma. A prospective cohort study was performed, consisting of 633 consecutive patients with non-melanoma skin cancer, who were followed for 2 years after treatment. Tumor-related quality-of-life scores 1Ð2 years after treatment were determined using the 16-item version of Skindex, a validated measuring index. Skindex quality-of-life scores ranged from 0 (best) to 100 (worst) and were assessed in three domains: Symptoms, Emotions, and Functioning. Treatment options included electrodessication and curettage (ED&C) in 21% (136 patients), surgical excision in 40% (251 patients), and Mohs surgery in 39% (246 patients). The study found that patients treated with Mohs surgery were more likely, than those treated with ED&C or surgical excision, to report worse emotional quality of life prior to therapy. However, after therapy, patients treated with surgical excision or Mohs surgery showed statistically signiÞcant improvements in all three quality-of-life domains (p < 0.05).