Practice Tips and Efficacy

The Importance of a Biopsy Site Photograph

By Mark Russell, MD, FACMS

“A picture is worth a 1000 words.” While the origin is uncertain, never was this phrase more applicable than in the case of biopsy site confirmation. If you do Mohs surgery long enough (and it doesn’t take very long) you will encounter a patient where the biopsy site is in question. This may be due to factors including non-specific documentation from the biopsying physician, inability to identify biopsy site on examination, and uncertainty of the patient.

Site identification is critical to avoid wrong-site surgery and remains a challenge for the Mohs surgeon. Wrong-site surgery accounts for an estimated 14% of malpractice claims for Mohs surgeons.¹ Reasons for misidentifying the biopsy site by either the physician or the patient include:  ≥6 weeks between biopsy and surgery, patient inability to see the biopsy site, cognitive impairment of the patient, and biopsy specimens from multiple sites.^2,3

While some tumors are large enough to remove any doubt, in some cases the Mohs surgeon relies heavily on the referring physician for information identifying the biopsy site. If this information is not available or not adequately detailed, and the patient cannot provide definitive site identification, the Mohs surgeon may need to postpone the procedure instead of risking wrong-site surgery. In one study, the patient incorrectly identified 45 of 271 surgical sites (16.6%), and the physician incorrectly identified 16 of 271 surgical sites (5.9%). The surgeon and the patient both incorrectly identified 12 of 271 sites (4.4%). However, all surgical sites were correctly identified with preoperative biopsy-site photography.⁴

Several methods exist to document biopsy sites including taking a photograph at the time of biopsy, making a detailed site description, and creating a labeled anatomic diagram. A consensus statement found that taking a high-quality photograph with ≥1 anatomic landmark had strong agreement as a helpful step in biopsy site identification.⁵  Biopsy site photography was also associated with reduced rates of postponed surgeries and improved rates of patient confidence in surgical site selection.²

In one survey, 88% of Mohs surgeons did not receive a photograph for three quarters of their referrals; however, 89% responded that a photograph is the most useful form of documentation.⁶ Biopsy site photography could be considered the gold standard for site confirmation, with other forms of site-specific documentation serving a supporting role.

A consensus statement regarding biopsy site identification concluded that the risk of wrong-site surgery could be reduced but not eliminated.⁵ High-quality biopsy site photos may be one way to reduce this risk. Communicating this information to referring physicians and patients may facilitate the acquisition of these photographs.

Practices to improve biopsy site identification:  (modified from ^{5, 7})

1. Communicate the importance of high-quality, site-specific documentation and biopsy site photography to the referring physician
2. Recommend biopsy site photographs by the patient on their smartphone⁸
3. Confirm that correct documentation has been received and can be used to identify the biopsy site prior to the day of surgery
4. If not routine, schedule a consult visit prior to the surgery date if any question remains regarding the biopsy site
5. Have the patient confirm the site in the mirror or by touch
6. Take a photograph of the marked biopsy site for medical records
7. If unsure ask the referring dermatologist for more documentation or clarification of the biopsy site.

Site confirmation is a critical step to avoid wrong-site surgery. There are several methods to adequately document biopsy site, all of which can be supportive, but high quality photography is especially valued by the Mohs surgeon. Communicating this information to referring physicians may prove beneficial for the patient and the Mohs surgeon. 

References   

1. Perlis CS, Campbell RM, Perlis RH, Malik M, Dufresne RG Jr. Incidence of and risk factors for medical malpractice lawsuits among Mohs surgeons. Dermatol Surg. 2006 Jan;32(1):79-83.
2. Zhang J, Rosen A, Orenstein L, et al. Factors associated with biopsy site identification, postponement of surgery, and patient confidence in a dermatologic surgery practice. J Am Acad Dermatol. 2016 Jun;74(6):1185-93.
3. Rossy KM, Lawrence N. Difficulty with surgical site identification: what role does it play in dermatology?  J Am Acad Dermatol. 2012 Aug;67(2):257-61.
4. McGinness JL1, Goldstein G. The value of preoperative biopsy-site photography for identifying cutaneous lesions. Dermatol Surg. 2010 Feb;36(2):194-7.
5. Alam M, Lee A, Ibrahimi OA, Kim N,et al. A multistep approach to improving biopsy site identification in dermatology: physician, staff, and patient roles based on a Delphi consensus. JAMA Dermatol. 2014 May;150(5):550-8.
6. Nemeth SA1, Lawrence N. Site identification challenges in dermatologic surgery: a physician survey. J Am Acad Dermatol. 2012 Aug;67(2):262-8.
7. St John J, Walker J, Goldberg D, Maloney ME. Avoiding Medical Errors in Cutaneous Site Identification: A Best Practices Review. Dermatol Surg. 2016 Apr;42(4):477-84.
8. Nijhawan RI1, Lee EH, Nehal KS. Biopsy site selfies--a quality improvement pilot study to assist with correct surgical site identification. Dermatol Surg. 2015 Apr;41(4):499-504.