Fotografie in der Dermatologie - ein Scoping Review: Praktiken, Skin of Color, Patientenpräferenzen und medizinisch-rechtliche Überlegungen

Die klinische Fotografie ist essentiell für die Dermatologie. Es gibt jedoch keine umfassende Aufarbeitung der Literatur zur Fotografie in der Dermatologie. Dieser Scoping Review soll die Literatur zu fotografischen Praktiken in der Dermatologie, der Fotografie stark pigmentierter Haut (Skin of Color), Patientenpräferenzen und medizinisch‐rechtlichen Überlegungen zusammenfassen. Die Datenbanken Embase, MEDLINE, PubMed und Evidence Based Medicine wurden im Einklang mit der PRISMA‐Erweiterung für Scoping Reviews durchsucht. Insgesamt wurden 33 Studien zusammengefasst. Die klinische Fotografie wird häufig für die Markierung von Biospiestellen, Beurteilung, Diagnostik, Krankheitsüberwachung, Bewertung des Ansprechens auf die Behandlung, medizinische Ausbildung, Forschung, das Einholen kollegialer Ratschläge und in der Teledermatologie eingesetzt. Obwohl es in der dermatologischen Fotografie weiterhin kaum Darstellungen von Skin of Color gibt, sind fotografische Überlegungen für dunklere Hauttypen verfügbar. Die meisten Patienten unterstützen die medizinische Fotografie. Dabei besteht der Wunsch, dass klinische Fotografien vom eigenen Arzt aufgenommen und bevorzugt klinikeigene Kameras und keine persönlichen Geräte verwendet werden. Relevante medizinisch‐rechtliche Fragestellungen umfassen Bedenken hinsichtlich des Datenschutzes, der Verwendung persönlicher Geräte und der Dokumentation der Einwilligung. Die Fotografie in der Dermatologie entwickelt sich ständig weiter und findet immer breitere Anwendung. Verbesserte Verfahren und Innovationen werden Menschen aller Hautfarben zugute kommen. Die Einhaltung der Zustimmung und des Datenschutzes muss gewährleistet werden, um die zunehmende Einfachheit der Bildaufnahme und ‐freigabe aufrechtzuerhalten.

Medical and Legal Aspects of the Practice of Teledermatology in Spain

Teledermatology is now fully incorporated into our clinical practice. However, after reviewing current legislation on the ethical aspects of teledermatology (data confidentiality, quality of care, patient autonomy, and privacy) as well as insurance and professional responsibility, we observed that a specific regulatory framework is still lacking and related legal aspects are still at a preliminary stage of development. Safeguarding confidentiality and patient autonomy and ensuring secure storage and transfer of data are essential aspects of telemedicine. One of the main topics of debate has been the responsibilities of the physicians involved in the process, with the concept of designating a single responsible clinician emerging as a determining factor in the allocation of responsibility in this setting. A specific legal and regulatory framework must be put in place to ensure the safe practice of teledermatology for medical professionals and their patients.

Prescribing Isotretinoin for Transgender Patients: A Call to Action and Recommendations

Case Scenerio: A 26-year-old patient presents to the dermatology clinic with severe nodulocystic scarring acne. The patient identifies as a transgender male and notes that he has been receiving hormone replacement therapy for the past 4 years with weekly intramuscular testosterone injections.

Medicolegal Aspects of Teledermatology

Teledermatology has facilitated specialist care during the crisis caused by the coronavirus disease 2019 pandemic, eliminating unnecessary office visits and the possible exposure of patients or dermatologists. However, teledermatology brings forward certain ethical and medicolegal questions. A medical consultation in which the patient is not physically present is still a medical act, to which all the usual ethical and medicolegal considerations and consequences apply. The patient's right to autonomy and privacy, confidentiality, and data protection must be guaranteed. The patient must agree to remote consultation by giving informed consent, for which a safeguard clause should be included. Well-defined practice guidelines and uniform legislation are required to preserve the highest level of safety for transferred data. Adequate training is also needed to prevent circumstances involving what might be termed «telemalpractice».

Invention in Dermatology: A Review

Dermatologists are among the most inventive physicians, trained in the multiple disciplines of medical dermatology, surgical dermatology, and dermatopathology. Many of the advances in dermatology practice have been derived from inventive colleagues who identify opportunities for improvement in practice, develop viable prototypes to address these practice opportunities, and persevere through the hard work of developing new technologies to advance the practice of dermatology. In this article, we will review the basic elements of invention, patents, and the range of outcomes associated with the pursuit of invention. Examples of innovative dermatologic technologies and approaches will be reviewed. Opportunities abound for dermatologists to contribute to the advancement of medical care through invention in our specialty. J Drugs Dermatol. 2019;18(9):904-908.

Medical Malpractice Issues in Dermatology: Clinical Safety and the Dermatologist

Clinical safety and medical liability are first-order concerns in today's medical practice. It is important to understand the circumstances under which medical acts fail to live up to the accepted standard of care and to recognize the impact that malpractice claims have on physicians. Practitioners must also grasp the concept of medical error, studying malpractice claims in order to identify the areas where improvement is needed. The risk of accusations of malpractice in dermatology is comparatively low, both in Spain and worldwide. However, a great variety of clinical scenarios in dermatology can potentially give rise to a claim, and malignant melanoma is most susceptible to risk. Dermatologists should know which actions during clinical consultation merit particular attention and care. Clinical practice carries inherent risk of malpractice claims, but taking certain recommended precautions can prevent them.

Medical Malpractice in Dermatology-Part I: Reducing the Risks of a Lawsuit

Malpractice risk is a common source of concern for the practicing physician. Dermatologists experience fewer lawsuits than most other specialists in medicine, but the risk is not negligible. All physicians should familiarize themselves with areas of potential risk and avoid medico-legal pitfalls. We present Part I of a two-part series addressing medico-legal questions common to most practitioners that cause a great deal of anxiety. Part I will focus upon risk management and prevention of future malpractice lawsuits, and Part II deals with suggestions and guidance once a lawsuit occurs. Herein, we discuss the primary sources of malpractice lawsuits delivered against healthcare practitioners including issues with informed consent, patient noncompliance, medical negligence, and inappropriate documentation, including use of electronic medical records. The overall goal is to effectively avoid these common sources of litigation. The risk management strategies discussed in this paper are relevant to the everyday practitioner and may offer physicians some degree of protection from potential liability.

Review of digital image security in Dermatology

The inherently visual nature of dermatology naturally lends itself to photography. As technology has evolved, smartphone cameras have become ubiquitous and have the potential to improve education and patient care in dermatology. Although patients and physicians may agree that photography can improve patient care, there are certain risks involved with smartphone photography in the medical field. Perhaps most concerning is the number of dermatologists using smartphones to take unsecured images in their daily practice. A recent study revealed that 22% of surveyed dermatologists used smartphone cameras multiple times per day in their practice. Dermatologists may also overestimate patient comfort with smartphone use in clinical photography. We present a review of the use of smartphones in dermatology and address the potential lack of security and accompanying ethical dilemmas.

LASERS and the LAW: what the dermatologist needs to know

Dermatologic laser surgery is a continuously evolving field of medicine. According to the American Society for Dermatologic Surgery, over 100 million laser and light source cosmetic procedures were performed by its members in 2003. Procedures, which include hair removal, nonablative treatments, as well as removal of pigmented lesions, tattoos, and unwanted vascular lesions, have revolutionized this field. With an increasing number of physicians and nonphysicians performing these procedures and with the availability of increasingly powerful laser technologies, the potential for problems and their legal consequences continue to increase. This article will address the concept of negligence and the potential for a resultant medical malpractice lawsuit that may arise in such a setting. Inherent in this issue are the associated problems that arise when these procedures are performed by physician extenders. An understanding of the basic principals of a cause of action in medical malpractice will likely protect a physician from losing such a case in a court of law.

Medicolegal aspects of prescribing dermatological medications in pregnancy

Medications are commonly used during pregnancy; in fact, female patients take an average of 2.9 medications during pregnancy. Due to this high prevalence, malpractice litigation poses a high legal risk to dermatologists who prescribe medications to female patients who are or may become pregnant. This article introduces the medicolegal risks involved in prescribing dermatological medications to a pregnant patient and discusses ways for a dermatologist to mitigate those risks. International safety classification systems are reviewed, and potential high risk dermatologic medications prescribed in acne, psoriasis, atopic dermatitis, and connective tissue disease are discussed. In addition, the article summarizes resources available to patients as well as the important elements for dermatologists to include when documenting their discussion with the patient in the medical record.

Teledermatology, teledermatopathology, interstate dermatopathology and the law

The expansion of telemedicine nationwide has resulted in many states adopting specific telemedicine regulations to avoid the issue of requiring a full medical license to practice telemedicine. How these laws and regulations relate to the practice of telepathology and teledermatology has not been well delineated. It is important to understand these regulations to avoid potential judicial penalties arising from non-compliance. This article aims to outline state-specific telemedicine regulations and penalties.

Dermatology and pathology arrangements: navigating the compliance risks

Purchased service arrangements, establishing in-house professional pathology services, conducting technical component histology within a dermatology practice, and electronic medical records technology donations are ways that dermatology practices are responding to the current health care delivery and payment changes. This article will provide a general framework for navigating the compliance risks and structure considerations associated with these relationships between dermatologists and pathologists.

Drug safety: implications for the dermatologist and dermatopathologist

The recent decades have seen a plethora of drugs removed from the world-wide market place over safety concerns and reported adverse events. In some cases, drugs with significant reports of adverse drugs events (ADEs) have remained on the market with either a Black Box warning, strict prescribing guidelines, or both. It has been reported that more than 2,000,000 Americans are harmed by ADEs each year. The financial costs associated with ADEs are staggering with over $170 billion spent annually in the United States as a result of ADEs. The implications for the dermatologist and dermatopathologist are daunting for the skin is the organ most frequently affected by ADEs. Many cases of drugs removed from the market are preceded by the filing of one or more product liability lawsuits. This means the dermatologist could be brought under claims of negligence, strict liability, breach of warranty, and consumer protection claims. The potential implications for the dermatologist or dermatopathologist are discussed along with an introduction to the legal process, which comes into play with the filing of the product liability lawsuit.

The dermatologist as expert witness-revisited: know the risks before you agree

Legal Standards and requirements exist for dermatologists wishing to serve as expert witnesses. Case law, statutes and licensing/credentialing groups exist to regulate the practice to ensure honesty and integrity. Penalties and sanctions exist for deceptive and fraudulent opinions. However, conversely, private groups must be careful in their efforts to not libel savvy experts or interfere with their legitimate work.

Employee contract issues for dermatologists

Employees and employers routinely face negotiating and preparing physician employment contracts. It is important for both sides to know and understand the basic information on what a comprehensive employment contract for a dermatologist should contain. There are various employment contract provisions from both the employee's perspective and the employer's perspective that must be considered when preparing physician employment contracts. This article provides basic advice and recommendations on requirements that should be included in such contracts. It suggests legal pitfalls that can be avoided through various contract clauses.

Patent law for the dermatologist

An exciting discovery in the laboratory may translate to a commercial product. How does the patent system fit into the picture? We first discuss the circumstances under which an invention is granted a patent. What is the purpose of a patent and what are the functions of the patent system? Who can apply for a patent? What makes an invention patentable? A patent does not automatically grant a right to make or sell a product. This is because multiple patents can cover a single pharmaceutical product. Understanding the patent landscape covering a product of interest is key to evaluating the risk of infringing another's exclusivity rights. We use a hypothetical example relating to skin cancer to guide a discussion of patent law.

Incidence of and Risk Factors for Medical Malpractice Lawsuits among Mohs Surgeons

BACKGROUND

Despite rising medical malpractice costs, little is known about the factors associated with claims filed against Mohs surgeons.

OBJECTIVE

We sought to define the scope of medical malpractice claims filed against Mohs surgeons and to identify salient factors associated with the filing and disposition of those claims.

METHODS

A comprehensive survey was mailed to 599 physicians with US addresses listed in the 2003 directory of the American College of Mohs Micrographic Surgery and Cutaneous Oncology.

RESULTS

Of the 300 completed surveys returned, 33 (11%) reported ever having been sued. Physicians who practiced Mohs surgery for a longer period of time were more likely to have been sued for malpractice. Physicians reported the wrong site and functional outcome as the most frequent causes of malpractice lawsuits.

[G-DRG version 2007: a short overview]

Just as in the year before, the structure and regulations of the new GDRG version 2007 was successfully agreed on a mutual basis by the national self-governing bodies in the German health care system. Although some problems in high-specialized medicine or day clinic care will remain, the current developments demonstrate once more the learning aptitude of the G-DRG-system. Some beneficial and major changes have been made in 2007, but most of them do not touch dermatology. Additional procedure-based payments have been introduced in 2007 including the parenteral administration of such expensive agents as etanercept and itraconazole. A statistical analysis of cost weights of the year 2006 versus 2007 for two university clinics suggests that in dermatology, the increasing complexity of the G-DRG system partly leads to lower cost weights. Overall in 2007 a remarkable increase of complexity and differentiation throughout the DRG-system can be identified as well as a careful expansion of procedure-based payments.

Legal Issues in Dermatology: Informed Consent, Complications and Medical Malpractice

Legal considerations can arise in almost any aspect of a dermatology practice. A full textbook on health care law would be required to adequately cover the varied legal issues as they relate to dermatology. This article will focus on the relationship between informed consent and the development of complications that may lead to a cause of action based on negligence. Because it is the lack of informed consent that may form the basis of a medical malpractice claim, the issues of what constitutes a medical malpractice claim will be fully described.

Dermatology: litigation and the NHS Redress Bill

This article considers an allegation of failure to diagnose a patient's condition by the consultant dermatologist and considers the likely repercussions if the NHS Redress Bill currently going before Parliament is passed and implemented.

Legal ramifications of off-label filler use

Dermal fillers are often used in an off-label manner. Most off-label use is not only legal, but represents an appropriate physician standard of care. This chapter will first explore what is and what is not considered off-label. Then the chapter will explore manufacturer promotion of off-label use of both drugs and devices. Finally, the legal ramifications of off-label dermal filler use will be discussed.

Dermatology: obtaining patient consent in clinical trials

This article considers the law which applies to the conduct of research on health service patients. It considers the ethical approvals which are required and the necessity to obtain consent from the patient. It must be made clear to the patient that a refusal to participate in a research project should have no adverse effect on their ongoing care and treatment.

[The new German educational law for medical schools: the Hamburg concept in dermatology and venereology]

Medical school graduates are required to deal with complex situations in their future work which require profound theoretical knowledge as well as many practical skills. The University of Hamburg used a new educational law (AappO 2002) as catalyst to define learning objectives relevant for practice and to guarantee a close connection between theory and practice. A newly founded curriculum committee with twelve members developed a strategy and structure for the new clinical curriculum (KliniCuM) in weekly sessions. The subject dermatology and venereology is taught in the thematic block "The Internal and External Human Being" in integrated courses with the subjects internal medicine, pathology and pharmacology. The teaching modules (introductory lectures, symptom-oriented lectures, problem-based tutorials and bedside-teaching) are practice oriented and teach diseases and skills of dermatology which are important for "general medicine". Written and practical exams take place at the end of the block. Although there is more required attendance and increased demands on students' time, dermatology has received very positive evaluation results. Students consider their gain in knowledge and skills as very high. The new curriculum in Hamburg could provide helpful orientation for other medical faculties in changing their curricula for the subject "dermatology and venereology" according to the new educational law.

Medicolegal aspects of neoplastic dermatology

Medical malpractice litigation is rising at an explosive rate in the US and, to a lesser extent, in Canada. The impact of medical malpractice litigation on health care costs and the cost of insurance is dramatic. Certain specialist categories are becoming uninsurable in some parts of the US, while in others, clinicians are retiring early, restricting or changing practice or changing states of residence in consequence of medical malpractice claims and of the cost and availability of insurance. This, in turn, has had the real effect of denying care to patients in some communities in the US. Some 13% of all medical malpractice claims relate to one area of neoplastic dermatopathology, specifically, melanocytic neoplasia. Certain steps can be taken by pathology laboratories to reduce, but never completely eliminate, the risk of medical malpractice claims. In this review, attention is paid to the source of medical malpractice claims and an abbreviated approach to specific strategies for risk management is presented.

[Current regulatory aspects: ambulatory surgery and dermatology]

Recently the catalogue for ambulatory surgery in hospitals has been updated presenting a successful integration into the classification of EMB 2000plus. A fundamental reconstruction resulted in changes to the specifications of health care services which are covered by the catalogue. The agreement became effective in April 2005. According to the new catalogue for ambulatory surgery, the procedure codes of the OPS classification and their transitions to a specified EBM-figure or category are relevant for the reimbursement of ambulatory services provided by a hospital or in private practice. Moreover, the regulations to avoid unnecessary bed days of hospital care and the criteria of the German appropriateness evaluation protocol (G-AEP) have to be considered carefully in terms of inpatient admissions. In the following the revised catalogue for ambulatory surgery is reviewed in detail with special relevance to dermatology.

An analysis of recent antitrust issues affecting specialty practice: is dermatology immune?

In the healthcare industry, the rules of regulation and competition often collide. Despite the view of Medicine as a "learned profession", it is clear that physicians will be subject to the same legal restrictions against sharing price information as those in place for any other industry. Thus, the relevant provisions of antitrust law will apply to most activities of physicians. Although recent case law has involved actions undertaken by physicians in other specialties of Medicine (e.g. oncology) the activities reviewed will likely be applicable to Dermatologists as well.

[Off-label use in dermatological practice. The conflict between professional duty and legal requirements]

When making therapeutic decisions, doctors often find themselves faced with a dilemma regarding ethical, professional, legal liability, social and service aspects of their duties. These conflicts may be enhanced when medications have to be prescribed for non-approved usages, known as off-label prescribing, because existing therapy options have been exhausted. This option become considerably more difficult since the German Federal Social Court decision of March 2002 which limited off-label use to a number of very strictly defined circumstances. In order to clarify the basis for taking decisions in a given situation, an oncology expert commission has been formed under the coordination of the Department of Health and Social Security. However, this is no solution for the great variety of uncommon dermatological diseases which often require off-label medication usage.

Interstate dermatopathology interpretations—50 separate licenses?

The increasing bureaucracy of health care has had a serious negative impact on physicians and patients for the last fifteen years. We report an example of this trend involving the interstate interpretation of dermatopathology specimens, which resulted in a significant interruption of diagnostic services to a large number of dermatologists. Temporary and long term solutions are discussed with the hope that dialogue and political consensus-building can bring resolution to the problem.

[New dermatologist's procedure. Research plans for improving secondary prevention of occupational dermatoses]

The dermatologist's procedure was introduced in 1972 by employers' liability insurance funds in the industrial, agricultural, and public sectors of Germany's statutory occupational accident insurance as a "procedure for early detection of occupational skin diseases." So far, it is still the most relevant tool for secondary prevention in occupational dermatology in Germany. According to the intention of this procedure, insured persons with a skin disease in which an occupational etiology is suspected must be offered preventive measures and, if necessary, given appropriate treatment to avoid job-loss. To improve the efficiency of the "classic" dermatologist's procedure, in 1999, on the initiative of the Central Federation of Industrial Professional Associations, a study group was founded in cooperation with the Task Force on Occupational and Environmental Dermatology of the German Dermatological Society and the Professional Organisation of German Dermatologists. In October 2002, a controlled intervention study started in North-western Germany to scientifically evaluate the "optimised" dermatologist's procedure, which was proposed by the study group and compare it to the standard ("classic") procedure. The study results should allow detailed suggestions for an improved dermatologist's procedure before it is introduced nationwide.

Medical malpractice and cancer of the skin

BACKGROUND

A litigation crisis exists in this country, and it may be better understood through analysis of lawsuits. Verdict summary analysis has been used for this purpose.

METHODS

Ninety-nine jury verdict reviews from 1986 to 2001 were obtained from a computerized database. Reviews compiled data on defendants, plaintiffs, allegations of wrongdoing, cancer cell types, sites, outcomes, and case summaries. Data was entered into a spreadsheet for analysis.

RESULTS

Failure to diagnose was alleged in 54%; of these, 48% alleged biopsies were inappropriately omitted. Allegations were highest for failure to diagnose in dermatologists and general practice physicians, for misdiagnosis in pathologists, and for complications in surgeons. Young patients and those with poor outcomes received more and larger awards. Trauma appears to have support for a role in causation of skin cancer in some courts.

CONCLUSIONS

The study of skin cancer suits may help develop risk management and prevention strategies.

Photographic images, digital imaging, dermatology, and the law

BACKGROUND

Patient photographic images play an important role in dermatological record keeping and training. An assessment of the legal implications of image taking is necessary to use images properly.

OBSERVATIONS

Images are parts of the medical record and must be treated with the same care as written medical records. Because multiple digital images are sometimes taken and digital images can be easily manipulated, they present novel issues in this regard. Images can be used as evidence in court. Issues regarding digital images include (1). authentication, (2). manipulation, (3). audit trail verification, and (4). data compression. The Health Information Portability and Accountability Act requires that health care providers control and track those who have access to identifiable digital medical information. This should facilitate the use of digital images as evidence because the provenance of digital images can be established. The Health Information Portability and Accountability Act covers the use and disclosure of protected health information, such as "full-face photographic images and any comparable images." To publish identifiable digital images (images of the face), it seems prudent for patients to waive in writing their rights to this protected health information. Conclusion Images will continue to enhance dermatological care, and understanding and accounting for the legal underpinnings of their use is prudent.

G-DRG Version 2004: Veranderungen aus Sicht der Dermatologie. G-DRG Version 2004: Changes in view of dermatology

In the year 2004 the obligatory introduction of the new hospital funding system based on a Diagnosis Related Groups (DRG) system will become reality for all German hospitals. After all fundamental items of the new G-DRG version were made generally known, the possible consequences had to be considered. The first mandatory German case-based lump sum catalogue differs importantly from the previous payment models and requires intensive study. Economic considerations will increasingly play a role in the daily routine of hospitals and influence treatment patterns. Therefore, comprehensive knowledge of basic principles of G-DRG is essential. In the following aspects of the reimbursement system with special relevance to dermatology are reviewed in detail. Additionally, the revised classification system versions OPS-301 SGB V and ICD-10-GM 2004 and the German coding standards version 2004 must be appropriately applied for dermatologic purposes.

Legal claims in Scottish National Health Service Dermatology Departments 1989-2001

BACKGROUND

An area of current National Health Service (NHS) interest is risk management as it is one of the requirements of clinical governance. If there are aspects of dermatological practice prone to mishap or dispute then a review of legal claims in dermatology may highlight these areas. This would then allow input into these specific areas of practice to try and minimize future risk.

OBJECTIVES

To review all legal claims relating to NHS Dermatology in Scotland and characterize the main areas of risk.

METHODS

Staff at the Central Legal Office in Edinburgh reviewed all legal claims in NHS Dermatology between 1989 and 2001. Details provided were general, and claimants, staff, hospitals and regions of Scotland could not be identified.

RESULTS

Thirty claims were identified relating to five main areas of dermatological practice: (i) phototherapy (eight claims); (ii) therapeutics (eight); (iii) cryosurgery/cryotherapy (six); (iv) surgery (four); and (v) misdiagnosis (three) and one alleged neurological problem after fainting. As well as consultants, nurses featured in phototherapy claims and junior medical staff in cryosurgery claims. Twelve of the 30 (40%) claims have reached settlement; three claims are presently outstanding.

CONCLUSIONS

Given the numbers of patients seen annually at Scottish NHS Hospital Dermatology units the absolute number of claims is low. Five main areas within dermatology were highlighted as at risk of litigation and this has implications for all U.K. dermatology departments with regard to funding, staff training and patient information and consent.

Under the microscope: doctors, lawyers, and melanocytic neoplasms

Misdiagnosed melanoma remains one of the most common causes of lawsuits in histopathology. Reasons for this are discussed in conjunction with relevant literature, common errors in diagnosis, and strategies to avoid them.