Inadequate Biopsy Technique and Specimen Size: An Alarming Trend That Compromises Patient Care and an Appeal to Our Clinical Colleagues

With changes in the delivery of health care in America looming, dermatologists may increase the number of patients they see per time unit and biopsies they perform in an attempt to balance declining reimbursement rates. In addition, roughly one-third of dermatologists employ physician extenders.¹ While this is often done with the explanation of a shortage of dermatologists, it may be also motivated by the desire to increase revenues.

In 2005, Fernandez et al² documented a trend toward smaller skin biopsy specimens over a period of 15 years (1988 to 2003) and concluded that a “definitive diagnosis may become increasingly difficult as the size of the biopsy specimens continues to get smaller.”^{2 (p339)} It is not only the size of the specimen but also the type of biopsy that affects the histopathologic interpretation. This was most recently documented in a study³ published in the March 2010 issue of the Archives of Dermatology, which implied that punch and shave biopsies of melanoma lesions led to a higher risk of histopathologic misdiagnosis.

The Figure depicts only 5 examples of too-small or inadequately sampled specimens, among them a curetted melanoma, a shave biopsy extending only into the midepidermis to rule out basal cell carcinoma, and a shave biopsy to rule out alopecia areata. Although these examples vary between different practices, many dermatologists and physician extenders submit these types of inadequate specimens for histopathologic diagnosis. The examples document a trend, already suspected to be influenced by pressure to see more patients, in which dermatologists choose faster biopsy techniques such as shave, curettage, or 2-mm punch biopsies.² When Kopf and Popkin⁴ initially popularized the use of the shave biopsy technique in dermatology in 1974, they certainly did not have in mind shaved specimens that barely scratch the skin surface. While aesthetic outcomes may be used as an argument, economic forces may play a larger role in the biopsy technique chosen.

Furthermore, lack of appropriate supervision of physician extenders can affect the patient care they provide, including their choice of biopsy technique and consequent too-small skin specimens for a reliable histopathologic diagnosis. As pointed out in the editorial published simultaneously with the study by Ng et al,³ “biopsy technique, per se, does not increase disease-specific mortality,”^{5 (p325)} but it certainly increases the risk of histopathologic misdiagnosis. The dermatologist's duties can be delegated to physician assistants or nurse practitioners, but liability or responsibility cannot.^{6 - 7}

We have to critically ask ourselves the following questions: How much are we willing to compromise biopsy size? And are we—as clinicians—truly aware of what we submit to the dermatopathologist and what effect our biopsy technique has on patient care? Or, to pose it more pointedly, are we practicing medicine to the highest ethical standards, if we submit biopsy specimens inadequate for histopathologic diagnosis? With America's health care system under critical review, we appeal to our clinical colleagues to seriously consider adequate sample size and biopsy technique to deliver the most accurate histopathologic diagnosis and result in the best patient care.

Correspondence: Dr Sellheyer, Nelson Dermatopathology Associates, 5775 Dupree Dr NW, Atlanta, GA 30327 (klaus.sellheyer@gmail.com).

Financial Disclosure: None reported.