Boondocks practice, but big-city liability?

February 1, 2007

Not all physicians have access to similar facilities and technology. Thus, the applicable standard of care may take into account restraints imposed by geographic location and limited economic resources.

A significant portion of Dr. Mole's practice deals with cutaneous oncology. He diagnoses at least two melanomas a week, has multiple patients with strong family histories of melanoma and sees many patients who have had more than one melanoma.

His customary practice is to perform total body examinations on such high risk patients twice a year. He has no access to sophisticated photographic techniques or associated computerized mole mapping techniques.

The deceased patient's estate brings forth an expert witness who testifies that although the lesion looked quite normal to the casual eye, it may very well have looked abnormal had the lesion been evaluated by a sophisticated mole mapping method. The expert further testifies that it was Dr. Mole's obligation to provide such diagnostic testing for his high-risk patients. Dr. Mole's defense is that such methods are not available in rural areas and he should not be held to the same standard as a big-city, academic dermatologist. Is he correct?

Four facts to prove malpractice

A successful suing plaintiff must prove four facts in order to win a medical malpractice case against his dermatologist.

In the context of a medical malpractice case, a physician-patient relationship is usually enough to establish that a physician owed his patient a duty of care. This relationship exists anytime a physician provides some sort of medically related opinion to an individual, regardless of whether that advice was offered in the physician's office, a hospital or even in the movie theater.

Defining duty

However, the determination of whether a physician actually breached that duty is generally less simple.

Simply showing the establishment of an error that resulted in a negative outcome is not enough. What is required is showing that the physician failed to meet the accepted standard of care. In general, this is defined by the prevailing medical practice. This is subsequently established by the testimony of an expert witness physician. In general, but not always, the expert practices within the same field as the defendant physician. The defendant physician must exercise a degree of care that would be expected of a minimally competent physician in the same specialty and under similar circumstances.

Implicit in this definition is the recognition that not all physicians have access to similar facilities and technology. Thus, the applicable standard of care may take into account restraints imposed by geographic location and limited economic resources. As such, a dermatologist in solo practice in a rural community (such as Dr. Mole) may not necessarily be held to the same standard of care as a dermatologist practicing in a large academic center in a major metropolitan area.

Out of town, not out of touch

There is evidence that total body cutaneous photography and specialized mole mapping methods can be helpful in the detection of early malignant change in pigmented nevi.