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On 6/15/2012, a 47-year-old female presented to a family practitioner with multiple lesions on her back, chest, and arms.

The family practitioner informed the patient that the lesions on her left humerus, right upper abdomen, mid upper back, left anterior mid chest, lower back, right lower back, and/or right upper anterior chest were malignant and/or potentially malignant.

On 7/6/2012, the family practitioner documented that the patient had a history of keloid formation after surgical excision.

On 6/15/2012, the family practitioner excised a lesion on the patient’s left humerus.  The lesion excised from the patient’s left humerus measured approximately 3 mm by 3 mm.  The family practitioner made an excision 4 cm by 4 cm or sixteen square centimeters to excise the lesion on the patient’s left humerus.

On 6/19/2012, a dermatopathology report determined that the excision taken from the patient’s left humerus was not malignant or premalignant.

On 6/27/2012, the family practitioner excised a lesion on the patient’s right upper abdomen.  The lesion on the patient’s right upper abdomen measured 3 mm.   The family practitioner made an excision 7 cm by 6 cm, or forty-two square centimeters to excise the lesion on the patient’s right upper abdomen.

On 6/29/2012, a dermatopathology report determined that the excision taken from the patient’s right upper abdomen was not malignant or premalignant.

On 7/6/2012, the family practitioner excised a lesion the patient’s mid upper back.  The lesion on the patient’s back measured approximately 3 mm.   The family practitioner made an excision 5 cm by 7 cm, or thirty-five square centimeters to excise the lesion on the patient’s mid upper back.

On 7/13/2012, the family practitioner excised a lesion on the patient’s left anterior mid chest.  The lesion on the patient’s left anterior mid chest measured approximately 4 mm by 4 mm.
The family practitioner made an excision 8 cm by 6 cm or forty-eight square centimeters to excise the lesion on the patient’s left anterior mid chest. He referred the patient for radiation treatment to prevent keloid formation.

On 7/20/2012, a dermatopathology report determined that the excision taken from the patient’s left anterior mid chest was not malignant or premalignant.

On 8/3/2012, the family practitioner excised a lesion the patient’s left lower back.  The lesion on the patient’s left lower back measured 5 mm by 4 mm.  The family practitioner made an excision 9 cm by 7 cm or sixty-three square centimeters to excise the lesion on the patient’s left lower back.

On 8/7/2012, a dermatopathology report determined that the excision taken from the patient’s left lower back was not malignant or premalignant.

On 8/10/2012, the family practitioner excised a lesion on the patient’s right lower back.  The lesion on the patient’s right lower back measured 4 mm by 4 mm.  The family practitioner made an excision 9 cm by 8 cm or seventy-two square centimeters to excise the lesion on the patient’s right lower back.

On 8/14/2012, a dermatopathology report determined that the excision taken from the patient’s right lower back was not malignant or premalignant.

On 8/27/2012, the family practitioner excised a lesion on the patient’s right upper anterior chest.  The lesion on the patient’s right upper anterior chest measured 2 mm by 2 mm.   He made an excision 10 cm by 7 cm, or seventy square centimeters to excise the lesion on the patient’s right upper anterior chest.

On 8/29/2012 a dermatopathology report determined that the excision taken from the patient’s right upper anterior chest was not malignant or premalignant.

The Board judged that the family medicine practitioners conduct to be below the minimal standard of competence given that he failed to perform a complete and comprehensive physical examination of the patient’s lesions; adequately consider the characteristics of the lesions, including the size, color, regularity, and degree of pigmentation; refer the patient for consultation with a dermatologist; refrain from diagnosing the patient with malignant and/or potentially malignant lesions without having adequate justification; accurately and appropriately diagnose the patient’s condition; confirm that each of the lesions on the patient was malignant or premalignant prior to excising the lesion; perform a shave biopsy, punch biopsy, or limited excisional biopsy with 1 mm margins on each of the lesions on the patient to determine whether the lesion was malignant or premalignant; make an excision with margins no greater than 5 mm to excise each of the lesion on the patient; refrain from making an excision on the patient without having adequate justification; avoid potential keloid formation on the patient, by making the fewest and/or smallest excisions appropriate and/or justifiable.

The family practitioner agreed to voluntarily cease practicing medicine and agreed to never reapply for licensure as a medical doctor in the state of Florida.

State: Florida

Date: August 2017

Specialty: Family Medicine, Dermatology

Symptom: Dermatological Abnormality

Diagnosis: Dermatological Issues

Medical Error: Unnecessary or excessive treatment or surgery, Failure to examine or evaluate patient properly, Failure to order appropriate diagnostic test, Referral failure to hospital or specialist, Lack of proper documentation

Significant Outcome: N/A

Case Rating: 1

Link to Original Case File: Download PDF

A 56-year-old woman’s annual mammogram showed a lesion in her right breast.  A needle core biopsy of the lesion was obtained on 4/28/2014.  A general pathologist reviewed the patient’s slides and diagnosed the patient with an invasive well-differentiated ductal carcinoma of the right breast.  Based on his diagnosis, the general pathologist ordered immunohistochemical stains for estrogen and progesterone receptors and other tests.  A surgical follow up was recommended.

The patient was referred to a surgeon who informed her she would undergo an immediate lumpectomy.  The patient sought further consultation from a general surgeon and plastic surgeon for evaluation and treatment of the cancer and reconstructive surgery.  The patient met with both on 5/6/2014, at which time she elected to proceed with a bilateral mastectomy, followed by breast reconstructive surgery. The general surgeon’s records show he ordered a consultation with the John Stoddard Cancer Tumor Board for another opinion. The general surgeon contacted the general pathologist and informed him of the findings.  On that same day, the general pathologist sent the slides to Mayo Clinic to be re-read.  The general pathologist also scheduled the case to be discussed at the Marshalltown Medical and Surgical Center’s Tumor Board on 5/19/2014.

The Mayo Clinic issued its report on 5/20/2014, diagnosing a complex sclerosing lesion with unusual ductal hyperplasia and microcalcifications.  On that same date, the general pathologist authored an addendum to his pathology report amending the diagnosis to conform with that of the Mayo Clinic and adding the following comment:

“The case is reviewed for tumor board.  After reviewing the case, the case was sent to Mayo Clinic for a second opinion and the [sic] diagnosis is changed from invasive ductal cell carcinoma to complex sclerosing lesion.  The changes in the diagnosis are communicated with the general surgeon.  Results of the correct report will be discussed with the patient by the general surgeon”.

The patient underwent a lumpectomy performed by the general surgeon on 5/22/2014.  Iowa Pathology Associates reviewed the slides from the lumpectomy and issued a histopathology report confirming the diagnosis of a complex sclerosing lesion.  The report stated, “there is no evidence of atypicality or malignancy.”

An audio recording made by the patient’s husband of a discussion he and the patient had with the general pathologist regarding the misdiagnosis was admitted into evidence.  In response to an inquiry regarding why the second opinion was not obtained prior to making an initial diagnosis, the general pathologist cited to the cost of a consultation.

A senior pathologist at the Iowa clinic reviewed the patient’s slides at the Board’s request and, in contrast to the general pathologist’s carcinoma diagnosis, arrived at a diagnosis of “radial scar” which term is often used interchangeably with “complex sclerosing lesion”.  The senior pathologist testified that she found the diagnosis to be an easy one and that an “average pathologist” would have been able to make it.  However, in her written report the senior pathologist relied on a textbook, which contained the following passage: “The importance of recognizing various patterns of adenosis and sclerosing lesions, and the reason why they are considered together in this chapter, is that they may be mistaken for invasive carcinoma…”  The senior pathologist noted that the condition she diagnosed is benign, although complete excision of the lesion is generally recommended if the diagnosis has been made on a needle biopsy because of the risk of associated malignancy which can be identified only after surgical excision.

The senior pathologist also questioned the general pathologist’s use of special stains in this case.  She explained that myoepithelial cells are not present in invasive cancers and, therefore, stains can be used to look for those cells.  If a stain is used and it shows that myoepithelial cells are present, the sample would not be consistent with invasive cancer.  The senior pathologist emphasized that had the general pathologist ordered the appropriate stains, such as P63, to confirm or rule out cancer in the patient’s case, he might not have misdiagnosed cancer.  On the other hand, the senior pathologist argued that the stains the general pathologist ordered were for breast cancer receptors (estrogen and progesterone) and for human epidermal growth factor receptor 2 (“HER2”) status and that the HER2 was sent for fluorescent in-situ hybridization (“FISH”) analysis, all of which were unnecessary because the patient did not have breast cancer.  The senior pathologist noted that these unnecessary steps added substantial costs to the patient’s care.

The senior pathologist emphasized that this patient might have undergone an unnecessary lumpectomy or mastectomy had her case not been reviewed further.  The senior pathologist found that the general pathologist failed to meet the standard of care when he misdiagnosed the patient because of a substantial lack of knowledge or ability to discharge the professional obligations within the scope of pathology practice.  She also determined that the general pathologist’s actions, in this case, showed a failure to possess and exercise the degree of skill, learning, and care expected of a reasonable, prudent physician acting in the same or similar circumstances.

In response to the Board’s inquiry regarding this patient, the general pathologist admitted his initial diagnosis was incorrect.  He stated, however, that he read the patient’s slides a few days later while preparing to present the case at a Tumor Board and began to have second thoughts about the diagnosis.  According to the general pathologist, he “mentally” amended the diagnosis at that time to being “suspicious of cancer”.  The general pathologist stressed that he discussed the case with the patient’s clinician and also sent it to the Mayo Clinic for a second opinion.  He explained that complex sclerosing lesions are very difficult to evaluate and are subject to misdiagnosis.  The general pathologist testified that when he received the pathology report from the Mayo Clinic on 5/20/2014, he authored a correction to his original report, amending the diagnosis to complex sclerosing lesion with unusual ductal hyperplasia and microcalcifications.

The general pathologist further testified at a hearing that the HER2 test and FISH analysis were requested by the patient’s clinician and were obtained due to that request.

The general pathologist emphasized that he learned from his error in this case and now requests additional immunostains and/or second opinions in these types of cases.

Another pathologist reviewed the case and while agreeing that the general pathologist reached an incorrect diagnosis at the outset, disagreed with the senior pathologist’s determinations that the misdiagnosis and use of stains demonstrated any lack of professional knowledge or a deviation from the standard of care from the general pathologist’s part.  He opined that this type of lesion can be difficult to evaluate, especially when the general pathologist has only a small amount of tissue provided by a needle core biopsy as opposed to a completely excised lesion.  The reviewing pathologist also emphasized that, while the senior pathologist opined the general pathologist ordered unnecessary stains, the pathologists at Mayo Clinic ordered additional stains when they re-read the slides involved.

The other reviewing pathologist offered his opinion that the general pathologist did not display professional incompetence or any behavior harmful or detrimental to the public in his review of the patient’s case.

For this allegation and others, the Board judged the general pathologist’s conduct to be below the minimum standard of competence given (his/her) lack of professional competency and practice that was harmful or detrimental to the public.  The general pathologist was warned that such practice in the future may result in further disciplinary action against his medical license.

For this allegation and others, the Board ordered the general pathologist to arrange in the auditing of 5% of his cases by outside pathology laboratory approved by the Board and ensure that the auditing entity submits a report to the Board on a quarterly basis.  He was also ordered to obtain consultation with a board-certified dermatopathologist in all suspected melanoma cases and author a paper discussing the diagnostic criteria for well-differentiated squamous cell carcinoma and keratoacanthoma in vulvar tissue.

State: Iowa

Date: June 2017

Specialty: Pathology

Symptom: N/A

Diagnosis: Dermatological Issues

Medical Error: Diagnostic error, Unnecessary or excessive treatment or surgery

Significant Outcome: N/A

Case Rating: 4

Link to Original Case File: Download PDF

In April 2013, a nurse practitioner collected a skin biopsy from a 20-year-old patient’s back.  That biopsy was reviewed by a general pathologist, who diagnosed superficial spreading of malignant melanoma (“SSMM”).  He did not consult with any other pathologist or dermatopathologist prior to providing the nurse practitioner with the SSMM diagnosis.

The patient was referred for treatment and a surgical consult was requested by her treating physician.  The same biopsy material reviewed by the general pathologist was also read by two pathologists, at the surgeon’s request.  Those pathologists agreed with the general pathologist’s diagnosis of SSMM.

After the patient underwent an excision, she was referred to a dermatologic surgeon, for annual skin examinations. The dermatologic surgeon noted the patient’s surgical scar and a few irregular moles during his 2013 exam.  During the 2014 examination, the dermatologic surgeon noted one irritated nevus, which was removed but saw nothing atypical.

Subsequently, in July 2014, the nurse practitioner collected a new shave biopsy from the patient’s back, near the site of the former biopsy.  The general pathologist discussed the proximity of the lesions with the nurse practitioner and the two agreed that, upon gross examination, the present biopsy material was similar in appearance to the first.  Upon microscopic examination, the general pathologist again arrived at a diagnosis of SSMM.  Once again he did not consult any other pathologist or dermatopathologist prior to providing the diagnosis to the nurse practitioner.

The nurse practitioner contacted the dermatologic surgeon with the patient’s diagnosis.  The dermatologic surgeon questioned the diagnosis because he examined the patient only two months earlier.  The dermatologic surgeon requested and received the slide on which the general pathologist based his SSMM diagnosis.  When he reviewed the slide, the dermatologic surgeon believed it showed an irritated nevus and not SSMM.

The dermatologic surgeon sent the slide from the patient’s latest biopsy to Iowa Pathology Associates, to be re-read.  A dermatopathologist reviewed the patient’s slide.  He found nothing in the sample which would point to melanoma.  He determined the slide showed an inflamed compound nevus.  Because his diagnosis conflicted with the general pathologist’s diagnosis, the dermatopathologist consulted with four of his colleagues, each of whom agreed the slide was not SSMM but an inflamed nevus.

The dermatopathologist then reported his findings to the dermatologic surgeon, who then began to question the patient’s SSMM diagnosis in 2013 SSMM.  The dermatologic surgeon obtained slides from the 2013 biopsy which looked to him to be identical to the slide from the 2014 biopsy.  The dermatologic surgeon then sent these slides to the dermatopathologist for review as well.

The dermatopathologist reviewed the slides from the 2013 biopsy and, once again, arrived at a diagnosis of inflamed compound nevus.  He shared these slides with the same four colleagues previously consulted, and once again, each concluded that the SSMM diagnosis was incorrect and that the slides showed an inflamed compound nevus.

Based on the dermatopathologist’s  diagnosis, the dermatologic surgeon alerted the patient’s mother that the patient did not have melanoma and the patient avoided a second surgery.

At the hearing, the dermatopathologist expressed his concerns with the general pathologist’s misdiagnosis in the patient’s case.  The dermatopathologist explained that a diagnosis of melanoma often makes it difficult for the patient to obtain health insurance and often he or she cannot obtain life insurance.  The dermatopathologist also explained that people diagnosed with melanoma are prohibited from donating tissue or blood.  Finally, the dermatopathologist testified to his fear that if the general pathologist misdiagnosed an inflamed compound nevus as malignant melanoma, that he might also be misdiagnosing malignant melanomas as inflamed compound nevi, thereby potentially exposing patients to the risk of developing metastatic melanoma.

A senior pathologist testified that neither of the biopsy specimens collected from the patient showed features of malignant melanoma.  She noted that there was no upward migration of atypical melanocytes or Pagetoid spread of atypical melanocytes. The senior pathologist explained the melanocytes in the patient’s biopsies showed no evidence of cytological atypia.  The senior pathologist also took issue with the fact that the general pathologist ordered a Melan-A stain, which, while it might have been appropriate had the biopsies shown malignant melanoma, was unnecessary since the correct diagnosis was inflamed compound nevus.

The senior pathologist emphasized the emotional strain placed on a patient once given a diagnosis of malignant melanoma.  She also noted that such a diagnosis might well result in a wider excision of the biopsy site, a regional lymph node excision, and chemotherapy; all unnecessary for an inflamed compound nevus.

The senior pathologist, dermatopathologist, and dermatologic surgeon all testified to the difficulty of making a diagnosis of malignant myeloma.  The senior pathologist wrote in her peer review to the Board:

“In my practice, EVERY case I think is malignant melanoma goes out for second (and sometimes third) opinion; regardless of how certain I am that the lesion is indeed a malignant melanoma. I feel that the practice of skin pathology (dermatopathology) is very difficult when it comes to accurately classifying atypical melanocytic proliferations, such as malignant melanoma and dysplastic nevi. Without special training, I believe it’s best to get second opinions on these cases; however that is my opinion and may not be shared by all pathologists”.

Likewise, while the dermatologic surgeon testified he was not an expert in pathology, he asserted that the diagnosis of an inflamed nevus is not a difficult one to make. He did admit, however, that the subspecialty of dermatopathology was developed specifically because of the difficulty in diagnosing melanomas.  He noted that, in his practice, he sees “problem after problem” with the diagnoses provided by general pathologists and that, as a result, he will not accept a diagnosis from a general pathologist without confirmation by a specialist.

The dermatopathologist noted that the practice of pathology involves, at best, the subjective interpretation of objective data and, at times, less than objective data. He stated that malignant melanoma is a particularly difficult diagnosis and urged that confirmation of that diagnosis could and should be had through consultation with a pathology group with subspecialty expertise such as the pathology group at Mayo Clinic.

In response to the complaint regarding this patient, the general pathologist noted that his 2013 diagnosis of SSMM was confirmed by the Ames Pathology Group who reviewed the biopsy at that time at the request of the patient’s surgeon. He stressed that he read the 2014 biopsy with the knowledge that this patient had been diagnosed with SSMM and that the diagnosis had been confirmed the previous year. He also noted that the 2014 biopsy was taken very close to the site of the 2013 biopsy.  The general pathologist noted that this information caused him to lean towards an SSMM diagnosis.  He also explained that, since the biopsy was from the patient’s back, an excision with a wider margin would not lead to any cosmetic defects.  He noted he was aggressive in this case because he did not want the patient to come back with metastatic melanoma.  He stressed the difficulty of diagnosing pigmented skin lesions.

At the hearing, the general pathologist testified that he remained convinced the patient’s 2014 biopsy showed SSMM.

Another reviewing pathologist expressed a different opinion in the patient’s case.  He stressed that the 2013 SSMM diagnosis had been confirmed after the slides were reread by the Ames Pathology Group and that fact, along with histology of the 2014 biopsy, would have led him to classify the latter specimen as, at the very least, an atypical compound melanocytic proliferation which would not rule out melanoma. The other reviewing pathologist stated that his review of the specimen revealed extensive lymphocytic reaction in the dermis which, in some cases, can mask an infiltrating tumor, He noted that in his practice, this sample would have been sent out for a consultation with a dermatopathologist.  However, once again the reviewing pathologist found no professional incompetency or harm to the public in the general pathologist’s action with regard to this case

For this allegation and others, the Board judged the general pathologist’s conduct to be below the minimum standard of competence given his lack of professional competency and practice that was harmful or detrimental to the public.  The general pathologist was warned that such practice in the future may result in further disciplinary action against his medical license.

For this allegation and others, the Board ordered the general pathologist to arrange in the auditing of 5% of his cases by outside pathology laboratory approved by the Board and ensure that the auditing entity submits a report to the Board on a quarterly basis.  He was also ordered to obtain consultation with a board-certified dermatopathologist in all suspected melanoma cases and author a paper discussing the diagnostic criteria for well-differentiated squamous cell carcinoma and keratoacanthoma in vulvar tissue.

State: Iowa

Date: June 2017

Specialty: Pathology

Symptom: N/A

Diagnosis: Dermatological Issues

Medical Error: Diagnostic error

Significant Outcome: N/A

Case Rating: 4

Link to Original Case File: Download PDF

A 70-year-old female underwent a right vulva punch biopsy on 7/1/2014.  The sample was delivered to a general pathologist who noted pigmented cells within the epidermis.  The general pathologist ordered five stains to confirm the diagnosis and rule out Paget’s disease.  All stains were negative and the general pathologist arrived at a diagnosis of condyloma acuminatum with low grade vulvar dysplasia.

A senior pathologist disagreed with the general pathologist’s diagnosis in this case.  She described her findings as “[h]igh grade squamous intraepithelial lesion characterized by severe squamous dysplasia” and noted “[t]his lesion requires complete excision to rule out invasive squamous cell carcinoma.  A wider excision to include negative margins should have been performed.”

The senior pathologist offered her opinion that the general pathologist became sidetracked when he saw pigmented cells in the dermis and dying squamous cells in the epidermis.  The senior pathologist testified she thought those findings led the general pathologist to believe he needed to rule out Paget’s disease and malignant melanoma, which led to the ordering of the five special stains.  She explained that, in her opinion, the dying squamous cells looked nothing like Paget’s cells and the pigmented cells in the epidermis did not appear at all atypical as they would in a malignant melanoma.  The senior pathologist stated both the ordering of the stains and the misdiagnosis showed a deviation from the standard of care on the general pathologist’s part.  She emphasized this was not a benign lesion and the proper diagnosis, high grade squamous dysplasia, requires the excision of additional tissue to rule out invasive squamous cell carcinoma.

In response to questions about his diagnosis and the use of stains, in this case, the general pathologist noted that he saw large epithelial cells with prominent nuclei in the specimen which may be seen in Paget’s disease as well as other diseases.  The general pathologist explained he ordered stains to rule out Paget’s disease and melanoma in-situ.

A reviewing pathologist agreed with the senior pathologist that the general pathologist arrived at a misdiagnosis in this case; however, he did not agree that the misdiagnosis or the use of stains constituted a violation of the standard of care.  The reviewing pathologist opined that the histology warranted the use of stains to rule out Paget’s disease and melanoma and he did not believe the failure to report moderate to severe dysplasia would have resulted in improper management of the patient’s care.

For this allegation and others, the Board judged the general pathologist’s conduct to be below the minimum standard of competence given (his/her) lack of professional competency and practice that was harmful or detrimental to the public.  The general pathologist was warned that such practice in the future may result in further disciplinary action against his medical license.

For this allegation and others, the Board ordered the general pathologist to arrange in the auditing of 5% of his cases by outside pathology laboratory approved by the Board and ensure that the auditing entity submits a report to the Board on a quarterly basis.  He was also ordered to obtain a consultation with a board-certified dermatopathologist in all suspected melanoma cases and author a paper discussing the diagnostic criteria for well-differentiated squamous cell carcinoma and keratoacanthoma in vulvar tissue.

State: Iowa

Date: June 2017

Specialty: Pathology

Symptom: N/A

Diagnosis: Dermatological Issues

Medical Error: Diagnostic error

Significant Outcome: N/A

Case Rating: 2

Link to Original Case File: Download PDF

A 74-year-old female underwent a vulvar punch biopsy on 7/11/2014.  A general pathologist reviewed the specimen and arrived at a diagnosis of lichen sclerosus, a nonmalignant condition.

A senior pathologist arrived at a diagnosis different from that of the general pathologist’s lichen sclerosis diagnosis. She found “[s]kin showing foamy histiocytes, chronic dermal inflammation, and hemosiderin deposition, with a subepidermal vesicle.”  She believed the changes represented a reaction to an injury which could be from a ruptured cyst or gland.  This is also a nonmalignant condition; however, the patient would be managed differently than would a patient with lichen sclerosus.

At the hearing, the senior pathologist emphasized that she saw no features of lichen sclerosus in her review of the slides.  She explained that lichen sclerosus features inflammation running parallel to the epidermis and that was not the case in the patient’s specimen.  She also testified that the pathology report issued by the general pathologist did not contain his microscopic findings so she was unable to determine exactly what features he saw that led him to his diagnosis.  The senior pathologist found the general pathologist did not meet the standard of care in this case.

The general pathologist noted that he found this to be a “rather straight forward case”.  He stated that his diagnosis fits the patient’s age, the clinical information supplied, and the histomorphology.  At the hearing, he pointed out that, even though the senior pathologist criticized his diagnosis, she did not provide a definitive diagnosis herself but only a descriptive diagnosis.  The general pathologist explained that he looks at possible cancer cases, such as this, first thing in the morning when his mind is fresh.  After he is able to rule out malignancy, as in the patient’s case, he waits for the surgical biopsy to correlate his initial diagnosis.  Once again, the general pathologist stressed that the patient did not have a malignant lesion.

Another reviewing pathologist disagreed with the senior pathologist’s diagnosis.  He found the general pathologist’s diagnosis to be more appropriate.  The reviewing pathologist opined that the biopsy “most likely represents a hypertrophic variant of lichen sclerosus et atrophicus, which has some evidence of trauma or irritation in the recent past.”  He stressed that he did not believe the general pathologist arrived at a misdiagnosis in this case or that he failed to meet the standard of care.

There was a divergence in the evidence surrounding the general pathologist’s diagnosis in the patient’s case.  The senior pathologist opined that the general pathologist arrived at an incorrect diagnosis and stressed that she could not even determine how he arrived at his conclusions because he failed to describe his microscopic findings in the pathology report.  The reviewing pathologist, on the other hand, found the general pathologist’s diagnosis to be more appropriate than the senior pathologist’s.

The Board was faced with two equally credible experts who arrived at differing views after reviewing the same slides on which the general pathologist based his diagnosis.  This fact highlights other testimony at the hearing describing pathology as a discipline in which two similarly trained pathologists can disagree on a diagnosis without either violating the standard of care. It leads the Board to the conclusion that the state failed in its burden to prove the general pathologist failed to meet the appropriate standard of care in the patient’s case or that he engaged in practice harmful or detrimental to the public.

The absence of microscopic findings in the patient’s case is concerning. The Board urges the general pathologist to exercise more care and attention in the communication of his findings.

For other various allegations, the Board judged the general pathologist’s conduct to be below the minimum standard of competence given (his/her) lack of professional competency and practice that was harmful or detrimental to the public.  The general pathologist was warned that such practice in the future may result in further disciplinary action against his medical license.

For other various allegations, the Board ordered the general pathologist to arrange in the auditing of 5% of his cases by outside pathology laboratory approved by the Board and ensure that the auditing entity submits a report to the Board on a quarterly basis.  He was also ordered to obtain a consultation with a board-certified dermatopathologist in all suspected melanoma cases and author a paper discussing the diagnostic criteria for well-differentiated squamous cell carcinoma and keratoacanthoma in vulvar tissue.

State: Iowa

Date: June 2017

Specialty: Pathology

Symptom: N/A

Diagnosis: Dermatological Issues

Medical Error: No error found

Significant Outcome: N/A

Case Rating: 2

Link to Original Case File: Download PDF

The Board received a complaint alleging failure to adequately conduct Mohs surgery.  During the Board’s investigation, the Medical Consultant reviewed the charts of three patients regarding the dermatologist’s performances of Mohs surgery for a patient with basal cell carcinoma of the left ear, a patient with squamous cell carcinoma of the left ear and preauricular face, and a patient with basal cell carcinoma of the right ear.  The Mohs histology slides prepared for each patient were reviewed.  The Medical Consultant concluded that in each case the dermatologist’s removal of either the basal cell carcinoma or squamous cell carcinoma was incomplete.  It was noted that there was insufficient tissue present on the histology slides to represent a complete margin of a 2 cm tumor of the ear.  The dermatologist’s Medical Consultants disagreed.

The Medical Consultants noted in that the patient with the basal cell carcinoma of the right ear, there was poor correlation with Mohs Map, the operative report, and the findings in the histology slides.  In addition, there was no documentation discussing adjuvant therapies, further staging work up, or the persistent tumor with the patient at the time of Mohs surgery.

These patients had documented recurrences of their skin cancers that required additional Mohs surgery and in some cases, lead to tissue loss, nerve damage, and the need for reconstruction.

The Board judged the dermatologist’s conduct to be below the minimum standard of competence given failure to completely remove the tumor for three patients.

The Board ordered dermatologist be reprimanded.

State: Arizona

Date: April 2017

Specialty: Dermatology

Symptom: Dermatological Abnormality

Diagnosis: Cancer, Dermatological Issues

Medical Error: No error found

Significant Outcome: N/A

Case Rating: 1

Link to Original Case File: Download PDF

On 6/20/2014, a pathologist performed Botox injection to a patient’s forehead and Radiesse injections to her cheeks in the pathologist’s home.

Three days later, on 6/23/2014, the patient complained of severe swelling and redness at the injection sites on her cheeks.

The pathologist advised the patient to use a cold compress, to apply hydrocortisone cream, to take Claritin and ibuprofen, and to return for follow up in two days.

Shortly thereafter, the patient began to experience more swelling and draining at the injection sites.

On 6/26/2014, the patient presented to the pathologist for a follow-up appointment.  The pathologist documented that the patient’s swelling had subsided and that her pain was mainly relieved.  The patient was instructed to continue to take Claritin and ibuprofen for two weeks.

On 7/10/2015, the patient presented to a physician with complaints of pain, swelling, and drainage at the injection sites.  The physician treated the patient for abscesses that had occurred at the injection sites.

The Medical Board of Florida judged the pathologists conduct to be below the minimal standard of competence given that the pathologist did not record the lot number of the Radiesse in the patient’s chart.  Also, the pathologist placed the injection too close to the patient’s eye area.  The pathologist placed the injections too superficially in the patient’s skin.  The pathologist incorrectly diagnosed the patient with a hypersensitivity reaction.

The Medical Board of Florida issued a letter of concern against the pathologist’s license.  The Medical Board of Florida ordered that the pathologist pay a fine of $5,000 against her license and pay reimbursement costs for the case at a minimum of $5,175.43 and not to exceed $7,175.43.  The Medical Board of Florida also ordered that the pathologist complete a records course within one year of the final order, complete ten hours of continuing medical education in cosmetic procedures, and complete five hours of continuing medical education in “risk management.”

State: Florida

Date: March 2017

Specialty: Dermatology, Pathology

Symptom: Dermatological Abnormality, Swelling, Wound Drainage

Diagnosis: Dermatological Issues

Medical Error: Diagnostic error, Lack of proper documentation, Procedural error

Significant Outcome: N/A

Case Rating: 1

Link to Original Case File: Download PDF

A physician was the co-owner and medical director of a dermal spa.  A patient received hair removal, photofacial, and skin tightening treatments at the dermal spa from 8/4/2014 through 9/10/2014.  These treatments were performed using an intense pulsed light (IPL) device.  The use of IPL devices, among other devices, is regulated by WAC 246-919-605 – commonly referred to as the “laser rules,” though that title is under-inclusive.

Contrary to laser rules, prior to initiating treatment with the IPL device, the physician failed to document or perform a history and physical examination.  The physician performed and supervised the patient’s treatments without creating a sufficient medical record or ensuring that a sufficient medical record was created.  The physician failed to provide or document the provision of instructions for emergency and follow-up care, as required by the laser rules.

The informed consent document signed by the patient, prior to her treatment, did not record that the patient was informed that a non-physician may operate the IPL device, as required by the laser rules.  Contrary to laser rules, the physician failed to ensure the existence of a quality assurance program and failed to have written office protocols for supervised professional staff to follow before delegating the use of the IPL device.

The physician delegated the performance of the final three treatments to an esthetician.  Following the final treatment on 8/4/2015, the dermal spa records indicated that the patient developed slight burns on her chest and forearms.  The notes further indicated that the patient “said she had sun exposure before treatments.”  The physician indicated that patients are advised to avoid sun exposure prior to treatment and advised to inform the dermal spa staff if they are exposed to the sun before treatment so that adjustments can be made to the IPL device.  However, there was no further documentation regarding this potential complication, or regarding the physician’s involvement or availability to treat potential complications or provide consultation.

The Commission stipulated the physician write and submit a paper of at least 1000 words, with annotations, regarding the Washington State “Laser Rules” and her plan for ensuring that she is in compliance with the laser rules, write and implement a quality assurance program at the dermal spa, ensure that each patient receiving treatment with the IPL has a complete medical record, and reimburse costs to the Commission.

State: Washington

Date: January 2017

Specialty: Dermatology

Symptom: Dermatological Abnormality

Diagnosis: Post-operative/Operative Complication, Dermatological Issues

Medical Error: Procedural error, Failure to follow up, Lack of proper documentation

Significant Outcome: N/A

Case Rating: 1

Link to Original Case File: Download PDF

On 5/5/2011, a patient presented to a cosmetic laser clinic.  At this initial appointment, a nurse recommended that the patient receive Intense Pulsed Light treatment (“IPL”) utilizing the Lumenis One machine to treat rosacea, redness, and discoloration on his neck and chest.  On 5/5/2011, a dermatologist approved the nurse’s treatment recommendations.  The proposed IPL treatments were to be administered over three clinical visits.  The patient was not informed of the potential risk of severe burn and significant scarring associated with IPL treatment.

On 5/16/2011, the patient underwent his first IPL treatment without any adverse outcome.

On 8/15/2011, the dermatologist performed the second IPL treatment on the patient’s neck and chest using the Lumenis One machine.  At the time that respondent performed the second IPL on the patient, she had not previously reviewed the clinic’s written IPL protocol.  The dermatologist did not adjust the settings on the Lumenis One machine and instead relied on the preset settings.  The patient complained of extreme pain during this administration of the IPL treatment.  The patient asked the dermatologist to stop the IPL treatment at least four times during the course of the treatment.  The dermatologist did not stop the treatment, but only hesitated momentarily to wait for the patient to regain his composure.

The dermatologist continually made comments to coax the patient to proceed with the IPL treatment.  The dermatologist did not adjust the settings on the Lumenis One machine during the course of the IPL treatment.

On 8/15/2011, following the IPL treatment, the patient observed two large purple spots with blistering on his chest.

On 8/19/2011, the patient returned to the clinic for an IPL follow-up appointment with the dermatologist.  During this visit, the dermatologist diagnosed the patient with post-IPL second-degree burns to the neck and chest area.

On 6/7/2012, the patient returned to the clinic for an IPL follow-up appointment with the dermatologist.  The dermatologist noted that the patient had hypopigmented rectangles on his chest.

The dermatologist failed to adequately inform the patient of the potential risks of IPL treatment including burns and scarring.  The dermatologist failed to read the protocol governing the Lumenis One machine prior to treating the patient and failed to adjust the machine to a lower energy prior to treating the patient.

The Board issued a reprimand to the dermatologist and ordered the dermatologist to enroll in a clinical in-service training provided by the vendor of the IPL medical device.

State: California

Date: October 2016

Specialty: Dermatology

Symptom: Dermatological Abnormality

Diagnosis: Dermatological Issues

Medical Error: Procedural error

Significant Outcome: N/A

Case Rating: 1

Link to Original Case File: Download PDF

On 9/30/2008, a mid-fifties male with a history of a spinal tumor that resulted in paraplegia saw Plastic Surgeon A for a decubitus ulcer that would not heal.  The patient also periodically took Avastin, a chemotherapy agent, which left his system immunocompromised.  As a result of this consultation, Plastic Surgeon A ordered laboratory tests to determine possible bacterial culture and sensitivity.  The patient returned to Plastic Surgeon A on 10/14/2008.  Based on the report of the September 2008 laboratory tests, Plastic Surgeon A determined that the patient had both a staphylococcus epidermidis and a candida albicans infection.  Plastic Surgeon A prescribed an antibiotic for the staphylococcus epidermidis infection and an antifungal agent for the candida albicans infection.

On 5/5/2009, the patient saw Plastic Surgeon A again regarding the decubitus ulcer.  The wound was located on the tailbone and had measurements of 5 cm (width) x 8 cm (height) x 0 cm (depth).  In the center of the wound, there was a small, slightly differently colored depression.  The wound had no odor, and Plastic Surgeon A assessed it as “scalded skin syndrome” with “possible infection.”  Plastic Surgeon A took samples and ordered labs to determine culture and sensitivity.  Plastic Surgeon A also ordered a fungal culture.  When the results of the 5/5/2009 laboratory testing were received, they indicated three types of bacteria for which Plastic Surgeon A prescribed two different antibiotics, namely, ampicillin and ciprofloxacin.  Also, candida albicans had been isolated in the fungal culture, for which Plastic Surgeon A prescribed fluconazole.  Plastic Surgeon A also prescribed the application of an aloe vera plant to the affected area.

On 6/2/2009, the patient again saw Plastic Surgeon A for the non-healing wound.  The overall surface area of the wound had increased to 5.8 cm (width) x 9 cm (height) x 0.1 cm (depth).  In the center of the wound was an ulcer with dimensions of 2.5 cm (width) x 5 cm (height) x 1.5 cm (depth).  The wound had the same red, “scalded” appearance that it had on 5/5/2009, but now had “pale, tan, dead tissue” in the central ulcer and an odor.  Plastic Surgeon A did a deep debridement of the wound and prescribed Santyl (an enzymatic debriding agent) for the peripheral area and Dakin’s solution (a diluted bleach solution) for the central, dead tissue area.  Plastic Surgeon A did not order any labs to determine culture and sensitivity nor did he order a fungal culture.  The patient’s prior courses of antibiotics had ended, and Plastic Surgeon A did not prescribe any additional or repeat antibiotics.

On 6/4/2009, the patient called Plastic Surgeon A’s office to say that after Tuesday’s debridement by Plastic Surgeon A, the patient had chills and a fever of 103 F.  Yesterday evening, the patient had had chills and a fever of 102.9 F, and that morning, the patient had chills and a fever of 101.2 F.  The wound was not red, and the patient asked about possibly being prescribed medication.  Upon being given this information, Plastic Surgeon A responded, “Not from wound, See primary care doctor for other sources of infection.”  Plastic Surgeon A did not examine the wound himself, order any labs or other tests, or speak to any other medically-trained personnel who had examined the wound.  No specifics regarding size or odor of the wound were sought or obtained by Plastic Surgeon A.

On the evening of 6/6/2009, Plastic Surgeon A received a call from the patient or from someone calling on his behalf.  According to the caller, the patient’s wound had taken a turn for the worse.  Plastic Surgeon A advised the patient to go to the emergency department, but made no note of the call or the information exchanged.  That same night, the patient was seen by a physician in the emergency department.  The ED physician’s diagnosis was “acute fever by history. Sacral decubitus ulcer with cellulitis, rule out necrotizing fasciitis.”  At approximately 9:20 p.m. on the same night, the ED physician spoke with Plastic Surgeon A and informed Plastic Surgeon A of his diagnosis.  Plastic Surgeon A asked for the patient to be admitted and said that he would see the patient the following day.  Still later that same night, the ED physician tried to get Plastic Surgeon B, who was on-call, to come treat the patient, but Plastic Surgeon B told the ED physician that he was not on-call for Plastic Surgeon A’s patients and refused to come to the hospital.  Plastic Surgeon B said that he would discuss this with Plastic Surgeon A personally.  After a discussion between Plastic Surgeon A and Plastic Surgeon B, Plastic Surgeon A spoke with the ED physician again at 11:15 p.m. and confirmed that he would not be coming to treat the patient.  Plastic Surgeon A further informed the ED physician that he would come and see the patient “in six and a half (6.5) hours.”

On 6/7/2009, Plastic Surgeon A attended to the patient at 9:30 a.m.  In the progress record for this visit, Plastic Surgeon A wrote that the patient’s sacral pressure ulcer was “now necrotic, infected, with cellulitis. Fever.”  Plastic Surgeon A planned to do surgical excision, obtain multiple cultures, send bone samples to pathology, and arrange an infectious disease consultation.

The surface area of the patient’s wound, which was surgically debrided by Plastic Surgeon A on the afternoon of 6/7/2009, was 51 cm x 16 cm x 2.5 cm.  Laboratory reports later revealed that osteomyelitis was present in the bone samples taken from the patient’ coccyx and/or sacrum, and various bacteria were identified for which two different antibodies were prescribed.

The Medical Board of California judged that Plastic Surgeon A was grossly negligent in his care and treatment of the patient because he failed to see the patient on 6/6/2009 when the evidence pointed to the ulceration being the cause of the immunocompromised patient’s worsening condition, fever, and chills as well as committed repeated negligent acts in his care and treatment of the patient due to failing to order laboratory tests to determine culture and sensitivity and/or fungal cultures, prescribe antibiotics to the patient, and take responsibility for the patient on 6/6/2009 (i.e. ensured and/or provided a back-up plastic surgeon for Plastic Surgeon A’s patients when he was unavailable on 6/6/2009 and/or was aware that no other plastic surgeon would be treating the patient that night, and/or he waited before seeing the patient himself despite the possibility that the patient had a potentially life-threatening condition).

The Medical Board of California ordered that Plastic Surgeon A be placed on probation for 2 years and complete a clinical training program and an education course (at least 40 hours on the topic of wound care, including treatment of decubitus ulcers) equivalent to the Physician Assessment and Clinical Education Program offered at the University of California San Diego School of Medicine.

State: California

Date: January 2015

Specialty: Plastic Surgery

Symptom: Dermatological Abnormality, Fever, Mass (Breast Mass, Lump, etc.)

Diagnosis: Dermatological Issues, Infectious Disease

Medical Error: Failure to examine or evaluate patient properly, Delay in proper treatment, Failure to order appropriate diagnostic test

Significant Outcome: N/A

Case Rating: 3

Link to Original Case File: Download PDF