Collegiality and dermatology.

I believe my good and learned colleague Dr Ackerman raises an interesting issue. Is it inherently unprofessional or unethical for a dermatologist who has performed a skin biopsy as part of his evaluation of a patient to render a pathology diagnosis as an additional part of his care of the patient? From the purest of motives, Dr Ackerman argues against such a practice since these dermatologists are only ‘‘pretending’’ to be dermatopathologists, driven by pure financial greed. But I see it differently. In this age of increasingly unrestrained medical expense, there is no way that every biopsy specimen can generate the sort of expense that is routinely billed by our colleagues in tertiary referral dermatopathology practices. Neither can every headache receive the assurance of a magnetic resonance imaging scan in the emergency department, nor every case of chest pain receive the benediction of the interventional cardiologist. Hence many of us commit the cardinal sin of triaging the ‘‘simple’’ from the ‘‘complex’’ cases, filtering the cases that truly benefit from consultation, often from more than one dermatopathologist at a time. Because of insurance limitations, many of these cases are precluded from tertiary dermatopathology consultation with colleagues whose opinions we trust. To obtain consultation from a consultant dermatopathologist, the cost frequently comes out of my pocket, not the patient’s insurance company’s nor the patient’s. The issue of dermatologists ‘‘pretending’’ to be dermatopathologists brings to my mind a parallel. It is the practice of many dermatopathologists to insert surgical instructions as part of their written conclusion and diagnosis of a specimen. To further explain,