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Thinking as a Lifesaver: What’s the Code for That?


My dermatologist had a gut feeling about a spot on my chest; that feeling saved my life. Code for "gut feeling," please.

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I noticed a rough spot on my hand I thought suspicious for skin cancer, so I called a dermatologist’s office for an appointment. I was self insured ( code for no insurance, but that’s a subject for another story). The dermatologist, whom I had picked at random, was booked, and I was told new patients were seen first by the nurse practitioner (NP).

The NP entered the room as I sat nervously on the exam table. I pointed out the lesion in question, and she agreed it was probably a squamous cell carcinoma. She did a full body skin exam and biopsied the lesion.

About a week later I received a call requesting I make an appointment with the dermatologist for treatment of my skin cancer.

Slightly less nervous this time, I listened as the  dermatologist explained the treatment, which sounded straightforward. Surgery on my hand complete, she glanced at my chest.

“It looks funny” are not words of comfort from a dermatologist examining a pigmented area of the skin.

She biopsied the lesion on my chest and within  two weeks I learned of my melanoma, which fortunately was in situ, and curable.

She had saved my life with her experience, her brain and her eyes, but the bulk of her payment was for a procedure.

Or course I paid whatever she charged, in this case, what Medicare would have paid had I been eligible for it. But it disturbs me that Medicare or any other insurer values the excision of a cancer more than the recognition of it. After all, distinguishing between my countless freckles and “ it looks funny” is the value I hold dear.

And so it follows for all our medical care, every day when we try to distinguish between anxiety and heart attack as a cause for chest pain, sort out irritable bowel syndrome from colitis, recognize the significance of an enlarged supraclavicular lymph node. We will reap a large fee for performing the colonoscopy, but not for processing the information that led us to order it. At times we use or judgement to recommend against expensive and potentially risky procedures, but the procedure that we advised against is reimbursed at a higher rate than our clinical judgement.

This all seems backwards to me, because in my view, my dermatologist recognizing “funny” is worth more than the shave biopsy confirming  her clinical acumen.

As a family doctor, the bulk of my work involves listening, looking, and thinking. With each patient encounter, I remember my dermatologist reminding me of the value of my brain, even if I can’t code for it.


Andrea L. Brand, MD is Clinical Assistant Professor of Family Medicine, Florida State University School of Medicine, and Senior Physician, Sarasota County Health Department, Sarasota, Florida.

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