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Are the margins clear?

Still in my early years of practice, it has been easy to rely on facts gleaned from residency, board reviews, and meetings. Then an Internet-educated patient came in the door and shook my core assumptions. Confronted with Web site research, I had to answer very logical, yet superficial, medical questions. The latest question summarized an ongoing dialogue in the dermatologic literature to 4 simple words: “Are the margins clear?” After this patient had curettage of an “actinic keratosis” on the forearm by another dermatologist, she demanded assurance from me. Waiting for recurrence was not an option. Recently, a change was made in the classification of actinic (solar) keratosis to “keratinocytic intraepidermal neoplasia,” and then to “squamous cell carcinoma, solar keratotic type, very superficial” to emphasize its malignant status. The new nomenclature more accurately describes the true nature of these carcinomatous lesions. This change creates a new subset of concerned patients with a cancer diagnosis. In addition, it justifies to the managed care administrator why removal is medically necessary. My new patient was unconvinced that the lesion had been adequately treated by a previous dermatologist. She wanted Mohs’ micrographic surgery, which was performed by a third dermatologist. This was overly conservative. The lifelong challenge of medicine is to apply scientific developments to optimize patient care. Today, as more patients are attempting to manage their own care, they still need our guidance. Knowledge is power, indeed.