What to do when you are curbsided by your patient's plus one

Dear Dr Dermatoethicist: I am in solo practice and recently saw an adolescent patient, accompanied by her father, for acne. Afterward, she asked if I could examine a suspicious pigmented lesion on her father’s back. How should I handle such requests?–A Concerned Dermatologist Dear Dr Dermatoethicist: I am in solo practice and recently saw an adolescent patient, accompanied by her father, for acne. Afterward, she asked if I could examine a suspicious pigmented lesion on her father’s back. How should I handle such requests? –A Concerned Dermatologist Dear Dr Conscientious: Prior ethical analyses of curbside consultations in dermatology have focused on when dermatologists are approached in an informal setting outside their clinic or notice alarming findings on a bystander.1Wolz M.M. Drage L.A. The unscheduled and incidental bystander: legal, moral, and ethical considerations in the office.J Am Acad Dermatol. 2013; 68: 332-334https://doi.org/10.1016/j.jaad.2012.09.019Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar,2Grant-Kels J.M. Kels B.D. The curbside consultation: legal, moral, and ethical considerations.J Am Acad Dermatol. 2012; 66: 827-829https://doi.org/10.1016/j.jaad.2011.12.025Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar Ethicists have argued that providing care in settings in which physicians feel uncomfortable, it is difficult to perform an examination, and/or clinic resources are lacking is unwise. However, their concerns can be conveyed and urgent follow-up visits arranged when appropriate.1Wolz M.M. Drage L.A. The unscheduled and incidental bystander: legal, moral, and ethical considerations in the office.J Am Acad Dermatol. 2013; 68: 332-334https://doi.org/10.1016/j.jaad.2012.09.019Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar,2Grant-Kels J.M. Kels B.D. The curbside consultation: legal, moral, and ethical considerations.J Am Acad Dermatol. 2012; 66: 827-829https://doi.org/10.1016/j.jaad.2011.12.025Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar The current scenario differs, in that the dermatologist is at their clinic when an explicit request for informal consultation occurs and they have not yet made any alarming findings. In this setting, some dermatologists may evaluate the lesion informally, others may require a formal appointment but see the guest immediately, whereas others may still ask the guest to schedule a later appointment to avoid interrupting an already busy clinic. An informal evaluation at a clinic may seem reasonable given that the patient’s guest is already present and the patient has a relationship with the dermatologist. However, the guest does not have completed intake forms, disclosed medication allergies, or appropriately disrobed, potentially compromising adequate care. Additionally, spending extra time with the guest increases wait times for scheduled patients. Justice demands that we balance providing immediate attention to the patient’s guest with delaying care for other patients who have been potentially waiting for months to obtain care. Finally, providing medical advice that extends beyond triage, even informally, can establish a patient-physician relationship, in which the physician is expected to provide the same standard of care as they would for a formal patient encounter, exposing the physician to legal liability.3Johnson L.J. Malpractice consult. Should you give informal medical advice?.Med Econ. 2007; 84: 36Google Scholar,4Eastwood G.L. When relatives and friends ask physicians for medical advice: ethical, legal, and practical considerations.J Gen Intern Med. 2009; 24: 1333-1335https://doi.org/10.1007/s11606-009-1127-1Crossref Scopus (9) Google Scholar Given the problems with informal evaluations, it may seem appropriate to reflexively require the guest to schedule a formal appointment without inquiring further. However, this too results in significant ethical problems because there are certain dermatologic diagnoses for which time is of essence. Given that recent years have seen increasing wait times5Greater access for patients partnership. Patients are waiting: America’s dermatology appointment wait times crisis.https://www.dermpa.org/page/GAPPDate accessed: April 18, 2022Google Scholar for dermatology appointments and early interventions are often associated with better outcomes, prospective patients with such diagnoses may be harmed by lack of access to timely care. Regardless of presumptive risks based on the guest’s description of complaints, further inquiry and examination (even if brief) would significantly aid the risk stratification of the complaint and minimize potential harm to the guest. Therefore, we recommend that because Dr Conscientious has the tools and expertise necessary and is in a professional setting, she triage the patient’s father after visually assessing his lesion and recommend the next best step. In certain cases, in which the diagnosis is certainly benign grossly, she may reassure the patient’s guest, with follow-up as desired. Otherwise, she may refer the patient’s guest to another provider with appropriate expertise or shorter wait times or offer an appointment with her clinic now or later. –Dr Dermatoethicist None disclosed.