Today there are many reasons why a patient may receive differing recommendations from various doctors regarding the treatment of a skin cancer. These include the type of specialist the patient is seeing, e.g., plastic surgeon, dermatologist, ear, nose and throat surgeon, general surgeon, family practitioner or internist. Many scientific studies have shown that the correct diagnoses and treatments for skin cancer are most frequently delivered by dermatologists. Consider that dermatologists study skin cancer constantly for three years during their training. Plastic surgeons train for only two years after their general-surgery training and usually have little training on the biological and microscopic behavior of skin-cancers and precancers. Internists and family practitioners frequently misunderstand and commit treatment failures because they study skin cancer for only a few days, if at all, during their specialty training. Ear, nose and throat surgeons (ENT) study skin cancer for a period of time, but their studies are much shorter than dermatologists'.

None of the above are hard and fast rules. There are some excellent plastic surgeons and ENT surgeons who are far better at treating skin cancer than most dermatologists. However, a high percentage of dermatologists, Mohs surgeons and dermatologic surgeons exist who would be considered the "best in the world" compared with ALL other doctors combined. Unfortunately for the public, there are many plastic surgeons, dermatologists and other specialists who are miserable skin-cancer surgeons, missing many tumors and scarring patients so irreparably that these patients no longer want treatment for remaining cancers. There are good and bad in all specialties; much time should be spent in research before choosing a skin-cancer specialist. The surgery may take only minutes or hours, but the effects will last the rest of your life.

Physicians in different specialties are taught different methods of skin-cancer treatment. True Mohs surgeons (Fellows of the American College of Mohs Micrographic Surgery and Cutaneous Oncology) study all skin-cancer treatments from A to Z, with the possible exception of radiation. Plastic surgeons are taught mostly the traditional vertical-section cutting-out. Most dermatologists are taught treatments from A to W and have not been formally trained in Mohs Surgery or radiation therapy for more than a few weeks. Internists and family practitioners learn whatever they can "pick up" during a few weeks of observational training. Some dermatologists who would like to be true Mohs surgeons "trained" themselves and recently formed the American SOCIETY for Mohs Surgery. (Note the amazing similarity of the name to that of the real specialty.) You can learn the difference by calling the American COLLEGE of Mohs Micrographic Surgery and Cutaneous Oncology in Illinois at (800) 500-7224, which will provide a list of true members.

When it comes to skin cancer, patients may get only whatever treatment their doctor is trained to give or feels like giving. That may leave important gaps. Frequently, the doctor must decide if you will tolerate the scar he/she is about to give you and whether his/her 90% cure (10% failure) rate could be a problem when/if your cancer returns, causing further scarring and deformity. Does the doctor want to lose the patient and possible future earnings by referring the skin-cancer patient to a specialist with the proper training and talent to reduce the scar and increase the cure rate to almost 100%? This is a difficult question to answer and must, of course, be taken on a case-by-case basis. Just remember, if your doctor is trained only in methods A-D, and it turns out that the best treatment was Q, you may not get the referral to the doctor who is an expert in treatment Q.

Other factors also play a role in how you will be treated by your skin-cancer specialist. Insurance companies and the government force or encourage doctors to use various particular treatments by instituting rules (arbitrary values) before surgery, limiting payment to certain procedures or auditing and refusing to pay for a procedure after it has been performed by the doctor. Almost all treatments for skin cancer have a CPT code developed by a Harvard Professor for the government. Almost all types of skin cancer or ailment have a certain ICD-9 code developed in the 1980's so the government and insurance companies can track diseases, follow your history and limit or assess payments. Government and the insurance industry (an industry responsible to stockholders and ruled by Boards of Directors with the bottom line--money--always in mind) have used the CPT and ICD-9 to lower skin-cancer treatment payments by up to 50% since 1992! How do doctors react to the following changes?

The aforementioned times include only surgery and not set-up times, discussion time that the doctor spends with the patient, follow-up visits that cannot be billed, like stitch removal, or anything else to do with the treated skin cancer. The doctor's overhead expenses for nurses, billing personnel, secretaries, rent, malpractice insurance, equipment leases, instruments, computers, licenses, government inspections/fees and non-durables may run up to $200 per hour, $3.33/minute. Even if the overhead is only half that, or $100 per hour, such half-overhead is $1.67/minute. Is it any wonder that treatments that cure less and scar more, like freezing and scraping (curettage), are used more often nowadays? The math is simple and the insurance companies and their MBA's and accountants know it. Please note that not all doctors are motivated by cost, and that many doctors act completely independently of monetary pressures.

If it isn't monetary pressure, then it could be insurance company contract pressure. (The author has yet to see any insurance contract that mentioned the Hippocratic Oath.) In many cases there is no way around "it" for your doctor. Most doctor's PPO contracts, for example, provide that the doctor "must treat with the most cost-effective method" . . . [and] the doctor must abide by the decisions of our managed-care review committee." The term "cost-effective" can be defined by the insurance company and its auditor any way they want, and at any time.

Many insurance-company review committees consist of doctors who didn't score high enough on their exams to get a specialty-training position or doctors who could not make it on their own in private practice. Your doctor may know and fear this because he/she usually has no recourse against decision makers of this type. If a PPO doctor chooses not to use "the most cost-effective method," he/she may forfeit all payment for a procedure.

Often your doctor may be bound by a contract "gag rule" not to complain to you about the wrong doings or potential wrongdoings of your insurance company. Such a gag rule is not a term that the doctor can negotiate. The insurance company can impose the gag rule in its contracts by virtue of its superior power in the market place. It is a good idea to ask your doctor whether he/she is bound by a gag rule. The doctor can legally answer this question. A few states are striking down HMO and PPO insurance company gag rules but this is rare because insurance companies contribute heavily to political campaign funds and/or give politicians stock shares in their companies. This creates a definite conflict of interest for the politicians: your health versus insurance companies' money.