Poor documentation has been the main reason for adverse action against physicians by disciplinary bodies and courts following patient complaints, a study indicated. Patient complaints, however, tend to focus on diagnosis and communication. 

Dermatologists, while accounting for a mere 1.3% of closed cases over the past 40 years, have also garnered disproportionately high patient complaint rates, especially when it comes to communication and information sharing. But overall numbers of cases have been small. 

“One of the most important findings is that dermatologists and other specialists treating skin cancer in Canada are not being sued a lot, which is reassuring for the physicians,” study coauthor Elena Netchiporouk, MD, assistant professor of dermatology and experimental medicine at McGill University and clinician-scientist at McGill University Health Centre, both in Montreal, told Medscape Medical News. “Where doctors were found to be guilty were mainly in cases of poor documentation in the chart,” she said. 

The review was published on September 23 in Journal of the American Academy of Dermatology. 

Documentation Crucial

Netchiporouk and her team examined publicly available medicolegal cases between November 1983 and March 2025 with the aim of identifying physician-involved allegations related to skin cancer diagnoses, management, or follow-up. Nonphysician cases were excluded, and extracted data focused on cancer type, physician specialty, geographical jurisdiction, case outcome, and practice setting. 

Of the 108 cases over the 40-year period, 52 were closed medicolegal cases, and 56 were related decisions such as appeals or procedural rulings. Provincial regulatory authorities in Ontario (75%, n = 39) and British Columbia (13.5%, n = 7) adjudicated most of the closed cases. Melanoma accounted for just over half (52.8%, n = 28) of cases and represented 87.5% (14 of 16) of cases where metastatic disease was present. Basal cell and squamous cell carcinomas were identified in 17.3% (n = 9) and 15.4% (n = 8) cases, respectively. 

Defendants were mostly family physicians (33.3%) and dermatologists (25.0%), followed by plastic surgeons (10.0%), and oncologists (8.3%). Most cases involved failure to diagnose (65.4%), inadequate communication (48.1%), and documentation deficiencies (44.2%). 

The primary reasons for administrative action against physicians, which occurred in 42.3% (n = 56 of 108) adjudicated cases, included failures to record lesion characteristics (ie, size, shape, and color), procedural details (eg, failure to biopsy suspicious lesions), and inadequate follow-up. 

“It’s a good reminder to physicians that even if we have no time, that if we don’t document it right, if the chart is incomplete, we will be held responsible,” said Netchiporouk. 

Though most decisions targeted documentation failure, findings also showed that patients tended to complain about failure to diagnose (65.4%), eg, physician nondisclosure of clinically suspicious lesions. Almost half (48.1%) of allegations involved inadequate communication, such as failure to introduce oneself. 

Study limitations included a reliance on publicly available case reports and a modest sample size. 

Limiting Skin Examinations

“There was a big discrepancy between what the patients were basing their complaints on and what was actually found by the adjudicators to have been done in error by the physician,” Marisa Ponzo, MD, PhD, practicing dermatologist at North York Dermatology Clinic in Toronto and clinical trialist, told Medscape Medical News. 

Ponzo, who was not involved in the study, said that the Canadian Medical Protective Association often sends letters to physicians discussing how a lot of these complaints can be mitigated by behavior and communication with patients. 

Both Netchiporouk and Ponzo pointed to the role that complex structural issues, (eg, resource constraints), as well as remuneration and physician access, play in driving the lack of documentation or even in terms of how much time physicians can spend and communicate with patients. Nevertheless, findings showed that the thoroughness of care should be a priority for practicing clinicians. 

“As clinicians, we are facing different issues. What is happening in Quebec is not representative of what is happening in Alberta,” said Netchiporouk, also noting that the research team provided tools within the paper to ensure that “we are structured to prevent poor outcomes in our patients, and also, legal hassles, which can be extremely demoralizing for physicians.” 

Ponzo said that two best practice suggestions stood out the most for her: initial assessment and documentation. 

“I like that they recommended limiting skin examinations to areas relevant to the referral,” she said. “Whereas we may think that patients want us to check their whole body, they may prefer, or at least it’s suggested from a medicolegal point of view, to just focus on the area listed in the referral and then document if they’ve declined an exam in certain parts of the body.” 

Additional documentation suggestions included recording lesion characteristics, clinical reasoning, diagnosis discussion, procedure consent, and follow-up plans (especially all patient outreach efforts for missed follow-ups). 

No funding for the study was reported. Netchiporouk reported having no relevant financial relationship. Ponzo reported receiving speaker fees and honoraria from AbbVie, Amgen, Bausch Health, BMS, Boehringer Ingelheim, Celgene, Eli Lilly, Galderma, Janssen, LEO Pharma, Naos, Novartis, Pfizer, Sanofi Genzyme, and SUN Pharma.

Liz Scherer is an independent health journalist who frequently reports on Canadian and global health news.