Names have been removed to protect privacy. Identifying letters are assigned in alphabetical order and bear no relationship to the person's actual name.
The Commissioner received a complaint from a mother about services provided to her daughter, (the consumer) by a general practitioner. The complaint is that:
- The GP removed two moles from the consumer but did not inform the complainant that the total cost would be $300.00. The complainant's recollection was that the cost would be $150.00. It was never stated that this fee would be per mole.
- The complainant believes that she was medically advised to do something that according to paediatricians at the Child Health Centre at the Hospital is unnecessary in a child of the consumer's age.
The Commissioner received the complaint on 13 March 1998 and an investigation was undertaken.
Information was obtained from:
- The Complainant
- The General Practitioner/Provider
- The Practice Nurse
Clinical records were obtained and viewed. The Commissioner sought advice from an independent General Practitioner and Dermatologist.
Outcome of Investigation
On a Saturday in January 1998 the GP agreed to provide free melanoma checks at an ambulance open day. On that day the complainant attended the melanoma check with her son and daughter (the consumer) who was then 10 years old.
The GP examined the consumer's two moles. There is conflicting information on what was said following the examination by the GP.
The GP's Account
The GP says that on enquiry as to why the complainant had not gone to her own general practitioner, the complainant responded by saying that she would not let their family doctor touch her children. Following this, the GP advised the complainant while referring to the consumer's moles that none of her children's lesions looked like malignant melanoma but this did not mean they would not change in the future. The GP then went on to examine the consumer's neck mole and considered it was suspicious because there was variable pigmentation, irregular borders, it was larger than 2mm in diameter, there was a family history of fatal melanoma and the lesions had recently appeared.
The GP says he then informed the complainant of the following options in regards to the consumer's moles:
- The GP to excise and refer for biopsy; or
- Referral to specialist for further advice; or
- Return to own general practitioner for further advice.
The GP then remarked that if the consumer was his own daughter he wouldn't leave it for more than two weeks.
The complainant then asked about the cost of removing the mole on the consumer's neck. The GP advised the complainant that because of the difficult position he would be using more of the cost unit-time of the practice if she decided to go ahead which would cost in the region of $250.00. However, since the consumer and provider were colleagues, the GP would charge $150.00. The complainant also asked about the cost of removing the mole on the consumer's back which he advised would be the same as the neck mole.
The GP is of the opinion that the consultation lasted some 25-30 minutes. The consumer was one of some 40 clients whom the GP saw that day.
The Complainant's Account
The complainant described the mole on the consumer's neck as black in appearance and about 2mm in size, whereas the mole on the consumer's back was brown in appearance. The consumer's two moles had been examined by the family's general practitioner about 18 months previously and the GP had advised the complainant to observe the consumer's moles which had not changed in the intervening period.
The complainant recalls the GP/provider discussing the following options:
- The GP to excise and refer for biopsy; or
- Referral to specialist for removal of mole and the cost involved with this particular option.
The GP informed the complainant that if she had the moles removed by a specialist it would cost $300.00, but the GP said that he would remove them for $150.00. The complainant said that at no time during this consultation did the GP advise that it was $150.00 per mole.
The complainant advised that the consultation was about 10 minutes' duration and she was given a surgery appointment which was written on the back of the GP's business card.
In late January 1998 the complainant and the consumer arrived at the GP's surgery. On arrival both the complainant and the consumer waited as the receptionist had no record of their appointment with the GP. After some time, the consumer was seen by the GP who went ahead with the excision of the mole located on the consumer's neck. This procedure took about 40 minutes because of the location of the mole. At the completion of the excision the GP then went ahead with removing the consumer's second mole after the complainant agreed that he should do so.
Advice to Commissioner
The general practitioner advising the Commissioner considered that the GP showed a low threshold for the removal of the consumer's moles. He noted that the "Guidelines for the Management of Cutaneous Melanoma" states:
"Surveillance of these very high groups (those with a first degree relative with confirmed melanoma, having a presence of multiple atypical naevi or moles) is not necessary before the early teenage years [and] prophylactic excision of dysplastic naevi and other benign naevi is not useful in minimising melanoma risk as a significant proportion of melanomas begin as new lesions rather than developing from pre-existing naevi."
Furthermore: "[N]ot all changing pigmented lesions are melanomas and skin surface microscopy is helpful in the assessment of changing lesions."
The advisor also stated:
"[m]elonoma is very unusual in children - I rarely remove moles from prepubertal children."
The Code of Health and Disability Services Consumers' Rights
The following Rights are applicable:
Right to to Freedom from Discrimination, Coercion, Harassment, and Exploitation
Every consumer has the right to be free from discrimination, coercion, harassment, and sexual, financial or other exploitation.
Right to be Fully Informed
1) Every consumer has the right to the information that a reasonable consumer, in that consumer's circumstances, would expect to receive, including -
b) An explanation of the options available, including an assessment of the expected risks, side effects, benefits, and costs of each option.
2) Before making a choice or giving consrnt, every consumer has the right to the information that a reasonable consumer, in that consumer's circumstances, needs to make an informed choice or give informed consent
Right to Make an Informed Choice and Give Informed Consent
1) Services may be provided to a consumer only if that consumer makes an informed choice and gives informed consent, except where any enactment, or the common law, or any other provision of this Code provides otherwise.
In my opinion the GP breached Right 6(1)(b), Right 6(2), Right 7(1) and Right 2 of the Code of Rights as follows:
Right 6(1)(b) and Right 6(2)
I accept the information provided by the complainant that the GP did not provide appropriate information in regards to an explanation of the options available, including expected risks, side effects, benefits, and costs. The GP discussed the issue of excision and biopsy, yet he did not inform the complainant that malignant melanoma is rare in pre-pubertal children.
I accept that the complainant was advised of the option of a referral to a specialist in terms of the likely cost involved of a specialist removing the mole. However this option of a specialist was simply in terms of the cost of the mole removal and did not extend to information on the benefits and risks. Further the option of doing nothing should have been explained. In my opinion this was also information that the complainant needed to make an informed choice.
In my opinion the complainant did not have sufficient information and therefore was unable to make an informed choice.
The GP's comment that if it was his own daughter with moles he would not wait 2 weeks to take action, was an inappropriate statement which led the complainant to believe that the situation was serious and that the moles needed to be removed urgently. In my opinion this statement was made to coerce the complainant into making a choice.
Opinion: No Breach
Costs of Removal
There is insufficient information to conclude that the GP breached the Code of Rights on this matter. In considering the issue of the cost of this procedure I received conflicting information and it is possible that there was a misunderstanding between the GP and the complainant regarding the costs of removing the moles. I am therefore unable to decide if the GP breached the Code of Rights on this matter and note that the complainant paid only $150.00 for the excision of the consumer's two moles.
I recommend the GP takes the following actions:
- Apologises in writing to the complainant for breaching the Code of Health and Disability Services Consumers' Rights. This apology is to be sent to the Commissioner who will forward it to the complainant.
- Reads the Code of Health and Disability Services Consumers' Rights and confirms in writing to the Commissioner that he fully understands his obligations as a provider of health services.
- Passes a credit note for the $150.00 not paid by the complainant to clear the billing issue.
A copy of my opinion will be forwarded to the Medical Council of New Zealand.
For further information, contact: HDC Communications Section (09) 373 1060.