Barbadian lilt sounds odd coming from the mouth of a pale white woman. Martha’s Caribbean childhood has left her with not just an exotic accent but an ongoing series of nonmelanoma skin cancers.

Unscheduled, she sat on my exam table last month. The slash across her nose and right cheek made her look like a dueling-society initiate.

Martha sounded as troubled as she looked. "Dr. Martini has done the Mohs surgery on me before," she said, "but this time, I’m not sure things were handled in the best way."

"What happened?"

"I got to his office at 8:30 in the morning. At 5:30, he had finished the fourth pass and said he still found more tumor, not deeper but at the sides. I took one look at the wound in my face and told him he had to get hold of a plastic surgeon. Fortunately, Dr. Seth was still at the hospital and agreed to stay around. Dr. Martini finished a fifth pass, and Dr. Seth sewed me up before I finally went home."

After a pause, Martha continued. "Look," she said, "this is not your fault. But the basal cell was just a pinpoint, and by the time Dr. Martini was done, there was a huge, gaping hole. I just don’t have confidence that this was done right."

I considered: how to be reassuring without sounding defensive, like just another doctor circling the wagons to protect a colleague. "As you know, Martha," I said, "the point of Mohs surgery is to make sure the whole tumor is removed. They make as many passes as needed, but there’s no way to know in advance how many of them it will take or how big the wound will be."

She seemed a bit mollified, so I went on.

"I’ve sent many patients to Dr. Martini," I said, "including you a couple of times. I really think he knows his business. This tumor just turned out to be bigger than anyone could have guessed. If anything, it shows that it’s a good thing you went for the Mohs, instead of a conventional excision that could have missed all the basal cells hiding under there."

"Well, if you think so," she said, wavering. She showed me another lesion on her shin. "Then you probably would suggest he also remove this squamous cell he biopsied on my leg." I agreed that she ought to proceed.

Having addressed Martha’s concerns, I thought about all the reasons she would not be one to question the propriety of her treatment. First, Martha is not a cranky troublemaker; she has always been calm and reasoned and gracefully stoic in the face of one biopsy and surgery after another. Second, she is educated and sophisticated. She knows all about Mohs surgery and its rationale, having undergone it several times. In fact, she has had it done a few times by Dr. Martini. In a rational world, every risk manager would agree that Martha of all people would have no reason for unreasonable dissatisfaction or anger.

But when an outcome is much worse than the patient expects, correctly or not, and when she feels the visceral terror brought by seeing her face hewn open, all these rational considerations go flying out the window. Fortunately for everybody involved – including Martha – she decided to air her concerns to someone in a position to defuse them, a person who knows both patient and surgeon. It’s easy to imagine any number of alternate scenarios. She might have taken her misgivings elsewhere and gotten confusing and conflicting advice that left her frustrated, mystified, and no better off.

This story has no special moral, other than the obvious ones: Keep lines of communication open when possible and be ready to deal with anger and fear when things turn out badly, or worse than what patients decide to expect.

It’s not really fair. But then neither is illness.

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