Melanoma and non-melanoma skin cancer (NMSC) are widely prevalent in New Zealand. Approximately 250 New Zealanders die of melanoma and 100 of NMSC each year.1 The incidence of non-melanoma skin cancers in New Zealand is in the order of 67,000 per year.1A large proportion of the GP workload is taken up by the review of suspicious skin lesions and because cancer cannot always be excluded clinically, a large number of excision biopsies are required. Excision of simple skin lesions can often be managed in primary care.More complicated lesions however often require input from secondary care such as a plastic surgeon or a dermatologist. Outside of the larger centres the provider is frequently a General Surgeon. Referral to secondary care has also been suggested to improve clinical quality measures such as completeness of excision although it may increase costs.2Many New Zealanders have multiple areas of sun-damaged skin and may present with a mixture of suspicious and non-suspicious areas. Index of suspicion may vary between different clinicians which can be confusing for the patient or worse lead to dissatisfaction with care if there is a conflict between opinions.When a clinician suspecting an area of skin cancer is referring to another clinician for management, accurate communication of the location of the lesion is self-evidently important. Different methods for communicating the location of the lesion exist. These include verbal, written and pictorial descriptions.While it may seem simple to merely ask the patient to point to the suspect area, this is often not possible; for example the lesion may be in a place the patient cannot see such as the back or buttock, the patient may be blind or may even lack capacity through psychiatric or organic illness.Patients with multiple areas of sun damage may also not be able to recall which areas aroused the suspicions of the physician who saw them initially. It is therefore not reasonable for the treating doctor to expect the patient to know the location of the suspect lesion in all instances and accurate localising information in skin lesion referrals between professionals is therefore clearly important.In our institution, surgical treatment of skin lesions suitable for local anaesthetic excision is provided in twice weekly registrar local anaesthetic lists. Referrals to the operating list are either direct from primary healthcare providers (GP) or from the General Surgical Outpatients (OPD). Usually the patient is not known to the operating doctor prior to meeting them immediately before surgery and information contained in the referral letter is relied upon to establish where the suspect lesion is and to decide on whether to proceed with the surgeryDifficulties were sometimes encountered identifying the site of the target skin lesion on the day of surgery. Consequently we set up an audit of referrals to our skin lesion operating list to quantify this problem. There are no clear guidelines on what type of information should be contained in a skin lesion referral.3,4Methods Data was collected on information available to the operating surgeon regarding location of the skin lesions using a predetermined proforma. Consecutive new referrals were audited between 4April 2012 and 1 June 2012. There were no exclusion criteria. The following information was recorded: The patients demographic details (name, age, address, GP, NHI). The date of surgery and the source of the referral (GP, OPD or other). The number of lesions that were described in the referral. Whether or not the patient was able to identify all of the suspect lesions. Whether or not the location of the lesions could be determined without ambiguity from the text in the referral letter. For example if a letter described a "lesion on the right arm suspicious for squamous cell carcinoma (SCC)" and there were two areas equally suspicious for SCC on the right arm then the location could not be determined without ambiguity unless there was supplementary information describing which of the two said areas had aroused suspicion. Whether or not a diagram of the lesion(s) had been included. Whether or not a photograph of the lesion(s) had been submitted along with the referral. Results 100 New patients were seen with skin lesions for consideration of excision in the skin lesion theatre between 4 April and 1 June 2012. Of these 56 were female and 44 were male with a median age of 61 (range 12–96) years; 64 referrals were from the patients' primary physician (GP) with a further 35 being referred having been seen in the General Surgical Outpatient Clinic (OPD). One patient had been referred having attended the Emergency Department (ED). Of the 100 patients seen during the allotted time period, 84 were able to identify the skin lesions with which they had been referred. 16 patients could not identify some or all of the lesions which had prompted their referral. The location of the lesion(s) could be accurately determined from the text in the written referral on 70 out of 100 occasions. On 30 out of 100 occasions, the operating doctor could not determine which lesion was to be removed on the basis of the text in the referral. Of the patients who could not identify the skin lesions to be excised 11 (17.2% of GP referrals) were referred from GP and 5 (14.3% of OPD referrals) were referred from outpatients. Among the patients whose skin lesion could not be localised from the text in the written referral 24 were from General Practice (37.5% of the total number of patients referred from General Practice) and five were from Surgical Outpatients (14.3% if the patients referred from the OPD). A further one patient was referred from the Emergency Department. A diagram depicting the location of the skin lesion was included in 19 out of 100 occasions. A photograph depicting the skin lesion was submitted in a total of 3 out of 100 occasions. Of the referrals with diagrams included, 2 were from General Practice (3% of the number of referrals from General Practice) and 17 were from Surgical Outpatients (49% of the referrals from the OPD). Of the referrals with photographs, all 3 were from GPs (5% of the GP referrals) and zero (0%) were from the Surgical Outpatients. Of the 16 patients who could not personally identify the skin lesion, the location was clear from the written text in three occasions, leaving 13 patients for whom the location of the skin lesion could not be confirmed. None of these 13 patients had diagrams or photographs included in their referral information. Management of these patients was at the discretion of the surgical registrar (scheduled to perform the local anaesthetic list on that day) who could either excise the lesion judged to be most suspicious on the day of surgery or chose an alternative plan. Management and outcomes for these 13 patients are shown in Table 1. The patients discharged to GP were followed up between three and 4 months after their surgical appointment. One patient had represented in primary care with skin lesions in the same area described in their original referral which were then treated with cryotherapy. The remainder had not sought further consultations with their GP for skin lesions. Table 1. Outcomes for patients where skin lesion location could not be confirmed. ID Problem Action Taken Consultant Involved Surgical Follow-up Histology Represented to GP 1 Lesion on back patient couldn't identify No excision No Discharged to GP None No 2 Patient not sure which lesions Punch biopsies No Discharged to GP Junctional naevi No 3 Lesions on back, previous similar lesions Excision with guidance from patient relative No Discharged to GP No evidence of neoplasia No 4 Listed for 2 lesions not identifiable at first visit Rebooked for another list No Lesions excised at 2ndappointment Solar keratosis and SCC No 5 ?BCC on nose had healed No excision No Discharged to GP None No 6 Unclear which lesion on ear Punch biopsies No Treated with efudix, OPD follow-up Dysplastic dolar keratosis Yes 7 No obvious lesion No excision No Discharged to GP None No 8 Multiple possible lesions Punch biopsies No Treated with efudix, OPD follow-up Solar keratosis ×5, Superficial BCC x 1 No 9 Multiple possible lesions Punch biopsies No Discharged to GP Solar keratosis No 10 Multiple possible lesions Excision most likely lesion Yes OPD follow-up (Did not attend) Compound naevus No 11 Multiple possible lesions Excision most likely lesion No Discharged to GP Compound and junctional naevus No 12 Multiple possible lesions Excision most likely lesion No Discharged to GP Seborrhoeic kerratosis No 13 Multiple possible lesions Excision most likely lesion No Discharged to GP SCC in situ and seborrhoeic kerratosis No BCC=basal cell carcinoma, OPD= General Surgical Outpatients [Department]; SCC= squamous cell carcinoma. Discussion Our results reveal that accurate identification of the target lesion on the day of surgery is problematic for many patients. For 13% there was no satisfactory way of knowing which lesions were due to be excised. For a further 17 although the referral information did not itself allow the lesion to be localised we were fortunate in that the patient was able to do the job for us. Nevertheless the fact that 16% of patients were not able to self-identify their lesions means we cannot justify a policy of expecting the patient to be able to accurately identify the lesion for the surgeon. Curiously for all of the patients who had diagrams and photographs submitted in their referral, the operating surgeon recorded that the lesion could be identified from the referral text. This perhaps reflects the diligence of the individuals making these referrals. However we speculate that if a diagram or even better a photograph was included as standard with every referral, there would be no patient for whom the lesion could not be confirmed from the referral information and moreover we would not have to put the patient in the position of having to take responsibility for identifying the lesion for the surgeon. While it may seem superficially appealing to make localising the lesion the patient's responsibility there are patient groups for whom this is an unfair burden. Where health professionals are referring a patient with a skin lesion on for surgical treatment we need to take responsibility for providing accurate information about the lesion's whereabouts. Our results showed there were significant lapses in this process both with referrals from Surgical Outpatients and from General Practice. We believe that pictorial information provides the best means of identifying a skin lesion. In the case of a photograph, a marker can be used to discriminate between lesions if more than one is visible in the picture. If properly done there can be no ambiguity between the referring professional and the operating surgeon. Digital photography is now widely available and pictures of skin lesions can nowadays be taken and rapidly uploaded onto a computer or sent via email so there is little excuse for doctors not to use this method of communication. Given the prevalence of melanoma and NMSC in New Zealand and the already widespread use of electronic communication, the purchase of an electronic photographic device seems a relatively small price to pay for accurate communication about this important health problem and is already available to most practicing doctors via the mobile phone. We intend to make a request for a photographic image of the suspicious skin lesion a standard part of the referral process to our local anaesthetic skin lesion operating list.

Melanoma and non-melanoma skin cancer (NMSC) are widely prevalent in New Zealand. Approximately 250 New Zealanders die of melanoma and 100 of NMSC each year.1 The incidence of non-melanoma skin cancers in New Zealand is in the order of 67,000 per year.1A large proportion of the GP workload is taken up by the review of suspicious skin lesions and because cancer cannot always be excluded clinically, a large number of excision biopsies are required. Excision of simple skin lesions can often be managed in primary care.More complicated lesions however often require input from secondary care such as a plastic surgeon or a dermatologist. Outside of the larger centres the provider is frequently a General Surgeon. Referral to secondary care has also been suggested to improve clinical quality measures such as completeness of excision although it may increase costs.2Many New Zealanders have multiple areas of sun-damaged skin and may present with a mixture of suspicious and non-suspicious areas. Index of suspicion may vary between different clinicians which can be confusing for the patient or worse lead to dissatisfaction with care if there is a conflict between opinions.When a clinician suspecting an area of skin cancer is referring to another clinician for management, accurate communication of the location of the lesion is self-evidently important. Different methods for communicating the location of the lesion exist. These include verbal, written and pictorial descriptions.While it may seem simple to merely ask the patient to point to the suspect area, this is often not possible; for example the lesion may be in a place the patient cannot see such as the back or buttock, the patient may be blind or may even lack capacity through psychiatric or organic illness.Patients with multiple areas of sun damage may also not be able to recall which areas aroused the suspicions of the physician who saw them initially. It is therefore not reasonable for the treating doctor to expect the patient to know the location of the suspect lesion in all instances and accurate localising information in skin lesion referrals between professionals is therefore clearly important.In our institution, surgical treatment of skin lesions suitable for local anaesthetic excision is provided in twice weekly registrar local anaesthetic lists. Referrals to the operating list are either direct from primary healthcare providers (GP) or from the General Surgical Outpatients (OPD). Usually the patient is not known to the operating doctor prior to meeting them immediately before surgery and information contained in the referral letter is relied upon to establish where the suspect lesion is and to decide on whether to proceed with the surgeryDifficulties were sometimes encountered identifying the site of the target skin lesion on the day of surgery. Consequently we set up an audit of referrals to our skin lesion operating list to quantify this problem. There are no clear guidelines on what type of information should be contained in a skin lesion referral.3,4Methods Data was collected on information available to the operating surgeon regarding location of the skin lesions using a predetermined proforma. Consecutive new referrals were audited between 4April 2012 and 1 June 2012. There were no exclusion criteria. The following information was recorded: The patients demographic details (name, age, address, GP, NHI). The date of surgery and the source of the referral (GP, OPD or other). The number of lesions that were described in the referral. Whether or not the patient was able to identify all of the suspect lesions. Whether or not the location of the lesions could be determined without ambiguity from the text in the referral letter. For example if a letter described a "lesion on the right arm suspicious for squamous cell carcinoma (SCC)" and there were two areas equally suspicious for SCC on the right arm then the location could not be determined without ambiguity unless there was supplementary information describing which of the two said areas had aroused suspicion. Whether or not a diagram of the lesion(s) had been included. Whether or not a photograph of the lesion(s) had been submitted along with the referral. Results 100 New patients were seen with skin lesions for consideration of excision in the skin lesion theatre between 4 April and 1 June 2012. Of these 56 were female and 44 were male with a median age of 61 (range 12–96) years; 64 referrals were from the patients' primary physician (GP) with a further 35 being referred having been seen in the General Surgical Outpatient Clinic (OPD). One patient had been referred having attended the Emergency Department (ED). Of the 100 patients seen during the allotted time period, 84 were able to identify the skin lesions with which they had been referred. 16 patients could not identify some or all of the lesions which had prompted their referral. The location of the lesion(s) could be accurately determined from the text in the written referral on 70 out of 100 occasions. On 30 out of 100 occasions, the operating doctor could not determine which lesion was to be removed on the basis of the text in the referral. Of the patients who could not identify the skin lesions to be excised 11 (17.2% of GP referrals) were referred from GP and 5 (14.3% of OPD referrals) were referred from outpatients. Among the patients whose skin lesion could not be localised from the text in the written referral 24 were from General Practice (37.5% of the total number of patients referred from General Practice) and five were from Surgical Outpatients (14.3% if the patients referred from the OPD). A further one patient was referred from the Emergency Department. A diagram depicting the location of the skin lesion was included in 19 out of 100 occasions. A photograph depicting the skin lesion was submitted in a total of 3 out of 100 occasions. Of the referrals with diagrams included, 2 were from General Practice (3% of the number of referrals from General Practice) and 17 were from Surgical Outpatients (49% of the referrals from the OPD). Of the referrals with photographs, all 3 were from GPs (5% of the GP referrals) and zero (0%) were from the Surgical Outpatients. Of the 16 patients who could not personally identify the skin lesion, the location was clear from the written text in three occasions, leaving 13 patients for whom the location of the skin lesion could not be confirmed. None of these 13 patients had diagrams or photographs included in their referral information. Management of these patients was at the discretion of the surgical registrar (scheduled to perform the local anaesthetic list on that day) who could either excise the lesion judged to be most suspicious on the day of surgery or chose an alternative plan. Management and outcomes for these 13 patients are shown in Table 1. The patients discharged to GP were followed up between three and 4 months after their surgical appointment. One patient had represented in primary care with skin lesions in the same area described in their original referral which were then treated with cryotherapy. The remainder had not sought further consultations with their GP for skin lesions. Table 1. Outcomes for patients where skin lesion location could not be confirmed. ID Problem Action Taken Consultant Involved Surgical Follow-up Histology Represented to GP 1 Lesion on back patient couldn't identify No excision No Discharged to GP None No 2 Patient not sure which lesions Punch biopsies No Discharged to GP Junctional naevi No 3 Lesions on back, previous similar lesions Excision with guidance from patient relative No Discharged to GP No evidence of neoplasia No 4 Listed for 2 lesions not identifiable at first visit Rebooked for another list No Lesions excised at 2ndappointment Solar keratosis and SCC No 5 ?BCC on nose had healed No excision No Discharged to GP None No 6 Unclear which lesion on ear Punch biopsies No Treated with efudix, OPD follow-up Dysplastic dolar keratosis Yes 7 No obvious lesion No excision No Discharged to GP None No 8 Multiple possible lesions Punch biopsies No Treated with efudix, OPD follow-up Solar keratosis ×5, Superficial BCC x 1 No 9 Multiple possible lesions Punch biopsies No Discharged to GP Solar keratosis No 10 Multiple possible lesions Excision most likely lesion Yes OPD follow-up (Did not attend) Compound naevus No 11 Multiple possible lesions Excision most likely lesion No Discharged to GP Compound and junctional naevus No 12 Multiple possible lesions Excision most likely lesion No Discharged to GP Seborrhoeic kerratosis No 13 Multiple possible lesions Excision most likely lesion No Discharged to GP SCC in situ and seborrhoeic kerratosis No BCC=basal cell carcinoma, OPD= General Surgical Outpatients [Department]; SCC= squamous cell carcinoma. Discussion Our results reveal that accurate identification of the target lesion on the day of surgery is problematic for many patients. For 13% there was no satisfactory way of knowing which lesions were due to be excised. For a further 17 although the referral information did not itself allow the lesion to be localised we were fortunate in that the patient was able to do the job for us. Nevertheless the fact that 16% of patients were not able to self-identify their lesions means we cannot justify a policy of expecting the patient to be able to accurately identify the lesion for the surgeon. Curiously for all of the patients who had diagrams and photographs submitted in their referral, the operating surgeon recorded that the lesion could be identified from the referral text. This perhaps reflects the diligence of the individuals making these referrals. However we speculate that if a diagram or even better a photograph was included as standard with every referral, there would be no patient for whom the lesion could not be confirmed from the referral information and moreover we would not have to put the patient in the position of having to take responsibility for identifying the lesion for the surgeon. While it may seem superficially appealing to make localising the lesion the patient's responsibility there are patient groups for whom this is an unfair burden. Where health professionals are referring a patient with a skin lesion on for surgical treatment we need to take responsibility for providing accurate information about the lesion's whereabouts. Our results showed there were significant lapses in this process both with referrals from Surgical Outpatients and from General Practice. We believe that pictorial information provides the best means of identifying a skin lesion. In the case of a photograph, a marker can be used to discriminate between lesions if more than one is visible in the picture. If properly done there can be no ambiguity between the referring professional and the operating surgeon. Digital photography is now widely available and pictures of skin lesions can nowadays be taken and rapidly uploaded onto a computer or sent via email so there is little excuse for doctors not to use this method of communication. Given the prevalence of melanoma and NMSC in New Zealand and the already widespread use of electronic communication, the purchase of an electronic photographic device seems a relatively small price to pay for accurate communication about this important health problem and is already available to most practicing doctors via the mobile phone. We intend to make a request for a photographic image of the suspicious skin lesion a standard part of the referral process to our local anaesthetic skin lesion operating list.