Myth #10: After taking my “after pictures” for a before-and-after series, I can forget about them.

Truth #10: I need to save pictures for 7 years.

Medical images that are part of the medical record need to be saved just as long as the medical record, which in most states is 7 years. Pictures are an essential part in the billing for MOHS, as images showing the defect are needed for the medical record.

Exceptions. Images taken for educational purposes or at medical conferences that are not parts of the medical record do not fall under the ambit for the strictures involved in retaining the integrity of the medical record. (Note that this issue has not been tested in court.) The taking of pictures for educational as opposed to clinical purposes must be made clear to the patient.

How to Store. If a practice still uses paper charts, images should be printed out and put in the paper chart. If a practice has an electronic medical record (EMR), the images should be put in that record. If the EMR does not allow for the addition of images, the images should be stored on the same backup system used for the EMR.

Which Images to Save. Case law exists suggesting that only saving the single best image or having definitive proof that images were not altered will not lead to an inference that the defendant destroyed or altered evidence. In Scardina vs. Maersk Line, Ltd., a slip-and-fall case on a ship, the plaintiff maintained that the defendant failed or refused to produce all original photographs and digital photographs taken of his back during his physical examination on the vessel after his fall. The plaintiff, Scardina, claimed that the one photograph of the his back produced as evidence by the defendant Maersk Line, Ltd., and admitted into evidence could have been altered by the defendant, that the photograph was not authenticated, and that more photographs had been taken by the doctor who worked for Maersk Line, Ltd., at the time of the accident. The court stated that the jury could reasonably have concluded that the defendant reviewed the photographs and selected the clearest one to keep, then discarded any others along with the digital file. Absent any evidence to the contrary, the court determined that the plaintiff was not entitled to an “adverse inference” jury instruction on the issue.

Myth #9: I can trust my Web designer to create a trouble-free site.

Truth #9: Data and goods exchanges are rarely trouble-free.

If a Web site contains content — images or text — it is important that the images and text not be taken from other Web sites without payment. Copyright law applies to such images or text.

A dermatologist I know learned this the hard way, after hiring someone to design a Web site. The Web designer created a demo with images and text taken from the internet. The Web site was activated, and later taken down. Six months after the Web designer and dermatologist parted ways, the dermatologist was contact by a company claiming the dermatologist had used its images without permission and requested several thousand dollars in licensing fees. The dermatologist was upset because he had not authorized this action. As the cost of litigation over this was so high, his advisors suggested that he be more careful in the future and try and negotiate a settlement, a course that was likely prudent.

Myth #8: If my laser makes a patient’s face green, the plaintiff’s lawyer makes a mint.

Truth #8: The plaintiff’s lawyer likely will not see any greenbacks.

The use of the argon laser in patients taking gold salts for the treatment of rheumatoid arthritis has resulted in spontaneous development of green pigmentation in treated areas. Such a striking side effect has been noted in case reports and by Dr. Roy Geronomus in a lecture.

I would guess, however, that none of these cases resulted in a malpractice recovery. Why? Because the doctors who performed these procedures obtained informed consent from their patients and likely noted in the written record that the patient was aware that rare and unforeseen side effects could occur, including scarring and pigmentary changes.

Simply put, discuss risks and benefits with patients and memorialize such discussion with a simple, clear one-page consent document.

It is a myth to think a plaintiff’s lawyer gets rich in every case. Cosmetic patients seldom collect damages when they are well informed, properly consented and suing well trained doctors.

Myth #7: Topical lidocaine is so safe that my patients can bathe in it to avoid large-area procedure pain.

Truth #7: Deaths have resulted from use of lidocaine on large areas under occlusion.

As I discussed in a recent column, application of lidocaine to large areas of the body can result in cardiovascular complications, including death. In particular, when applied under occlusion in combination with other agents such as tetracaine, this can be an issue.

There is no easy out when it comes to treatment. All risks and benefits must be considered, even for topical medications. Doctors have been held negligent for adrenal suppression related to the topical application of corticosteroids.

Myth #6: My malpractice insurance covers my use of all my cosmetic tools and devices.

Truth #6: Malpractice insurance specifically excludes substances or devices not approved by the FDA.

The statement above must be taken with several caveats.

Firstly, off-label use of FDA-approved products that are within the standard of practice are almost certainly covered by your malpractice carrier. Products that are parts of clinical trials can be used, but often the company running the study provides the malpractice coverage. Studies have shown that nearly all dermatologists use medications off-label, and the FDA was intended by Congress to regulate the sellers of medical devices and products, not doctors’ practices. These days, all dermatology malpractice insurance will likely cover the use of Botox and hair removal lasers.

What is not covered is Botox illegally imported into the United States from Brazil. Your malpractice may cover the use of injectable silicon, as it is approved for certain uses in the United States, but using a filler only approved in Europe for clinical use outside the ambit of a clinical trial will not be covered and could be illegal.

Myth #5: My PAs are so well trained, I do not need to supervise them.

Truth #5: You are responsible for what your PAs do.

While laws differ in the 50 states, as a general rule, physicians must supervise the physician assistants who work with them. Physicians must consult with their malpractice carriers to find out what must be done to obtain insurance for physician extenders. Physicians must also be aware of the changing environment for reimbursement by Medicare for work done by physician assistants. While physician assistants can be a valuable part of a team, the law sees them as role players, not captains, and you should, too.

Myth #4: Free Botox, laser use and rep demos are regulation-free.

Truth #4: There is no such thing as a free lunch.

As a rule, it is not a good idea to sell what you get for free, and it’s generally illegal to sell prescription samples.

Consider the utility of this principle in the use of demos of cosmetic equipment. While a company representative can show you how to use a machine, it is likely problematic to have the representative, who is not licensed in any way, perform what are effectively medical services. This issue was illustrated — excuse my use of TV as an explicator of reality — on an episode of “Law and Order” in which a patient died in the OR while a company representative was using the patient to show a doctor how a machine worked. Consider these issues and consult with your carrier if you have any questions.

Myth #3: Dispensing is a cinch.

Truth #3: Business is never so simple.

It should go without saying at this point that nothing is as easy as it seems. When physicians extend their activities outside the provision of medical services, they become subject to commercial laws. Thus, physicians must obey tax laws and sell only products that are legal for sale in their own state. Some physicians are unaware that there is currently a class action lawsuit against the makers of sun block for making claims on which the product does not deliver. While it is unlikely that a physician entering into the hurly burly of the market might become enmeshed in such a lawsuit, it is something to consider, even when selling cosmeceuticals.

Myth #2: I never need to refuse patients requesting cosmetic work.

Truth #2: There are some patients on whom cosmetic procedures should not be performed.

There is much discussion among plastics surgeons about patient selection. Some patients who seek out cosmetic services have body dysmorphic disorder and will never be happy with any outcome. Thus, consider the patient and the patient’s psyche, not just the patient’s pocket book.

Things to keep in mind: Pick patients with care; get clear consent before procedures; engage patients if problems arise; know that law suits arise largely from bad feelings, not bad outcomes; and some cosmetic adventures — even if technically correct — should never be undertaken.

Myth #1 I am so skilled, I never get sub-par results.

Truth #1 Everyone gets sub-par results.

Sometime things do not go as planned. This is true for everyone. If a result is a very problematic, notify your carrier, even if the patient does not contact you first.

Your malpractice carrier fills three functions:

(1) You can call your carrier for advice if you get requests for medical records by a lawyer or suspect a patient might litigate.
(2) The malpractice carrier will pay the defense lawyer, if malpractice litigation ensues.
(3) If you lose your case, the carrier will pay the damages up to the policy maximum (which in New York is $1.3 million).

Take advantage of these functions. For starters, to know what to do if sub-par results occur, take your carrier’s risk management course. In addition, be sure to accurately document situations and never alter or destroy the medical records.

Dr. Scheinfeld graduated from Harvard Law School in 1989 and Yale Medical School in 1997. He’s an Assistant Clinical Professor at Columbia University.