Doctor failed to do skin biopsy when making diagnoses, hearing told

A consultant dermatologist incorrectly diagnosed at least six patients where a biopsy would have helped him to make a correct diagnosis, it was alleged at a Medical Council fitness-to-practise hearing.

Dr Adam Jacobus Smith (65) is facing more than 100 allegations of poor professional performance, or professional misconduct, in relation to 12 patients who attended the Whitfield Clinic, Waterford, from 2006 to 2009.

In treating patient J, Dr Smith failed to do a skin biopsy, take pre-treatment blood tests or confirm the patient’s diagnosis before prescribing Dapsone, the inquiry heard yesterday.

Patient hospitalised

It was the second instance in a three-month period where a patient of Dr Smith was hospitalised from side-effects when treated with Dapsone for suspected dermatitis herpetiformis, or celiac disease rash, when they did not have that condition.

Asked under cross-examination by counsel for the Medical Council JP McDowell if he accepted that failing to do a biopsy or take bloods before prescribing the drug wasn’t an appropriate diagnostic method, Dr Smith said, “I accept that”.

Asked why he started the patient on the drug before getting the results of celiac screening tests conducted by the patient’s GP, he said the risk from Dapsone was “low” and the drug was to alleviate itching.

Dr Smith said he was using Dapsone as a “diagnostic tool”, and he planned to carry out a biopsy later. Put to him that he failed to carry out tests a dermatologist is expected to do before prescribing the drug and that he took a risk, he said, “I didn’t think the risk was significant.”

When the patient’s son noticed a blue discoloration of his father’s skin, he was admitted to hospital. A celiac blood test revealed the man did not have the condition the drug treats.

Asked why he did not order a biopsy, Dr Smith said he was only able to book biopsies with the laboratory every three weeks.

‘Maybe nit-picking’

In relation to his failure to take a skin biopsy in the case of patient I, Dr Smith said to call this “a serious falling short” was “being absolutist and maybe nit-picking”. He diagnosed bullous pemphigoid with “an outside chance” of bullous impetigo. He said when a biopsy was ultimately done, it had proved his clinical diagnosis of bullous pemphigoid right. The hearing continues today.