With an unknown primary site you are screwed as a doctor. Like many dumb things in medicine it protects the doctor because people try and sue all the time. I’m in Colorado and they just increased the amount that doctors can be sued for. Malpractice insurance expenses have gone through the roof, reimbursement has not kept up with inflation and I can’t afford the cost of a lawsuit or the stress. So anything I take off goes to the lab.

I had a lady I saw with a lesion on her foot. A podiatrist took it off and called it a “granuloma” and tossed it in the garbage. She came to me and I biopsied it. She was muttering about sueing the podiatrist as she walked out. It was a melanoma, very deep. She died 3 months later. So an experienced podiatrist assumed it was benign and it very much was not. Clinical diagnosis are ok and mostly right. But not always.