Some of the most contentious and relevant ethical issues in dermatopathology include client billing, the practice of dermatopathology by physicians without board certification in dermatopathology, and the practice of including recommendations regarding further surgery in dermatopathology reports. Client billing is a system in which clinicians directly compensate laboratories for pathology services and directly bill patients and/or third-party payers. Although proponents argue that this system can reduce health care costs and increase efficiency, others have argued that it creates an environment that fosters unethical, and potentially illegal, behavior. The development of various types of laboratory models, commonly referred to as "contractual joint ventures," has served to expand client billing. Although the field of dermatopathology is considered a subspecialty of both clinical dermatology and anatomic pathology, dermatopathology is commonly practiced by clinical dermatologists and general anatomic pathologists who are not board certified in dermatopathology. Although these physicians are legally entitled to practice dermatopathology, some have questioned the ethics of this situation, especially when board-certified dermatopathologists are available. Finally, dermatopathology reports, on occasion, include suggestions regarding the need for additional surgery or other clinical courses of action. Although established guidelines do not fully endorse or discourage this practice, various opinions exist regarding its affect on patient care.