Interested Mohs Fellowship

[Skinvestigator]

Hey guys,

I'm starting to develop an interest in the procedural aspects of dermatology, so Mohs is something I am considering. Hoping that the fellow members on this board can help with the following questions:

1. Is it more common to do 1 or 2-week visiting electives with each program?
2. How many elective weeks on average does the typical Mohs applicant complete prior to application?
3. Are the fellowship positions in the Eastern and Western coasts more competitive compared to the Midwest and Southern?
4. Any difference in ACMS vs ACGME accredited fellowships in terms of billing?
5. Any useful resources that I can consult to find out more information? I have been to the SF match website but the information on there is sparse.

Any additional helpful advice would be sincerely appreciated.

Thanks in advance.

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[reno911]

Hey guys,

I'm starting to develop an interest in the procedural aspects of dermatology, so Mohs is something I am considering. Hoping that the fellow members on this board can help with the following questions:

1. Is it more common to do 1 or 2-week visiting electives with each program?
2. How many elective weeks on average does the typical Mohs applicant complete prior to application?
3. Are the fellowship positions in the Eastern and Western coasts more competitive compared to the Midwest and Southern?
4. Any difference in ACMS vs ACGME accredited fellowships in terms of billing?
5. Any useful resources that I can consult to find out more information? I have been to the SF match website but the information on there is sparse.

Any additional helpful advice would be sincerely appreciated.

Thanks in advance.

1 .No
2. Median is probably close to zero
3. Not really.
4. They are all ACGME now. If they're not ACGME, they're effectively not accredited.
5. Best resource is probably sitting down with the Mohs surgeon in your program and talking to them. They will have their biases, but there will be a lot of useful info as well.

Only advice is to apply widely, go on as many interviews as you can and make your ranking based on how the interview day goes. You will learn a lot more about the program from the interview day than by any other method.

 

[Skinvestigator]

1 .No
2. Median is probably close to zero
3. Not really.
4. They are all ACGME now. If they're not ACGME, they're effectively not accredited.
5. Best resource is probably sitting down with the Mohs surgeon in your program and talking to them. They will have their biases, but there will be a lot of useful info as well.

Only advice is to apply widely, go on as many interviews as you can and make your ranking based on how the interview day goes. You will learn a lot more about the program from the interview day than by any other method.

Thanks so much reno911.

I am frankly a little surprised that most resident have not done electives in Mohs. How are the program directors supposed to evaluate the work ethic and technical skills of the resident then? Based on the letter of reference from their respective program directors?

 

[ymeacisrej]

Thanks so much reno911.

I am frankly a little surprised that most resident have not done electives in Mohs. How are the program directors supposed to evaluate the work ethic and technical skills of the resident then? Based on the letter of reference from their respective program directors?

I’ve heard that some interview days include scrubbing in on the day of!

 

[asmallchild]

Thanks so much reno911.

I am frankly a little surprised that most resident have not done electives in Mohs. How are the program directors supposed to evaluate the work ethic and technical skills of the resident then? Based on the letter of reference from their respective program directors?

Basically. How much Mohs are you really doing on your own anyway as a resident? Off those limited cases a PD is expected to judge your ethic and technical skills? It often is a game of who you know, not necessarily what you know.

Get good letters from Mohs surgeons. Prepare to show your skills if they ask you during the interview (1 program asked me out of the 5 or 6 that I interviewed at)

 

[reno911]

Thanks so much reno911.

I am frankly a little surprised that most resident have not done electives in Mohs. How are the program directors supposed to evaluate the work ethic and technical skills of the resident then? Based on the letter of reference from their respective program directors?

First of all, residents (with extremely rare exceptions) have at best mediocre technical skills when it comes to skin surgery. You don't get enough reps to become good. Nor should you. There is plenty of other stuff you need to be learning in residency. So, if you are asked to assist in surgery on the interview day, I wouldn't sweat it very much. Hopefully all they're trying to make sure is that you're not a complete klutz. The point of the fellowship is to teach you how to do it.

Based on my experience and talking to my colleagues, here are the important things that fellowship directors tend to look at.

1. Personality/how you will fit in with the rest of the team.
2. Letters from people they know and respect
3. What they think your are going to do when you're done with fellowship (which may or may not be different from what you claim you will do when you're done)
4. Some place value on lots of publications and/or research

And if all of that makes it sounds like a giant crapshoot, that's because it kind of is. Every single applicant already got into derm, so they're nearly all smart, hard-working, and don't have difficult personalities. Distinguishing among such people is always going to be difficult and at least somewhat subjective.

 

[reno911]

Actually, while I'm giving out advice, here's one last piece. When I was in academia, I was often asked by residents fairly early on, for what they should do to get a Mohs fellowship. I always told them the same thing. Just forget about Mohs. Do everything you can to be the best possible resident you can be. Attempt to learn and be good at everything. If you succeed at that, the whole Mohs thing will work itself out.

 

[Skinvestigator]

Basically. How much Mohs are you really doing on your own anyway as a resident? Off those limited cases a PD is expected to judge your ethic and technical skills? It often is a game of who you know, not necessarily what you know.

Get good letters from Mohs surgeons. Prepare to show your skills if they ask you during the interview (1 program asked me out of the 5 or 6 that I interviewed at)

First of all, residents (with extremely rare exceptions) have at best mediocre technical skills when it comes to skin surgery. You don't get enough reps to become good. Nor should you. There is plenty of other stuff you need to be learning in residency. So, if you are asked to assist in surgery on the interview day, I wouldn't sweat it very much. Hopefully all they're trying to make sure is that you're not a complete klutz. The point of the fellowship is to teach you how to do it.

Based on my experience and talking to my colleagues, here are the important things that fellowship directors tend to look at.

1. Personality/how you will fit in with the rest of the team.
2. Letters from people they know and respect
3. What they think your are going to do when you're done with fellowship (which may or may not be different from what you claim you will do when you're done)
4. Some place value on lots of publications and/or research

And if all of that makes it sounds like a giant crapshoot, that's because it kind of is. Every single applicant already got into derm, so they're nearly all smart, hard-working, and don't have difficult personalities. Distinguishing among such people is always going to be difficult and at least somewhat subjective.

Actually, while I'm giving out advice, here's one last piece. When I was in academia, I was often asked by residents fairly early on, for what they should do to get a Mohs fellowship. I always told them the same thing. Just forget about Mohs. Do everything you can to be the best possible resident you can be. Attempt to learn and be good at everything. If you succeed at that, the whole Mohs thing will work itself out.

Thanks so much reno911 and asmallchild. I really appreciate the advice. It's contributors like yourselves that foster such a helpful environment on SDN. Guess its back to reading Bolognia.

 

[RashDecisions]

I have an opportunity, after practicing general derm for a few years, to do a 'fellowship' for two years with an ASMS fellow. He is retiring soon and would like to train someone outside of the ACGME world. I respect his approach and I think he is really thoughtful and academic about everything. I'd really like to do more surgery and it seems like the bulk of my days would be 7-10 Mohs cases. However, I am wary of getting involved in a lower-pay 2 year 'fellowship' when the only real opportunity after it is to stay on in their practice. They have not been completely up front about how the partnership works. Am I being too cautious here or should I run with it?

 

[asmallchild]

I have an opportunity, after practicing general derm for a few years, to do a 'fellowship' for two years with an ASMS fellow. He is retiring soon and would like to train someone outside of the ACGME world. I respect his approach and I think he is really thoughtful and academic about everything. I'd really like to do more surgery and it seems like the bulk of my days would be 7-10 Mohs cases. However, I am wary of getting involved in a lower-pay 2 year 'fellowship' when the only real opportunity after it is to stay on in their practice. They have not been completely up front about how the partnership works. Am I being too cautious here or should I run with it?

I'm biased having completed an ACGME fellowship but it does not seem like my cup of tea

Positives:
- 7-10 Mohs cases is a healthy amount of cases
- Is the arrangement where he retires and you inherit his cases? That could be worthwhile depending on how much you like surgery and how much you like his practice

Negatives:
- Lower pay. I don't like fellowships that do this. I particularly don't like it when it's across 2 years.
- 2 years. This would be a deal breaker for me. Is there something compelling that his fellowship offers to make it 2 years? If not, it seems like a good way to trap someone for two years. 7-10 Mohs cases/day is more than enough to be "competent" after 1 year. Is there added cosmetic exposure? Research? Not seeing why this is 2 years and not 1 year beyond wanting to abuse the fellow
- Why would the only real opportunity be to stay with the practice? Once you become an ASMS member, aren't you allowed to practice Mohs wherever you want?

I think being cautious is the right decision here. I'm not seeing anything that screams "run with this" unless you are deadset on inheriting his practice and they put it in writing that his surgical cases go to you upon completion of your fellowship.

 

[Skindoc83]

I also did an ACGME Mohs fellowship and this sounds suspect to me. Two years is a lot of time and money lost and if he can’t be upfront with what partnership entails, I think it will likely be a bad deal (I.e. 7 figure buy in and still not be 50/50 partner). Why not just do a real ACGME accredited fellowship? It’s shorter, will make you more marketable, and will likely give you a wider exposure to pathology and techniques. Plus there won’t be a non-compete

 

[RashDecisions]

I'm biased having completed an ACGME fellowship but it does not seem like my cup of tea

Positives:
- 7-10 Mohs cases is a healthy amount of cases
- Is the arrangement where he retires and you inherit his cases? That could be worthwhile depending on how much you like surgery and how much you like his practice

Negatives:
- Lower pay. I don't like fellowships that do this. I particularly don't like it when it's across 2 years.
- 2 years. This would be a deal breaker for me. Is there something compelling that his fellowship offers to make it 2 years? If not, it seems like a good way to trap someone for two years. 7-10 Mohs cases/day is more than enough to be "competent" after 1 year. Is there added cosmetic exposure? Research? Not seeing why this is 2 years and not 1 year beyond wanting to abuse the fellow
- Why would the only real opportunity be to stay with the practice? Once you become an ASMS member, aren't you allowed to practice Mohs wherever you want?

I think being cautious is the right decision here. I'm not seeing anything that screams "run with this" unless you are deadset on inheriting his practice and they put it in writing that his surgical cases go to you upon completion of your fellowship.

Regarding positives: He does about 1200 cases a year. Most cases are closed by PS in the building. It's understood that I will inherit his cases but I don't know when he will retire (could be 5 years) and it's not in writing.

Regarding negatives: The two year part of it seems long to me too, since both of the younger partners I talked to recently told me that they were offered partnership only after one year. The buy in is in the low 5 figures every year over 5 years, but I have not been allowed to see any financial information (collections, overhead, etc). There is added exposure to small procedures that I already know how to do. Opportunities in the area without a real fellowship are low as this is a real ACGME Mohs town.

I'd certainly like to do an ACGME fellowship but I after I declined to stay on as an attending at my home program there is some bad blood regarding rec letters and so forth. I have no connections to speak of other than that.

 

[RashDecisions]

I also did an ACGME Mohs fellowship and this sounds suspect to me. Two years is a lot of time and money lost and if he can’t be upfront with what partnership entails, I think it will likely be a bad deal (I.e. 7 figure buy in and still not be 50/50 partner). Why not just do a real ACGME accredited fellowship? It’s shorter, will make you more marketable, and will likely give you a wider exposure to pathology and techniques. Plus there won’t be a non-compete

See above, thank you

 

[asmallchild]

Regarding positives: He does about 1200 cases a year. Most cases are closed by PS in the building. It's understood that I will inherit his cases but I don't know when he will retire (could be 5 years) and it's not in writing.

Regarding negatives: The two year part of it seems long to me too, since both of the younger partners I talked to recently told me that they were offered partnership only after one year. The buy in is in the low 5 figures every year over 5 years, but I have not been allowed to see any financial information (collections, overhead, etc). There is added exposure to small procedures that I already know how to do. Opportunities in the area without a real fellowship are low as this is a real ACGME Mohs town.

I'd certainly like to do an ACGME fellowship but I after I declined to stay on as an attending at my home program there is some bad blood regarding rec letters and so forth. I have no connections to speak of other than that.

Yeah I don't think it's a great idea. The bolded portions are all worrisome to me and not something I would choose to do. Obviously this depends on how badly you want to add Mohs to your repertoire.

A big part of the training is the ability to learn how to do the closures. If plastics closes everything, I really don't see the point of pursuing fellowship training let alone 2 years of fellowship training. Heck, you could do a research year with an ACGME program that almost guarantees acceptance and just do a standard 1 year ACGME fellowship after in that time. It certainly doesn't take 2 years to learn how to take Mohs layers and read basic Mohs pathology.

If it's not in writing, then it isn't true and I wouldn't give up 2 years of my life (and 2 years of an attending salary) to pursue what sounds increasingly like a bogus fellowship

If this is something you really want to pursue, I would strongly suggest an ACGME-accredited fellowship. That's rather petty of your home program to deny you LORs because you didn't stay as a teaching attending (how many residents do nowadays anyway?). I would try to set up some shadowing rotations to see if you can get some exposure, I would reach out to your old program and see what letters you can obtain (time heals a lot of old wounds), and I would go from there.

 

[reno911]

Regarding positives: He does about 1200 cases a year. Most cases are closed by PS in the building. It's understood that I will inherit his cases but I don't know when he will retire (could be 5 years) and it's not in writing.

Regarding negatives: The two year part of it seems long to me too, since both of the younger partners I talked to recently told me that they were offered partnership only after one year. The buy in is in the low 5 figures every year over 5 years, but I have not been allowed to see any financial information (collections, overhead, etc). There is added exposure to small procedures that I already know how to do. Opportunities in the area without a real fellowship are low as this is a real ACGME Mohs town.

I'd certainly like to do an ACGME fellowship but I after I declined to stay on as an attending at my home program there is some bad blood regarding rec letters and so forth. I have no connections to speak of other than that.

This sounds like some incredibly poor training to me.

As pointed out by asmallchild, you've got "most cases are closed by PS in the building" in the wrong category. Learning reconstruction well is a very important part of the training. Now it is possible to be very good at Mohs and not do reconstruction (after all, Fred Mohs didn't reconstruct anything), but that's not a combination I see that often these days. Most of these Mohs surgeons (especially non-fellowship trained ones) aren't very good at Mohs surgery either. If you throw a poorly differentiated perineural SCC at them, it's just not likely to go well. And that's the kind of thing that fellowship should teach you how to do.

I've actually encountered two "Mohs surgeons" who have almost exactly the same practice that you are describing (non-Fellowship trained, good volume of Mohs, don't repair anything or if they do it's awful). I can say that neither should have any business training a fellow.

I want to reiterate that the above is just my personal experience and likely reflects some biases that I'm going to have. It is certainly theoretically possible for a non-fellowship trained person who repairs hardly anything, to be an otherwise great Mohs surgeon. I've just never seen or heard of it from someone reliable.

So, a lot of what this comes down to is what you want to get out of fellowship. If it's an education you want, I doubt you're going to get it. If it's a back door into a nice partnership position, I'm not sure you have enough of guarantee of that based on what you've written, but if this is a someone who you have extremely good reason to trust, maybe it will work out.

 

[RashDecisions]

Thanks for all of your input. You are mirroring what I am feeling. I do trust them, but they seem to have a high overhead but I've not been allowed to see financials. I do like the idea of being able to do a board certification through that initial 5-year eligibility pathway, but who knows when the board exam will actually be available and if there will be adequate study materials for someone outside the ACGME world.

 

[tigers96]

There are a lot of folks doing mohs not via fellowship but you need to be comfortable with it. I am interested but have been practicing for a couple years. A practice did offer something similar. Does about 1000-1100 cases per year and wants me to join. Does most repairs himself with good results. Big repairs will be able to send out. Also complex tumor path or large pigmented may send out. Does not do MART-1.

Difference for me would be full salary and benefits doing gen derm and slowly working into cases. Double headed microscopes to look over slides and talk about repairs etc. Biggest thing I think folks with iterate is getting comfortable with path again. That’s the deal breaker. Then get enough case load and take boards eventually in the 5 yr window. I did 4 months laser/mohs in residency. It was military program so we could do as much as attending was comfortable, didn’t have billing issues. Also not mohs but have been solo for 3 years.

I don’t think a reduced salary as a fellow (for 2 years) is worth it. That’s a huge opportunity cost and would pursue ACGME program even though there is considerable pain to do that if you are practicing. Most programs are 1 year with more than adequate numbers. Even with my offer I was thinking to do ACGME just for sheer cases numbers in short period of time

I also think there is a divide between “college” (fellowship) and “society” (on your own). Not everyone feels that way but you run into it a lot

 

[tigers96]

I also was able to discuss overhead, numbers, staffing, expected salary, workload, partner tract openly. This is a big red flag if there isn’t transparency about this. Tread lightly

 

[Skinvestigator]

What is the possibility of returning to do an ACGME Mohs fellowship after one has been out in practice for a few years? Any reason why not more individuals are doing this (besides those running their own practice)? Thanks in advance.

 

[MOHS_01]

What is the possibility of returning to do an ACGME Mohs fellowship after one has been out in practice for a few years? Any reason why not more individuals are doing this (besides those running their own practice)? Thanks in advance.

I have known several to do this, so it's not hard. Most people don't because... what's the point? As of right now you will be boarded all the same, paid all the same, and you are quite unlikely to find a Mohs only job either way so.... the return is often viewed as not worth the sacrifice. It's a different world than it was 15-20 years ago when I was making the decision.

 

[Slack3r]

There’s definitely an opportunity cost of giving up a year of attending salary, but if you’re interested in Mohs you should pursue the fellowship. Believe it or not, there is more to it than what you’ll ultimately be paid down the line.

 

[MOHS_01]

There’s definitely an opportunity cost of giving up a year of attending salary, but if you’re interested in Mohs you should pursue the fellowship. Believe it or not, there is more to it than what you’ll ultimately be paid down the line.

Like being competent at what you do and knowing better how to recognize when things are not simple or as they appear and the sheer intensity of volume and repetition that are required for excellence?

I'm still a little chafed about this whole Mohs BC thing....

 

[Skinvestigator]

I have known several to do this, so it's not hard. Most people don't because... what's the point? As of right now you will be boarded all the same, paid all the same, and you are quite unlikely to find a Mohs only job either way so.... the return is often viewed as not worth the sacrifice. It's a different world than it was 15-20 years ago when I was making the decision.

Thanks for the response! Not really doing it for the money, but rather the increased comfort of being able to perform more complex reconstructions. I generally enjoy surgery and "think" I am decent with the scalpel and needle driver.

I assume that the application process would be the same regardless? How would they acquire reference letters given that they have already been out in practice for several years and no one is really watching them perform procedures anymore?

 

[asmallchild]

Thanks for the response! Not really doing it for the money, but rather the increased comfort of being able to perform more complex reconstructions. I generally enjoy surgery and "think" I am decent with the scalpel and needle driver.

I assume that the application process would be the same regardless? How would they acquire reference letters given that they have already been out in practice for several years and no one is really watching them perform procedures anymore?

I've known a few who have done this. The application process is fairly similar. You arguably would have more time on your hands as an attending to shadow or do visiting rotations if you need more letters. Most people will return to their home program for their letters and perhaps submit letters from any potential colleagues where they're currently working.

The point of the letters are to evaluate how strong a resident you are/were and how well you work with others. There's obviously a basic floor of competency that the programs expect but I don't think they need letters touting your ability to complete a PMFF in <15 mins. For many of these programs, they are looking for a strong resident and since most of these programs are small, someone pleasant to spend a year with.

My understanding is that applying for Mohs has gotten significantly more competitive and quite a few applicants went unmatched this year. In the past, I think it was actually a strength for an applicant to work first. I think it brings a more mature applicant to the table who has a better idea of how they would structure what they learn from the fellowship into practice because they have actual practice experience. I don't know if previous work experience is viewed in the same light now given the increase in interest from applicants.

 

[Skinvestigator]

I've known a few who have done this. The application process is fairly similar. You arguably would have more time on your hands as an attending to shadow or do visiting rotations if you need more letters. Most people will return to their home program for their letters and perhaps submit letters from any potential colleagues where they're currently working.

The point of the letters are to evaluate how strong a resident you are/were and how well you work with others. There's obviously a basic floor of competency that the programs expect but I don't think they need letters touting your ability to complete a PMFF in <15 mins. For many of these programs, they are looking for a strong resident and since most of these programs are small, someone pleasant to spend a year with.

My understanding is that applying for Mohs has gotten significantly more competitive and quite a few applicants went unmatched this year. In the past, I think it was actually a strength for an applicant to work first. I think it brings a more mature applicant to the table who has a better idea of how they would structure what they learn from the fellowship into practice because they have actual practice experience. I don't know if previous work experience is viewed in the same light now given the increase in interest from applicants.

Thank you for your response. I am strongly considering this route (practice x 1-2 years, before deciding if Mohs is really my calling).

Can anyone briefly explain this BC in Mohs? Assuming I am helping out with some Mohs during my practice and feel comfortable, I can simply write the examination? How will they evaluate one's surgical abilities?

 

[asmallchild]

Thank you for your response. I am strongly considering this route (practice x 1-2 years, before deciding if Mohs is really my calling).

Can anyone briefly explain this BC in Mohs? Assuming I am helping out with some Mohs during my practice and feel comfortable, I can simply write the examination? How will they evaluate one's surgical abilities?

I don't understand it completely myself. It's a mess.

My limited understanding is that currently, there are 2 pathways and the exam throws in a 3rd monkey wrench:

1) You can be a member of the American Society for Mohs Surgery which means you have done a minimum of 75 Mohs cases (45 of which could have come during residency)

2) You can be a member of the American College of Mohs Surgery which means you completed an approved fellowship with a minimum case load of 500 cases

3) Now to add to the mess, you can be board certified in the Micrographic Dermatologic Surgery Subspecialty via the certification exam. For an initial 5 year period, you do not have to be fellowship-trained to take this exam. As with any written exam (you can criticize the general dermatology certification exam similarly too), how well you do on the test may or may not correlate with how good a clinician you actually are.

As a member of the ACMS, my argument would be that someone who is fellowship-trained (ACMS) and (as stupid as the exam is) "board-certified" by passing the MDS certification exam, is likely to be the "most qualified" on paper.

 

[Slack3r]

I think “fellowship trained” is going to be the new barometer since “board certified” isn’t going to mean much.

 

[Skinvestigator]

I don't understand it completely myself. It's a mess.

My limited understanding is that currently, there are 2 pathways and the exam throws in a 3rd monkey wrench:

1) You can be a member of the American Society for Mohs Surgery which means you have done a minimum of 75 Mohs cases (45 of which could have come during residency)

2) You can be a member of the American College of Mohs Surgery which means you completed an approved fellowship with a minimum case load of 500 cases

3) Now to add to the mess, you can be board certified in the Micrographic Dermatologic Surgery Subspecialty via the certification exam. For an initial 5 year period, you do not have to be fellowship-trained to take this exam. As with any written exam (you can criticize the general dermatology certification exam similarly too), how well you do on the test may or may not correlate with how good a clinician you actually are.

As a member of the ACMS, my argument would be that someone who is fellowship-trained (ACMS) and (as stupid as the exam is) "board-certified" by passing the MDS certification exam, is likely to be the "most qualified" on paper.

There are ACGME-accredited Mohs fellowships, and then there are also non-listed "private" Mohs fellowships that are led by FACMS surgeons. Are fellows in the latter group considered "fellowship-trained" and can they qualify for ACMS membership as well?

 

[reno911]

There are ACGME-accredited Mohs fellowships, and then there are also non-listed "private" Mohs fellowships that are led by FACMS surgeons. Are fellows in the latter group considered "fellowship-trained" and can they qualify for ACMS membership as well?

I think that as of right now, if the fellowship is unaccredited, they can't be ACMS members. However after the board certification occurs, it is possible ACMS may let in any board certified Mohs surgeon (accredited fellowship, non-accredited fellowship, or no fellowship). I sure hope not, but it wouldn't surprise me if that happened.

 

[Skinvestigator]

If I am unsuccessful at matching to Mohs, but still wish to practice Mohs in my future practice, are there other training options to at least obtain ASMS? TIA.

 

[reno911]

If I am unsuccessful at matching to Mohs, but still wish to practice Mohs in my future practice, are there other training options to at least obtain ASMS? TIA.

You pretty much don't need training to be ASMS. That's the whole point.

 

[Skinvestigator]

You pretty much don't need training to be ASMS. That's the whole point.

Do ASMS fellows have a H&N reconstructive surgeon on standby quite regularly?

Although I am fairly confident of my surgical training that I have received, I have not yet seen nor perform a PMFF or cervicofacial. I have been getting by with just bilobed/trilobed, V-Y pedicles, and FTSGs only...

 

[reno911]

Do ASMS fellows have a H&N reconstructive surgeon on standby quite regularly?

I'm not exactly sure what you mean. It's easy enough to find someone who will do reconstructions that you don't want to do. Conversely, any good fellowship trained Mohs surgeon will have someone reliable that they can work with on complex cases. I don't refer out many reconstructions, but there are all sorts of reasons I might involve other specialists (e.g. sentinel lymph node biopsies, extirpation of large areas of bony involvement, tumor extending down ear canal farther than I can reach, etc. ). These are generally cases that non-fellowship trained folks won't even perform the Mohs surgery on.

Although I am fairly confident of my surgical training that I have received, I have not yet seen nor perform a PMFF or cervicofacial. I have been getting by with just bilobed/trilobed, V-Y pedicles, and FTSGs only...

Don't take this the wrong way, but if you're a resident, you are not very good at these things and have no good basis for confidence. If you need convincing, talk to anyone who has done a fellowship. Ask them how good they were at the beginning of fellowship vs the end. After you get that answer, consider the fact that a newly graduated fellow is still extremely inexperienced.

Again, I'm sure this sounds harsh, but I used to feel just like you did at that stage of the game.

At best you have a great foundation upon which to build your skills. And that's nothing to sneeze it. Many residents don't even get that.

 

[Skinvestigator]

Don't take this the wrong way, but if you're a resident, you are not very good at these things and have no good basis for confidence. If you need convincing, talk to anyone who has done a fellowship. Ask them how good they were at the beginning of fellowship vs the end. After you get that answer, consider the fact that a newly graduated fellow is still extremely inexperienced.

Again, I'm sure this sounds harsh, but I used to feel just like you did at that stage of the game.

At best you have a great foundation upon which to build your skills. And that's nothing to sneeze it. Many residents don't even get that.

This was not harsh at all If anything, I thought it was well said and I could not have liked it more.

I agree with everything you said, hence I am looking to obtain extra surgical training. It is unfortunate given how competitive Mohs is. At some point in time, we just have to be realistic, move on, and learn on the job I guess...

 

[mohsbro525]

This was not harsh at all If anything, I thought it was well said and I could not have liked it more.

I agree with everything you said, hence I am looking to obtain extra surgical training. It is unfortunate given how competitive Mohs is. At some point in time, we just have to be realistic, move on, and learn on the job I guess...

On a slightly different note, what are ppls thoughts on 2 year ACGME accredited Mohs fellowships?

 

[Skindoc83]

On a slightly different note, what are ppls thoughts on 2 year ACGME accredited Mohs fellowships?

Is that a thing now? Seems predatory

 

[reno911]

On a slightly different note, what are ppls thoughts on 2 year ACGME accredited Mohs fellowships?

They're fine. The disadvantage is obvious. The advantage is that they generally will have a focus on some particular skill that you will spend the extra year developing. But that's only an advantage if that thing is something you have a real interest in. Most of the time that's not actually the case and the fellow just accepts the extra year because they couldn't get a one year fellowship. After all, a 2 yr fellowship is far better than no fellowship.

 

[reno911]

This was not harsh at all If anything, I thought it was well said and I could not have liked it more.

I agree with everything you said, hence I am looking to obtain extra surgical training. It is unfortunate given how competitive Mohs is. At some point in time, we just have to be realistic, move on, and learn on the job I guess...

While it is competitive, the vast majority of people who really want a fellowship will find one. If you apply very broadly and more than once (if needed), you have an extremely high likelihood of matching.

Just matching into derm was harder and you've already done that.

 

[Skinvestigator]

Is that a thing now? Seems predatory

Yes its a thing now. Seems like the more prestigious programs like Brigham, Columbia, and Northwestern are now two years long.

 

[Skinvestigator]

While it is competitive, the vast majority of people who really want a fellowship will find one. If you apply very broadly and more than once (if needed), you have an extremely high likelihood of matching.

Just matching into derm was harder and you've already done that.

I hope so. Will keep my fingers crossed.

On a separate note, when job postings are looking for "fellowship-trained Mohs surgeons", are they specifically looking for ACMS fellows, or even the ASMS fellows who underwent 1 year of Mohs training can also qualify? Thanks.

 

[Slack3r]

I hope so. Will keep my fingers crossed.

On a separate note, when job postings are looking for "fellowship-trained Mohs surgeons", are they specifically looking for ACMS fellows, or even the ASMS fellows who underwent 1 year of Mohs training can also qualify? Thanks.

Nobody considers ASMS “fellowship trained”, probably including the ASMS people. There’s no comparison.

 

[reno911]

Yes its a thing now. Seems like the more prestigious programs like Brigham, Columbia, and Northwestern are now two years long.

The "prestige" is hard to quantify and it kind of depends on what you mean. Those are certainly all great places to train, but there are plenty of places that are as good or better depending on what your specific interests are. These other places would be prestigious if you asked other Mohs surgeons, but they may not sound as impressive to your future patients.

 

[reno911]

Nobody considers ASMS “fellowship trained”, probably including the ASMS people. There’s no comparison.

There are people who do non-accredited 1-year fellowships (of varying quality) and then after they are done they join the ASMS.

I think those people can legitimately claim they are "fellowship-trained", ASMS Mohs surgeons.

And to answer the original question, I know of a couple of cases of such people getting jobs that are advertised for "fellowship-trained" surgeons.

 

[Skindoc83]

Yes its a thing now. Seems like the more prestigious programs like Brigham, Columbia, and Northwestern are now two years long.

Not to sound mean but I wouldn’t consider those programs to be top places, and to require two years is absurd. They likely just want you to publish and staff clinics

 

[reno911]

Not to sound mean but I wouldn’t consider those programs to be top places, and to require two years is absurd. They likely just want you to publish and staff clinics

I'm sure there is some of that, but the Brigham one, for example, expects you to get an MPH while you're doing the fellowship.

That's great if that is what you're interested in, and kind of a waste of time if you're not.

 

[mohsable]

Not to sound mean but I wouldn’t consider those programs to be top places, and to require two years is absurd. They likely just want you to publish and staff clinics

Are there programs that are considered top tier Mohs programs by general consensus (irrespective of location or personal ties)? It seems like everybody just dances around the subject and falls back on "oh, it depends on your interests and where you want to spend the year." I've heard Zitelli & Brodland... anyone else?

 

[asmallchild]

Are there programs that are considered top tier Mohs programs by general consensus (irrespective of location or personal ties)? It seems like everybody just dances around the subject and falls back on "oh, it depends on your interests and where you want to spend the year." I've heard Zitelli & Brodland... anyone else?

That advice really is true

I knew I wanted to go into private practice and favored surgery > cosmetics so I selected a fellowship that would accommodate those goals. I was operating from Day 1, I saw high volume, I got some cosmetics exposure but the majority of my focus was on operating.

There are more academically oriented fellowships, more cosmetically oriented fellowships (with one PD even admitting to me he barely reaches the minimum surgical caseload, his passion is on the laser side), etc

EDIT: I also wanted to add the advice about where you want to spend the year also makes a huge difference. The dermpath fellow at my home program told me to really enjoy your fellowship year and that for her, it was the most rewarding year of training for her. In many ways, she was right, I found it to be one of the best (if not the best) years of education because you can really focus on the science and not have to worry about the business side, about studying (well, maybe not anymore thanks to this MDS subspecialty certification exam nonsense), etc. It's also a chance, if you wanted to, to pick up for a year and not only pick up a fantastic skill set but explore a part of the country you've never seen before. I will concede I eliminated many programs from consideration simply because I did not want to be there for one year, no matter how fantastic the training may be.

 

[Skindoc83]

Are there programs that are considered top tier Mohs programs by general consensus (irrespective of location or personal ties)? It seems like everybody just dances around the subject and falls back on "oh, it depends on your interests and where you want to spend the year." I've heard Zitelli & Brodland... anyone else?

off the top of my head: Zitelli, glen Goldman, Chris Miller, Jeremy Bordeaux, Ian Maher, Geisenger, Anna bar, Joel cook, and Scripps. These are not the only great programs but I think those would top most peoples lists.

 

[Skinvestigator]

If I am unsuccessful at matching to Mohs, would I be better off completing a Cosmetic Derm Fellowship, or work for 1 year before reapplying in the following cycle? Or perhaps pursue a 1-year non-ACGME-accredited Mohs fellowship? Any thoughts or wisdom would be greatly appreciated.

Just received my first rejection email via SFMatch, so I am just trying to prepare for the worst outcome. Thanks in advance.

 

[Skindoc83]

Do not do an unaccredited fellowship. My practice would never hire someone for mohs that was not ACGME trained. Doing a cosmetic fellowship will likely not help your chances in matching into mohs. The only reason to do one is if you want to do a cosmetics fellowship. Also undsrstand that you will be sacrificing a years salary, which is not insignificant. I personally think your best option is to work for a year or two. If you work a year or two in academics, and get along with their mohs fellowship director, I am sure they would take you on as a fellow or write you a great LOR that will get you in somewhere else