mohs job market

[exeunt]

---

Members don't see this ad.

i've been hearing it's pretty difficult to get a good mohs gig in highly desirable locations these days (i.e. manhattan, LA, bay area) and that it'll only continue to get harder, in addition to the high likelihood of reimbursement getting cut. just wondering exactly how hard it is and if it's worth doing mohs if you want to work in one of these markets?

 

[asmallchild]

i've been hearing it's pretty difficult to get a good mohs gig in highly desirable locations these days (i.e. manhattan, LA, bay area) and that it'll only continue to get harder, in addition to the high likelihood of reimbursement getting cut. just wondering exactly how hard it is and if it's worth doing mohs if you want to work in one of these markets?

It is very difficult to get a 100% Mohs position in highly desirable locations. If you are willing to do mostly general derm and slowly build up your Mohs caseload, it's still doable.

Is it worth doing Mohs if you insist on working in one of those markets? That's a decision you'll have to make. If you can afford to take the year off and enjoy surgery, it will be worth it. If you are looking at Mohs as a ticket to riches, you'll find that taking a year off to do the fellowship and having to struggle to build up your case load may not be worth your while.

 

[reno911]

Forget highly desirable locations. Even in moderately desirable locations a full time Mohs job is hard to come by.

Also the money isn't as great as everyone thinks. Especially w/ pending cuts. If you're a recent graduate you can make as much or more doing general derm with some cosmetics mixed in as you can trying to be a 100% Mohs surgeon who does nothing else.

 

[Slack3r]

What if you like Mohs but would actually prefer to still do a fair amount of general derm?

 

[exeunt]

thanks for the comments. if it's this tough to get a job, why do so many people still want to do mohs fellowship?

 

[asmallchild]

thanks for the comments. if it's this tough to get a job, why do so many people still want to do mohs fellowship?

The same reason people pursue dermpath or cardiology or plastic surgery: because they enjoy the work. It's tough to get a 100% Mohs job but not impossible. You can always work outside of those highly desirable places and you have to be realistic about building up a Mohs practice. Or maybe you get lucky and inherit a Mohs practice from someone looking to retire

As for the question about liking Mohs but preferring to still do a fair amount of general derm, those jobs are much easier to come by. The question then is if it's worth it to take an entire off to pursue a Mohs fellowship if you'll only be doing it part time

 

[Gracile]

Is it possible to do MOHs part time without a fellowship?

 

[asmallchild]

Is it possible to do MOHs part time without a fellowship?

It is possible to join the Mohs society and do Mohs that way (it's not difficult, you get the training on how to excise tumors in residency, on how to read the path in residency, and how to close defects in residency)

The two problems I've seen friends run into:

1) In underserved areas, neglected tumors can result in significant defects. Without the volume in fellowship, some may not be comfortable taking care of those lesions.

2) In more popular/competitive areas (like where I currently work), I've had patients call the office and ask for my bio card before making an appointment. Some patients may ask for someone who is fellowship trained. (And certainly, your competition in the area will advertise the fact that they're fellowship trained and you are not)

 

[charmiedermie]

The same reason people pursue dermpath or cardiology or plastic surgery: because they enjoy the work. It's tough to get a 100% Mohs job but not impossible. You can always work outside of those highly desirable places and you have to be realistic about building up a Mohs practice. Or maybe you get lucky and inherit a Mohs practice from someone looking to retire

As for the question about liking Mohs but preferring to still do a fair amount of general derm, those jobs are much easier to come by. The question then is if it's worth it to take an entire off to pursue a Mohs fellowship if you'll only be doing it part time

But isn't the whole point to doing a fellowship is to practice it full-time, like Cardiology or Plastics?

 

[asmallchild]

But isn't the whole point to doing a fellowship is to practice it full-time, like Cardiology or Plastics?

It's different for every field. Unfortunately right now, it's difficult to find a 100% Mohs or 100% dermpath job immediately after fellowship. If you enjoy the work and are cognizant that it may take some time to build up such a practice, the fellowship can still be worthwhile.

 

[charmiedermie]

It's different for every field. Unfortunately right now, it's difficult to find a 100% Mohs or 100% dermpath job immediately after fellowship. If you enjoy the work and are cognizant that it may take some time to build up such a practice, the fellowship can still be worthwhile.

Thank you. I guess that's the question whether it is worthwhile. If fee-for-service will really be gone, which I believe it will, I think it will have a huge impact in terms of pursuing those fellowships.

If you really enjoy it, then its all irrelevant, but sad that you can't necessarily practice it full time just bc u want to and are fellowship trained. I would have thought Derm's tight control of numbers would have avoided that.

 

[asmallchild]

Thank you. I guess that's the question whether it is worthwhile. If fee-for-service will really be gone, which I believe it will, I think it will have a huge impact in terms of pursuing those fellowships.

If you really enjoy it, then its all irrelevant, but sad that you can't necessarily practice it full time just bc u want to and are fellowship trained. I would have thought Derm's tight control of numbers would have avoided that.

I think it has less to do with fee-for-service and more to do with available volume.

Mohs and dermpath tend to reimburse more (for now) and in highly desirable areas, the more established physicians have already staked out their share of surgical patients (or providers who send specimens in the case of dermpath)

You'll just have to work harder to establish market share if you are interested in doing 100% Mohs or dermpath.

Conversely, if you don't mind moving to the middle of nowhere, you may (or may not) have access to all the Mohs cases you want. (Dermpath is trickier since providers can send to any lab anywhere in the country they please. Despite moving to the middle of nowhere, you may still be competing with the major national labs for specimens as a dermatopathologist)

 

[charmiedermie]

I think it has less to do with fee-for-service and more to do with available volume.

Mohs and dermpath tend to reimburse more (for now) and in highly desirable areas, the more established physicians have already staked out their share of surgical patients (or providers who send specimens in the case of dermpath)

You'll just have to work harder to establish market share if you are interested in doing 100% Mohs or dermpath.

Conversely, if you don't mind moving to the middle of nowhere, you may (or may not) have access to all the Mohs cases you want. (Dermpath is trickier since providers can send to any lab anywhere in the country they please. Despite moving to the middle of nowhere, you may still be competing with the major national labs for specimens as a dermatopathologist)

Wow, of course!! Thank you for explaining. I have to realize a lot of the ones who do their fellowship specialty full time have good business and market acumen as well and came in at a better time.

 

[Member1]

Any info on volume (tumors/day), overhead, for more rural located Mohs surgeons and how their practice/reimbursement may differ from their peers based in larger cities?

 

[asmallchild]

Any info on volume (tumors/day), overhead, for more rural located Mohs surgeons and how their practice/reimbursement may differ from their peers based in larger cities?

It's a generalization but typically volume will be larger (less providers in a given area), tumors will be larger (difficulty in gaining access to care means the tumors can often be larger resulting in larger defects and more complicated repairs), overhead is typically significantly less, and reimbursement per case may be greater as well.

The tradeoff is can you accept living in such a location? Is it worth it to be 100% Mohs (or even to make more money) but to be away from friends/family/whatever else larger cities can typically offer someone.

 

[MOHS_01]

I think y'all are grossly overestimating the need or even the potential for new grads in today's market. I am booked out the longest of any Mohs surgeon in my state; while maybe 4 months out of the year I could use some part time help, the other 6-8 I wouldn't even consider it.

We have over trained dermatology subspecialists relative to the need - and the new guys will continue to bear the brunt of the prior generation's mistake(s).

 

[asmallchild]

I think y'all are grossly overestimating the need or even the potential for new grads in today's market. I am booked out the longest of any Mohs surgeon in my state; while maybe 4 months out of the year I could use some part time help, the other 6-8 I wouldn't even consider it.

We have over trained dermatology subspecialists relative to the need - and the new guys will continue to bear the brunt of the prior generation's mistake(s).

Oh I agree, I just don't feel pursuing additional training is necessarily a bad thing if the applicant is aware of the market. The big question will be if it's worth it to dedicate one year towards fellowship training if you'll only be doing part time Mohs (at best) in a competitive market initially.

 

[MOHS_01]

Oh I agree, I just don't feel pursuing additional training is necessarily a bad thing if the applicant is aware of the market. The big question will be if it's worth it to dedicate one year towards fellowship training if you'll only be doing part time Mohs (at best) in a competitive market initially.

Until this Medicare Advantage (and potential IPAB) problem(s) are resolved I'm uncertain of the wisdom of pursuing additional training. I don't know, but some who are more involved with the background politics of the situation are quite worried about the near to intermediate term.

 

[asmallchild]

Until this Medicare Advantage (and potential IPAB) problem(s) are resolved I'm uncertain of the wisdom of pursuing additional training. I don't know, but some who are more involved with the background politics of the situation are quite worried about the near to intermediate term.

That is true, it's one of the reasons I was disappointed in the split from procedural derm back into separate Mohs and cosmetic fellowships (although I will say I'm also not aware of the background politics of that decision). The fellowship would be more worthwhile if added multiple new skillsets (one that is still oversaturated in popular locations but at least is cash pay). I agree it would be worrisome to be starting or applying to a Mohs-only fellowship today

 

[DermatoFIGHT]

This makes me sad 🙁

 

[exeunt]

is it true that it's not a big deal if your program doesn't train you in cosmetics bc it's easy to learn post residency?

 

[asmallchild]

is it true that it's not a big deal if your program doesn't train you in cosmetics bc it's easy to learn post residency?

Depends what you are looking to do. If you are looking to practice primarily cosmetic dermatology, you'll probably feel more comfortable pursuing a fellowship anyway. If you are looking to just augment to a primarily gen derm practice, then yes, you can probably pick up what you need to know after residency via workshops or meetings.

 

[DermatoFIGHT]

Depends what you are looking to do. If you are looking to practice primarily cosmetic dermatology, you'll probably feel more comfortable pursuing a fellowship anyway. If you are looking to just augment to a primarily gen derm practice, then yes, you can probably pick up what you need to know after residency via workshops or meetings.

What do you define as "cosmetic dermatology"? Liposuction or just fillers?

 

[asmallchild]

What do you define as "cosmetic dermatology"? Liposuction or just fillers?

Even for "just fillers", you may not have enough of a comfort level to do a high volume without a fellowship. There are multiple dermatologists in my group who won't do Radiesse or Sculptra or Voluma or even fillers of any sort because they haven't done or seen enough cases to feel comfortable handling a complication. This can be area dependent as well as more competitive areas tend to have more finicky patients who will look into your background before allowing you to do any cosmetic procedure. Even if it is something as simple as Botox or filler.

Cosmetic dermatology may also include liposuction, fat transfer, any array of lasers, blepharoplasty, sclerotherapy, chemical peels, and any number of other procedures. If you are lucky enough to gain enough experience to them during residency, great. I would not go about selecting a residency based solely on what they can offer cosmetically though.

 

[charmiedermie]

Even for "just fillers", you may not have enough of a comfort level to do a high volume without a fellowship. There are multiple dermatologists in my group who won't do Radiesse or Sculptra or Voluma or even fillers of any sort because they haven't done or seen enough cases to feel comfortable handling a complication. This can be area dependent as well as more competitive areas tend to have more finicky patients who will look into your background before allowing you to do any cosmetic procedure. Even if it is something as simple as Botox or filler.

Cosmetic dermatology may also include liposuction, fat transfer, any array of lasers, blepharoplasty, sclerotherapy, chemical peels, and any number of other procedures. If you are lucky enough to gain enough experience to them during residency, great. I would not go about selecting a residency based solely on what they can offer cosmetically though.

I was wondering this as well. Is the advantage to doing a Procedural Derm fellowship purely because of volume or bc you see certain cosmetic procedures or machines used that you just don't see in residency?

I didn't ask anything about cosmetics exposure on any of my interviews as I just didn't want to risk it.

I want to be a well-rounded dermatologist and that includes cosmetics even though so programs don't want to acknowledge it.

 

[asmallchild]

I was wondering this as well. Is the advantage to doing a Procedural Derm fellowship purely because of volume or bc you see certain cosmetic procedures or machines used that you just don't see in residency?

I didn't ask anything about cosmetics exposure on any of my interviews as I just didn't want to risk it.

I want to be a well-rounded dermatologist and that includes cosmetics even though so programs don't want to acknowledge it.

My understanding is that procedural dermatology fellowships have once again been split into separate Mohs and cosmetic fellowships but admittedly I may be a bit out of touch with all those changes.

The advantage of doing any fellowship is volume. Just as you'll feel more comfortable with admissions after admitting hundreds and hundreds of patients as an intern, you'll feel more comfortable with Mohs or cosmetics or whatever it is you are pursuing by doing a high volume fellowship.

You may also gain exposure to procedures that you would not have ordinarily gained exposure to. For instance, some laser fellowships have upwards of 30 devices available for their fellows. I doubt any residency program has even 10+ lasers on site for their residents to play around with.

 

[charmiedermie]

My understanding is that procedural dermatology fellowships have once again been split into separate Mohs and cosmetic fellowships but admittedly I may be a bit out of touch with all those changes.

The advantage of doing any fellowship is volume. Just as you'll feel more comfortable with admissions after admitting hundreds and hundreds of patients as an intern, you'll feel more comfortable with Mohs or cosmetics or whatever it is you are pursuing by doing a high volume fellowship.

You may also gain exposure to procedures that you would not have ordinarily gained exposure to. For instance, some laser fellowships have upwards of 30 devices available for their fellows. I doubt any residency program has even 10+ lasers on site for their residents to play around with.

Thanks! Does everyone else get that training at CME type conferences or cosmetic boot camps, although inherent volume won't be there?

Sorry for all these questions. I definitely won't rank based on cosmetics training, but helps to know how to make it up in some other way. Would have been nice to get to ask solely for information purposes.

 

[exeunt]

My understanding is that procedural dermatology fellowships have once again been split into separate Mohs and cosmetic fellowships but admittedly I may be a bit out of touch with all those changes.

The advantage of doing any fellowship is volume. Just as you'll feel more comfortable with admissions after admitting hundreds and hundreds of patients as an intern, you'll feel more comfortable with Mohs or cosmetics or whatever it is you are pursuing by doing a high volume fellowship.

You may also gain exposure to procedures that you would not have ordinarily gained exposure to. For instance, some laser fellowships have upwards of 30 devices available for their fellows. I doubt any residency program has even 10+ lasers on site for their residents to play around with.

i heard about this on the interview trail but obv not sure what the ramifications are. does that mean from now on fellowships will be exclusively either mohs or cosmo? or will there still be fellowships where you can train in both?

 

[reno911]

My understanding is that procedural dermatology fellowships have once again been split into separate Mohs and cosmetic fellowships but admittedly I may be a bit out of touch with all those changes.

The advantage of doing any fellowship is volume. Just as you'll feel more comfortable with admissions after admitting hundreds and hundreds of patients as an intern, you'll feel more comfortable with Mohs or cosmetics or whatever it is you are pursuing by doing a high volume fellowship.

You may also gain exposure to procedures that you would not have ordinarily gained exposure to. For instance, some laser fellowships have upwards of 30 devices available for their fellows. I doubt any residency program has even 10+ lasers on site for their residents to play around with.

I'm not sure what you mean by "once again" as it was never really that way before and I'm not sure it ever will be.

In the past, Mohs fellowships were accredited by the Mohs College. There was a minimum amount of Mohs that was expected, but beyond that there was a vide variation what all of these Mohs fellowships offered. Some offered a lot of cosmetic training, some just offered just a ton more Mohs and reconstruction, and there were some in which you had some flexibility to focus more on what you were most interested. All these fellowships were accredited by the Mohs college. After the ACGME took over (and the name changed to procedural dermatology), almost all of them jumped through the hoops to become ACGME accredited, however that really didn't change the day-to-day experience the fellow would have within a given fellowship. Once again the name is changing ("Micrographic Surgery and Dermatologic Oncology" -- I think...I'm too lazy to look it up right now), but the actual day-to-day experience of a fellow in a given fellowship will still probably remain unchanged.

At the same time there were other cosmetic fellowships available. These were (and still are) non-accredited fellowships that allowed residents to get a high volume of hands-on cosmetic experience that they would not have had a chance to get in residency. The movement is for these fellowships to become formalized and accredited, and this process is ongoing. However, when these fellowships are accredited, it will not change the Mohs fellowships in any meaningful way. The Mohs fellowships that offer cosmetic training will not discontinue that. There will still be Mohs fellowships that offer a little less Mohs and a little more cosmetics for those fellows who seek that type of experience.

 

[exeunt]

Even for "just fillers", you may not have enough of a comfort level to do a high volume without a fellowship. There are multiple dermatologists in my group who won't do Radiesse or Sculptra or Voluma or even fillers of any sort because they haven't done or seen enough cases to feel comfortable handling a complication. This can be area dependent as well as more competitive areas tend to have more finicky patients who will look into your background before allowing you to do any cosmetic procedure. Even if it is something as simple as Botox or filler.

Cosmetic dermatology may also include liposuction, fat transfer, any array of lasers, blepharoplasty, sclerotherapy, chemical peels, and any number of other procedures. If you are lucky enough to gain enough experience to them during residency, great. I would not go about selecting a residency based solely on what they can offer cosmetically though.

if a program does not offer any cosmetics at all, is it fair to consider that a minus?