Mohs without fellowship?

[Toosieslide]

Hey all,

I got offered a job with ~30% MMS. I am not fellowship trained and the other two Mohs surgeons in the practice are not fellowship trained either. They also advised I take the MMS board exam. Does anyone know how common this is? If I later decide to do a fellowship, will it be a problem that I am already practicing Mohs and have a board certification?

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[asmallchild]

You can imagine how ACMS members feel about those who do Mohs without the appropriate training. Choosing to advertise yourself as a board certified Mohs surgeon when many patients do not know the difference between board certified and fellowship trained is also frowned upon by ACMS members. I don't think it would bode well for your chances to snag an ACMS fellowship down the road.

 

[carolp]

There is nothing ethically or medically wrong with doing Mohs without a fellowship. Many residencies do a ton of Mohs cases and you can graduate being comfortable with most Mohs cases. If you never left the academic high tower you would think only cosmetic fellowship trained dermatologists should be doing Botox or that pediatric fellowship is required to treat children. There is a ton of skin cancer in the US, much of which is being excised by general surgeons and family medicine docs that have minimal training in residency, or by NPs and PAs. I have seen some pretty poor cosmetic outcomes from fellowship trained Mohs and great results from society members. At a time when nurse practitioners are opening up dermatology offices, fellowship trained people should pick their battles and accept that a board certified mohs surgeons who didn’t do a fellowship are equals.

In terms of how common this is, I think about half of Mohs cases are from people who did not do a fellowship, so extremely common.

 

[asmallchild]

There is nothing ethically or medically wrong with doing Mohs without a fellowship. Many residencies do a ton of Mohs cases and you can graduate being comfortable with most Mohs cases. If you never left the academic high tower you would think only cosmetic fellowship trained dermatologists should be doing Botox or that pediatric fellowship is required to treat children. There is a ton of skin cancer in the US, much of which is being excised by general surgeons and family medicine docs that have minimal training in residency, or by NPs and PAs. I have seen some pretty poor cosmetic outcomes from fellowship trained Mohs and great results from society members. At a time when nurse practitioners are opening up dermatology offices, fellowship trained people should pick their battles and accept that a board certified mohs surgeons who didn’t do a fellowship are equals.

In terms of how common this is, I think about half of Mohs cases are from people who did not do a fellowship, so extremely common.

I don't bother getting into debates like this anymore re: ACMS vs ASMS vs board certification because they inevitably devolve into ridiculous statements like this from the side that lacks the formal training and expertise.

If that is what people choose to believe, that's fine. Clearly, there are enough skin cancers out there for people to do Mohs without fellowship training. For those who feel they don't need the additional training, my advice would be good luck and move forward with Mohs as part of your practice.

It doesn't change my original advice about the OP's situation: someone who wants to try dipping their toes into Mohs and then possibly consider fellowship training afterwards. ACMS fellowship program directors obviously won't agree with that bolded line of reasoning. In the PD's eyes, I don't think previous Mohs experience and board certification would be a plus on the application unless it was followed by the mea culpa "I realized I was doing a disservice to patients and want to do it correctly now"

 

[reno911]

accept that a board certified mohs surgeons who didn’t do a fellowship are equals.

No they aren't. People who did a fellowship have more training than those who don't.

That doesn't mean that non-fellowship trained folks, can't do Mohs, shouldn't do Mohs, or can't be as good or better than someone who did do a fellowship. But it doesn't change the fact that their training is not equal. That's not really even debatable.

 

[doctalaughs]

No they aren't. People who did a fellowship have more training than those who don't.

That doesn't mean that non-fellowship trained folks, can't do Mohs, shouldn't do Mohs, or can't be as good or better than someone who did do a fellowship. But it doesn't change the fact that their training is not equal. That's not really even debatable.

I would agree.

Additionally - beyond fellowship the more you do something the better at it you are. I would not send to a mohs person that does it 1-2 days a week (ours are full time 100% mohs, in house fellowship-trained so not an issue).

Our mohs people fully admit they would be terrible at managing complex medical derm cases and prescribing systemic meds for inflammatory conditions, because they haven’t done it for years.

On the flip side (or maybe additionally) there is a ton of mohs going on in this country for stuff that absolutely doesn’t need mohs. It’s best to separate who is deciding it goes for mohs and who is doing it, or you get a ton of dinky easy ridiculous cases that are a waste of time and resources. Sort of like people who read their own path but send out everything hard / melanocytic etc

 

[dermie1985]

Personally, I think Mohs fellowship is important because Mohs is hard (taking layers is not....but accurately reading frozen sections, and doing complex repairs is pretty hard). From a medico-legal risk perspective, surgical cases are much higher risk for litigation that most of what you do in general dermatology. I don't think anyone really gets enough training in residency to be ready to be a true Mohs surgeon after residency. We see a fair amount of cases from non-mohs trained dermatologists and I see a lot of recurrences and a lot of terrible scars.

As with anything in medicine, do what you ware comfortable doing based on your training. If you're working in a rural area without easy access to Mohs otherwise, you're potentially doing a service to the local community by providing easier access to a specialty procedure that they'd otherwise have to travel hundreds of miles to receive. If you're working in an urban or saturated market, I would be more careful and definitely limit Mohs to low-risk, low complexity cases and send complex tumors to someone with more training. In terms of board certification, there's always rumors that some insurers may eventually deny reimbursement for Mohs for physicians without board certification, although who knows if this will ever actually happen.

 

[reno911]

Personally, I think Mohs fellowship is important because Mohs is hard (taking layers is not..

I have to kind of disagree with this too. If you're chasing a tumor deep into the orbit or 5 cm inside the urethra (both of which I have had to do in the past several months) taking a complete layer where you can be confident in the margins is anything but trivial.

But even setting this really complex stuff aside, even for a routine tumor on the ala, just taking a layer in such a way to ensure that it can be embedded well and mapped accurately requires skill. There are all sorts of minor things that one can do which can potentially make a difference. But if someone just views taking a layer as not much more than cutting of a piece of skin, then these subtleties are not even appreciated. People don't know what they don't know.

 

[reno911]

I would agree.
I would not send to a mohs person that does it 1-2 days a week

I agree with one small caveat. Once I'm about 20yrs out of full-time, 100% Mohs I'll probably be cutting down to 2 days a week. I think I'll be fine doing that for a while. I'd hope you would be confident in someone like that.

 

[doctalaughs]

I agree with one small caveat. Once I'm about 20yrs out of full-time, 100% Mohs I'll probably be cutting down to 2 days a week. I think I'll be fine doing that for a while. I'd hope you would be confident in someone like that.

Yeah I’d be comfortable with that especially if I’d sent to that person prior.

Im more talking those that split time and do something like “70% cosmetics 30% mohs” or do mostly general/medical derm with a day or two of mohs (and send themselves lots of easy cases).

 

[zanzizic]

Mohs surgeon here. I love how people worry about Mohs and "resources". I think every dermatology text mentions how expensive Mohs surgery is. Have you ever seen any other procedure (CABG, gastrectomy, cervical colposcopy, etc) ever have cost mentioned in a textbook?

Can Mohs be over utilized? Sure. So can biologics or cryotherapy or anything else. Zitelli did a study years ago showing that considering recurrences that Mohs surgery is actually cost effective. I have seriously had people say that they won't send a case to Mohs because "too expensive". So the patient is referred to a plastic surgeon who does the case (probably $1200 for Mohs) in a hospital or surgery center and the surgeon fee, anesthesiology fee, and facility fee hit $10,000. And they feel good about no over utilization? This happens more often than you'd think.

 

[doctalaughs]

Mohs surgeon here. I love how people worry about Mohs and "resources". I think every dermatology text mentions how expensive Mohs surgery is. Have you ever seen any other procedure (CABG, gastrectomy, cervical colposcopy, etc) ever have cost mentioned in a textbook?

Can Mohs be over utilized? Sure. So can biologics or cryotherapy or anything else. Zitelli did a study years ago showing that considering recurrences that Mohs surgery is actually cost effective. I have seriously had people say that they won't send a case to Mohs because "too expensive". So the patient is referred to a plastic surgeon who does the case (probably $1200 for Mohs) in a hospital or surgery center and the surgeon fee, anesthesiology fee, and facility fee hit $10,000. And they feel good about no over utilization? This happens more often than you'd think.

I would agree with you on resources for mohs vs excision, especially in terms of sending to plastics (I never do that).

However when we are talking about ED&C vs mohs— especially at the time of the biopsy — it’s a different story. If you know what you are doing with a dematoscope, how to choose lesions and how not to do tiny biopsies then 90% of BCC/SCC can be cured before the path comes back. Rest I send to our in-house mohs or (rarely) excise myself.

Sure - I leave money on the table not being able to bill two procedures and doing multiples lesions at a time but the 70-90 year-olds appreciate not going to mohs 10 times a year.

I don’t particularly understand dermatologists who will never ED&C anything on the face in anyone or for some crazy reason think you can never ED&C an invasive SCC.