pathologists doing MOHS

[generic pathologist]

I have been reading this forum long enough and I am perplexed at a lot of issues I see and hear about in path. As the title suggests, I think it's odd that plastics can do a dermatopath fellowship and we are unable to do MOHS fellowship. I am aware that 1) it deals with live patients 2) it is a 'surgical' procedure; what I don't get is, the most important part is reading the slides. Who would be able to read the slide better? I think we can all agree a pathologist would. If physicians/dentists/non-healthcare workers can take courses to do botox I am certain pathologist can take a 1-2 year fellowship and learn how to stitch pretty little bow-ties. So, why have pathologist not advocated for this?

Before everyone goes up in arms, I understand some people would NOT like to do this and I get that. However, I think if pathology diversifies it would 1) increase interest in the field 2) increase income options for the pathologist.

Tl;dr: why cant pathologist do MOHS fellowship?

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[Unty]

If I was a patient I wouldn't want a pathologist doing surgery on me. You can't compare botox with MOHS surgery.

I never met or heard of a plastic surgeon who did dermatopathology fellowship. This is true?

If you want to do MOHS go do a dermatology residency.

 

[generic pathologist]

If I was a patient I wouldn't want a pathologist doing surgery on me. You can't compare botox with MOHS surgery.

I never met or heard of a plastic surgeon who did dermatopathology fellowship. This is true?

If you want to do MOHS go do a dermatology residency.

I don't like derm but it's just a way to diversify the field and being able to generate money by other means. I am a resident and I consistently see the debate regarding the state of pathology and lack of jobs/interest by students etc. This would help alleviate some of these problems by allowing us to diversify.

I am aware that it's not as simple as botox hence why I suggested 1-2 years fellowship and not a weekend resort-style course with a certificate.

The following is from the ACGME website: Prior to appointment in the program, fellows must have successfully completed an ACGME-accredited residency in dermatology, anatomic pathology (AP-3), or anatomic and clinical pathology (APCP-4), or an equivalent program located in Canada and accredited by the RCPSC. " it can be found here: https://www.acgme.org/Portals/0/PFA...logy_2017-07-01.pdf?ver=2017-04-26-170436-407

We can't just keep complaining about the lack of pay if we don't advocate for ourselves.

 

[Dave1980]

That wouldn't work logistically for many reasons. You couldn't get enough patients to consistently fill a day (or half day) with Mohs procedures.

No one would refer to you since the dermatologist sees the patient and biopsies the skin cancer. When it comes back malignant they either want to perform the Mohs procedure themselves or refer to a colleague dermatologist who does the procedure. No way could you convince a dermatologist or a PCP to refer to a pathologist for an invasive procedure.

 

[Daddydoc]

Open your own biopsy clinic and hire PA's or NP's to do the biopsies and excisions.

Target rural/semi rural areas where there aren't enough dermatologists.

 

[mario2010]

If I was a patient I wouldn't want a pathologist doing surgery on me. You can't compare botox with MOHS surgery.

I never met or heard of a plastic surgeon who did dermatopathology fellowship. This is true?

If you want to do MOHS go do a dermatology residency.

BTW- the issue regarding seeing patients. In dermpath fellowship, fellows with path background are required to see patients and do procedures. Current requirement is 1000 patients and at minimum documented 50 biopsies. In my Dermpath fellowship, I saw more than 1000 patients and did hundreds of procedures. BTW, doing procedures was the easiest part in the entire fellowship, literally anyone can do that with some training. In derm, in quite a few states, NPs are independent now and run their own clinics, routinely doing excisions and closures without supervision.

 

[generic pathologist]

That wouldn't work logistically for many reasons. You couldn't get enough patients to consistently fill a day (or half day) with Mohs procedures.

No one would refer to you since the dermatologist sees the patient and biopsies the skin cancer. When it comes back malignant they either want to perform the Mohs procedure themselves or refer to a colleague dermatologist who does the procedure. No way could you convince a dermatologist or a PCP to refer to a pathologist for an invasive procedure.

It doesn’t necessarily have to replace your whole schedule but even 1 day/week is better than nothing. The reason for mohs (or any other procedure) is that healthcare reimbursed those more. For some reason diagnosing a very hard tumour is compensated much less compared to a procedure like cataracts where you can treat an 18 year old kid to do.

I do agree with you regarding the referral problem. However, if we push this to the other specialties, it will pick up. Look at IR doing LPs for neurologist. It’s a win-win because IR gets paid well (or used to at least) and neuro needs it for diagnosing.

I think it’s the mentality of calling it ‘invasive’ that needs to change. Thoracentesis is technically invasive as well but internist can do them. No one asks for surgeons to do them. This is just one of many examples.

 

[generic pathologist]

Open your own biopsy clinic and hire PA's or NP's to do the biopsies and excisions.

Target rural/semi rural areas where there aren't enough dermatologists.

I’m not sure how feasible this is or the logistics for it but would love other people’s input that are more knowledgeable. Sounds like a good idea though

 

[generic pathologist]

BTW- the issue regarding seeing patients. In dermpath fellowship, fellows with path background are required to see patients and do procedures. Current requirement is 1000 patients and at minimum documented 50 biopsies. In my Dermpath fellowship, I saw more than 1000 patients and did hundreds of procedures. BTW, doing procedures was the easiest part in the entire fellowship, literally anyone can do that with some training. In derm, in quite a few states, NPs are independent now and run their own clinics, routinely doing excisions and closures without supervision.

Thank you for your input. I don’t doubt that the procedure is probably one of the easier things in the fellowships. Have you guys done mohs? As far as I’m aware, mohs is a separate fellowship exclusive to derm.

Has it ever been brought up why path doesn’t expand into mohs? I’d love your input!

I’m thinking of doing dermpath fellowship but I’m still debating. How is the market place for them?

 

[Dave1980]

I think a pathologist doing Mohs is one of those things that theoretically is possible but can't realistically happen.

 

[generic pathologist]

I think a pathologist doing Mohs is one of those things that theoretically is possible but can't realistically happen.

I agree; but’s still unfortunate because it would not only create a potential new revenue stream, it would increase the appeal of the field for new pathologists. It doesn’t have to be MOHS but anything to advance and advocate for the field is better than what the current management is doing.

 

[gbwillner]

You have the legal ability to go out there right now and perform MOHS or even brain surgery, assuming you have an MD and a valid state medical license. Everything else is politics, caution, experience, and exposure. You cannot be prohibited from performing this procedure; however, it may be difficult/impossible to get liability insurance, and other practical problems.

 

[qxrt]

I do agree with you regarding the referral problem. However, if we push this to the other specialties, it will pick up. Look at IR doing LPs for neurologist. It’s a win-win because IR gets paid well (or used to at least) and neuro needs it for diagnosing.

I think it’s the mentality of calling it ‘invasive’ that needs to change. Thoracentesis is technically invasive as well but internist can do them. No one asks for surgeons to do them. This is just one of many examples.

The difference is that IR does LPs, thoras, and other procedures in a different manner (imaging-based) compared to how the typical non-proceduralists do it. We in IR often get referred the LPs that are difficult to do (i.e. obese patient without palpable landmarks, post-spine surgery patients, etc.), the thoras that are difficult (small pleural effusion, for diagnostic thora), etc., and the "easier" LPs and thoras referrals kind of naturally stem from our ability to do the harder ones. A typical neurologist isn't going to be doing enough LPs to justify learning how to do it with fluoroscopic guidance, and neither is the internist for the thora with ultrasound guidance.

Conversely, what would a pathologist be contributing to the procedural component of doing MOHS that a dermatologist/plastic surgeon isn't able to do?

 

[generic pathologist]

You have the legal ability to go out there right now and perform MOHS or even brain surgery, assuming you have an MD and a valid state medical license. Everything else is politics, caution, experience, and exposure. You cannot be prohibited from performing this procedure; however, it may be difficult/impossible to get liability insurance, and other practical problems.

That’s very true. I wasn’t suggesting me do it solo but more so as a mentality change in that field and hence opening up more work opportunities for our field.

I would love for a dermatopathologist can give their opinion regarding the feasibility of this if the medical community was open to it. Would dermatopathology be adequate enough to allow pathologist to do this? As mentioned above, if NP can do excisions, I’m pretty sure we can manage.

 

[generic pathologist]

The difference is that IR does LPs, thoras, and other procedures in a different manner (imaging-based) compared to how the typical non-proceduralists do it. We in IR often get referred the LPs that are difficult to do (i.e. obese patient without palpable landmarks, post-spine surgery patients, etc.), the thoras that are difficult (small pleural effusion, for diagnostic thora), etc., and the "easier" LPs and thoras referrals kind of naturally stem from our ability to do the harder ones. A typical neurologist isn't going to be doing enough LPs to justify learning how to do it with fluoroscopic guidance, and neither is the internist for the thora with ultrasound guidance.

Conversely, what would a pathologist be contributing to the procedural component of doing MOHS that a dermatologist/plastic surgeon isn't able to do?

I was just giving and example so I might be wrong, but from my understanding for IR doing LPs vs neurologist doing them was purely because of a symbiotic relationship. From what I’ve been told, IR gets paid for doing them and neuro doesn’t hence shifting the work to IR. I was also told compensation for IR has decreased significantly for them and hence IR wants to shift it back to neuro to do them.

From first hand anecdotal experience and what I’ve been told, neurologist simple don’t get paid to do them so they send to IR out of laziness and status quo. I do appreciate what IR does for the more difficult ones.

Regarding mohs, I think the most crucial part is the diagnosis. Would you want someone who’s done 5 years of path + fellowship and very fluent with recognizing cancer or someone who’s done 1 year fellowship in it but can tie an arguably better knot? Pathologist can contribute a lot more than derm. Our contribution would be the diagnosis; which is the most important part. I believe a better question is, what is derms contribution that pathologist can’t do?

For more evidence of how things change with time and advancement of technology is interventional cardio. They can do TAVR which has taken away work from cardiac surgeons. We can have symbiotic relationships where more people benefit.

I would envision that path does the mohs then all follow ups are with derm. Path can bill for procedure as well as slide readout and derm can bill for all the follow up. Less procedure for derm means they can see more patients and hence bill more. I’m not sure how many patients extra they’d need to see to make up for the lack of income from the procedure though.

 

[jupiterianvibe]

I was just giving and example so I might be wrong, but from my understanding for IR doing LPs vs neurologist doing them was purely because of a symbiotic relationship. From what I’ve been told, IR gets paid for doing them and neuro doesn’t hence shifting the work to IR. I was also told compensation for IR has decreased significantly for them and hence IR wants to shift it back to neuro to do them.

From first hand anecdotal experience and what I’ve been told, neurologist simple don’t get paid to do them so they send to IR out of laziness and status quo. I do appreciate what IR does for the more difficult ones.

Regarding mohs, I think the most crucial part is the diagnosis. Would you want someone who’s done 5 years of path + fellowship and very fluent with recognizing cancer or someone who’s done 1 year fellowship in it but can tie an arguably better knot? Pathologist can contribute a lot more than derm. Our contribution would be the diagnosis; which is the most important part. I believe a better question is, what is derms contribution that pathologist can’t do?

For more evidence of how things change with time and advancement of technology is interventional cardio. They can do TAVR which has taken away work from cardiac surgeons. We can have symbiotic relationships where more people benefit.

I would envision that path does the mohs then all follow ups are with derm. Path can bill for procedure as well as slide readout and derm can bill for all the follow up. Less procedure for derm means they can see more patients and hence bill more. I’m not sure how many patients extra they’d need to see to make up for the lack of income from the procedure though.

I wouldn't trust half of pathologists to do pathology, let alone cut into someone. Our field has a huge quality problem. Maybe dermpaths association with dermatologists insulates their field from this unfortunate fact. The cream of the crop does derm. The bottom of the barrel does path.

 

[Dral]

I was just giving and example so I might be wrong, but from my understanding for IR doing LPs vs neurologist doing them was purely because of a symbiotic relationship. From what I’ve been told, IR gets paid for doing them and neuro doesn’t hence shifting the work to IR. I was also told compensation for IR has decreased significantly for them and hence IR wants to shift it back to neuro to do them.

From first hand anecdotal experience and what I’ve been told, neurologist simple don’t get paid to do them so they send to IR out of laziness and status quo. I do appreciate what IR does for the more difficult ones.

Regarding mohs, I think the most crucial part is the diagnosis. Would you want someone who’s done 5 years of path + fellowship and very fluent with recognizing cancer or someone who’s done 1 year fellowship in it but can tie an arguably better knot? Pathologist can contribute a lot more than derm. Our contribution would be the diagnosis; which is the most important part. I believe a better question is, what is derms contribution that pathologist can’t do?

For more evidence of how things change with time and advancement of technology is interventional cardio. They can do TAVR which has taken away work from cardiac surgeons. We can have symbiotic relationships where more people benefit.

I would envision that path does the mohs then all follow ups are with derm. Path can bill for procedure as well as slide readout and derm can bill for all the follow up. Less procedure for derm means they can see more patients and hence bill more. I’m not sure how many patients extra they’d need to see to make up for the lack of income from the procedure though.

I am a derm trained dermpath. First off, good luck getting this from derms. I know that sounds nasty, but I don't intend it to...I'll explain: If a starting med derm makes 450k, a starting mohs in the same market makes 700k. Procedures pay. You will NEVER tell mohs trained people "hey, we'll take over so you can get back into clinic to see more patients, but make less money." Unless the derm is supervising others I don't see how a clinic med derm practice could ever make as much as Mohs if taken on a single per person basis. Also, the Mohs group and the AAD in general are very active and good at defending and protecting the field. They aren't perfect, just like any other society, but they do a damn good job. I actually lobbied with the AAD in DC last summer and I believe one of our asks was signed into legislature.

I'm not saying I'm opposed to it, but what I am saying is...well, I can't explain just how much mohs folks giving up mohs would never happen.

Dx already happens for patients before they get to Mohs most of the time. One is doing less diagnosing and more 'checking margins' in mohs. I can tell you that derm trained residents are typically better at dermpath diagnosis than path residents are at residency graduation. Mohs doesn't have to take a lot of effort to check the majority of their cases. They use tol blue for bcc's typically, mart if they do LMs, and H/E for scc and the other things like dfsp. It's not too difficult to get that in a year of training beyond what they already know from residency.

I'm not trying to discount the importance of interpreting slides for Mohs, but I feel a pathologists skills are wasted by doing that.

It's overall an interesting idea, but just not likely in the current medical climate.

And yah, I'm not familiar with plastics residents doing dp fellowships. The following is taken from the GME documentation on dermpath fellowships:

"Prior to appointment in the program, fellows must have successfully completed an ACGME-accredited residency in dermatology, anatomic pathology (AP-3), or anatomic and clinical pathology (APCP-4), or an equivalent program located in Canada and accredited by the RCPSC. (Core)"

https://www.acgme.org/Portals/0/PFAssets/ProgramRequirements/100_dermatopathology_2017-07-01.pdf

 

[generic pathologist]

I wouldn't trust half of pathologists to do pathology, let alone cut into someone. Our field has a huge quality problem. Maybe dermpaths association with dermatologists insulates their field from this unfortunate fact. The cream of the crop does derm. The bottom of the barrel does path.

Aside from derm, plastsics , ortho, ENT, if you look at the NRMP data, pathology is on par with all the other medical specialities in terms of step 1 scores. So this bottom of the barrel idea is false.

I agree that there could be more consistency in the training but look at family and IM. They have a much bigger issue as they have community programs at some very questionable places.

I also agree that derm protects them much more than our current lack of leadership does. That’s a post for another day. Maybe I’ll make a post in what people think is wrong and what should be changed to protect path.

 

[generic pathologist]

I am a derm trained dermpath. First off, good luck getting this from derms. I know that sounds nasty, but I don't intend it to...I'll explain: If a starting med derm makes 450k, a starting mohs in the same market makes 700k. Procedures pay. You will NEVER tell mohs trained people "hey, we'll take over so you can get back into clinic to see more patients, but make less money." Unless the derm is supervising others I don't see how a clinic med derm practice could ever make as much as Mohs if taken on a single per person basis. Also, the Mohs group and the AAD in general are very active and good at defending and protecting the field. They aren't perfect, just like any other society, but they do a damn good job. I actually lobbied with the AAD in DC last summer and I believe one of our asks was signed into legislature.

I'm not saying I'm opposed to it, but what I am saying is...well, I can't explain just how much mohs folks giving up mohs would never happen.

Dx already happens for patients before they get to Mohs most of the time. One is doing less diagnosing and more 'checking margins' in mohs. I can tell you that derm trained residents are typically better at dermpath diagnosis than path residents are at residency graduation. Mohs doesn't have to take a lot of effort to check the majority of their cases. They use tol blue for bcc's typically, mart if they do LMs, and H/E for scc and the other things like dfsp. It's not too difficult to get that in a year of training beyond what they already know from residency.

I'm not trying to discount the importance of interpreting slides for Mohs, but I feel a pathologists skills are wasted by doing that.

It's overall an interesting idea, but just not likely in the current medical climate.

And yah, I'm not familiar with plastics residents doing dp fellowships. The following is taken from the GME documentation on dermpath fellowships:

"Prior to appointment in the program, fellows must have successfully completed an ACGME-accredited residency in dermatology, anatomic pathology (AP-3), or anatomic and clinical pathology (APCP-4), or an equivalent program located in Canada and accredited by the RCPSC. (Core)"

https://www.acgme.org/Portals/0/PFAssets/ProgramRequirements/100_dermatopathology_2017-07-01.pdf

I completely agree with procedures pay hence this suggestion . I'm just trying to get the field to expand and do more procedures ESPECIALLY considering all this doom and gloom around AI. Also, I am not suggesting the derm takes a pay cut; contrary; I have given numerous examples of symbiotic relationships. I'm not saying I know WHAT or IF this is the solution, I am just trying to 'think outside the box' literally and figuratively.

I am truly happy that the AAD lobbies for your speciality; ours doesn't seem to be doing enough. I am a resident and I'm just starting to see the political side of path; it's not looking good. I am extremely interested in healthcare reform and why not start with my speciality?

I agree mohs is more about margins then diagnosis. What I am skeptical about is derm is better at dermpath than path; I will take your word but I don't know many of either nor have read 'stats' to have an actual opinion. You might be right in that pathologist can probably invest their time more efficiently pushing out more slides but then we go back to the whole point of this; new revenue source (more specifically, procedures). As far as I can tell, funding agencies think procedures (even minor) are worth WAY more than brain power. There are many interesting fields in path like cyto that are interesting and challenging but compared to GI, it don't pay as much (again from what I'm hearing).

I am embarrassed that you have used my quote and link as I completely misinterpreted what Unity was saying above. Plastics as far as I am aware can't do dermpath. I misinterpreted plastics as derm hence my link. I apologize for that; more so to Unity if I sounded hostile.

 

[Dral]

In regards to Pathology skills being wasted on Mohs, I don't think it's so much about Pathologists pushing more slides, but more about how they possess skills to sign out cases. Diagnosing/margins is one thing, having the skills to artfully put together a sign out that gives information the clinician needs while being succinct is another. This is something that pathologists do that Mohs folks typically don't.

This is another difference (at least in my experience/opinion) comparing the typical derm trained person vs path trained person entering fellowship. Derm trained people seem to be more 'this needs a diagnosis, I think it's this, done' while path trained people are more willing to accept (at least initially) that not everything needs a cut an dry diagnosis, but sometimes it's ok to just describe the process and give ideas/opinions about what could be going on.

 

[generic pathologist]

In regards to Pathology skills being wasted on Mohs, I don't think it's so much about Pathologists pushing more slides, but more about how they possess skills to sign out cases. Diagnosing/margins is one thing, having the skills to artfully put together a sign out that gives information the clinician needs while being succinct is another. This is something that pathologists do that Mohs folks typically don't.

This is another difference (at least in my experience/opinion) comparing the typical derm trained person vs path trained person entering fellowship. Derm trained people seem to be more 'this needs a diagnosis, I think it's this, done' while path trained people are more willing to accept (at least initially) that not everything needs a cut an dry diagnosis, but sometimes it's ok to just describe the process and give ideas/opinions about what could be going on.

That’s a fair point you make. I guess this stems from my frustration with the forum and current situation of pathology. It seems that our skills to diagnose things are completely under appreciated (more so underfunded) but then again looking at the medscape physician compensation a lot of specialities can say the same. I’m more inline that all medical specialities should get paid similar wage (somewhat similar to Canada).

I would like to involve hands on component to not only have another financial stream but to make it more appealing to the future generations.

I completely agree that in my experience pathologist tend to philosophize about the potential diagnosis then give an actual one. Both have have pros/cons.

I guess my initial post, which has been somewhat answered, is why this can’t be done. Probably more political than feasible; that’s the state of most of medicine now I suppose.

 

[mario2010]

Mohs is a thorny topic these days. Technique wise it’s nothing complicated. You take a small excision, process entire tissue in a certain way and evaluate entire margins. 100% evaluation of margins. Complicated closures can be done by plastics or ENT guys . Currently Medicare allows any licensed physician with some documented Mohs training to bill for Mohs. By definition, ‘ Mohs specialist acts as a surgeon and a pathologist ‘ . There is infighting b/w ASMS and ACMS these days and just last year Mohs board certification through ABD got finally approved in the 3rd try. There are physicians from different specialties, plastics, ENT, derm- dermpath without Mohs fellowship and path- dermpaths without Mohs fellowship doing Mohs in mainly big group settings mainly in states like FL, CA, AZ and TX. But these are exceptions not a norm. Essentially in all of these settings these physicians are part of larger derm groups with a patient population heavy on skin cancer and built in referral base from within the group. It is near impossible for a general pathologist to have a viable stand alone Mohs practice simply because majority of skin cancer referrals are generated by general derms who won’t refer to any one else. It is definitely doable for a path-dermpath to get some Mohs training and practice Mohs within a derm group while also signing out dermpath for the group, if there is large enough referral base available and the General derms in the group don’t wanna do Mohs. But as you can imagine this will be a rare situation. Bottom line is, it all depends on the referral base. A 100% Mohs position is hard to find these days and whoever controls the patient base rules.

 

[generic pathologist]

Mohs is a thorny topic these days. Technique wise it’s nothing complicated. You take a small excision, process entire tissue in a certain way and evaluate entire margins. 100% evaluation of margins. Complicated closures can be done by plastics or ENT guys . Currently Medicare allows any licensed physician with some documented Mohs training to bill for Mohs. By definition, ‘ Mohs specialist acts as a surgeon and a pathologist ‘ . There is infighting b/w ASMS and ACMS these days and just last year Mohs board certification through ABD got finally approved in the 3rd try. There are physicians from different specialties, plastics, ENT, derm- dermpath without Mohs fellowship and path- dermpaths without Mohs fellowship doing Mohs in mainly big group settings mainly in states like FL, CA, AZ and TX. But these are exceptions not a norm. Essentially in all of these settings these physicians are part of larger derm groups with a patient population heavy on skin cancer and built in referral base from within the group. It is near impossible for a general pathologist to have a viable stand alone Mohs practice simply because majority of skin cancer referrals are generated by general derms who won’t refer to any one else. It is definitely doable for a path-dermpath to get some Mohs training and practice Mohs within a derm group while also signing out dermpath for the group, if there is large enough referral base available and the General derms in the group don’t wanna do Mohs. But as you can imagine this will be a rare situation. Bottom line is, it all depends on the referral base. A 100% Mohs position is hard to find these days and whoever controls the patient base rules.

That was very informative, thank you. I wasn’t aware of what Medicare looks for in regards to who they pay. I suppose it’s possible for someone to get a few cases during a dermpath fellowship.

From my understanding, the mohs board is available for candidates who have done a mohs fellowship. Mohs fellowship is only available to dermatologists. Is there a decrease in pay to physicians who don’t have the board vs those with?

I was envisioning more of a few cases to supplement work rather than the main work.

It’s true for any speciality that whoever controls the patients controls everything. I guess this is turning more into a pipe dream now....

 

[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?​