Using Initial Biopsies and Vertical Sections to Improve Trainees' Confidence in Performing Mohs Surgery.

BACKGROUND: Tissue preservation and tumor clearance are hallmarks of Mohs micrographic surgery, but no standardized method currently exists to guide trainees on how to balance the two. OBJECTIVE: The authors provided residents and fellows with additional histologic information to enhance their surgical decision-making without changing the standard methodology of Mohs surgery. METHODS AND MATERIALS: Trainees were provided initial biopsy slides (IS) and frozen vertical sections (VS) of the first Mohs layer. All Mohs layers were excised in standard fashion, and vertically oriented sections were taken from the layer without disturbing the surgical margins to obtain VS. Surveys were used to assess trainees' confidence in performing Mohs surgery with and without these tools. RESULTS: Trainees reported increased confidence in performing Mohs surgery when they reviewed IS before surgery and viewed VS of the first layer. CONCLUSION: Reviewing IS and VS improved trainees' confidence in performing Mohs surgery. This additional histological information was obtained while maintaining the usual steps of Mohs surgery. Objective information obtained from IS and VS may explain why trainees' confidence increased using this technique. Both IS and VS can be valuable teaching tools that may enhance trainees' ability to perform Mohs surgery.

Education and Perspectives on the Use of Oral Skin Cancer Chemoprophylaxis: A Cross-Sectional Survey of Current Fellows in Mohs Micrographic Surgery & Dermatologic Oncology.

BACKGROUND: According to the curriculum guidelines of the Accreditation Council of Graduate Medical Education and the American Board of Dermatology, Mohs micrographic surgery & dermatologic oncology (MSDO) fellows must demonstrate competency in the use of oral skin cancer chemoprophylaxis. The current level of education in this area is unknown. OBJECTIVE: To characterize oral skin cancer chemoprophylaxis education for acitretin and nicotinamide among current MSDO fellows and to compare the clinical indications felt most appropriate for prescribing to a previously published expert consensus. METHODS: An electronic survey was distributed to all active MSDO fellows by the American College of Mohs Surgery. RESULTS: Responses were received from 63 (69.2%) MSDO fellows. Twenty (31.7%) and 37 (58.7%) fellows reported receiving fellowship training on acitretin and nicotinamide, respectively. Fifty-seven (90.5%) intend to prescribe chemoprophylaxis after training. Sixteen (28.1%) and 43 (75.4%) report feeling very comfortable prescribing acitretin and nicotinamide, respectively. Fellow concordance with a previously published expert consensus opinion on appropriate prescribing indications is variable. Forty-one (65.1%) indicated that additional education would increase the likelihood to prescribe after training. CONCLUSION: Although most MSDO fellows intend to prescribe oral skin cancer chemoprophylaxis, a standardized curriculum may promote increased use and concordance with expert consensus recommendations.

Characteristics and comorbidities of Medicare beneficiaries receiving care from Mohs micrographic surgeons based on fellowship training and practice setting.

The characteristics and medical conditions of patients being managed by Mohs micrographic surgeons (MMS) have not been extensively established. In this cross-sectional review of 2017 Medicare Public Use data, we compared patient demographics and medical comorbidities among dermatologists billing for MMS based on surgeon fellowship training and practice settings. Overall patient complexity, as measured through Medicare's Hierarchical Condition Category (HCC) score, did not significantly differ by fellowship training status. However, among fellowship-trained surgeons, those in academic centers managed a higher proportion of dual Medicare-Medicaid beneficiaries (9.4% versus 5.4%, P<0.0001) with higher mean HCC scores (1.33 versus 1.13, P<0.0001). Depression and chronic kidney disease were notably more common among academic beneficiaries. These findings help to establish the patient complexity distribution among dermatologic surgeons, which may have important implications for perioperative management and monitoring given the growing prevalence of skin cancer and other medical comorbidities.

Characterization of the 2019 Micrographic Surgery and Dermatologic Oncology Standardized Letter of Recommendation.

BACKGROUND: Traditional letters of recommendation used for postgraduate medical training applications have multiple limitations, including a lack of clarity, inflated and overly flattering assessments, and low reliability between interpreting faculty. A micrographic surgery and dermatologic oncology (MSDO) standardized letter of recommendation (SLOR) was created to improve the efficiency, validity, and stratification of applicants to dermatology fellowship training programs. OBJECTIVE: To analyze the MSDO SLOR for trends in grading based on letter-writer and applicant characteristics and to evaluate its ability to demonstrate differences between applicants. METHODS: Standardized letter of recommendations received by 4 fellowship programs from the 2019 San Francisco Match application cycle were reviewed retrospectively. RESULTS: Two hundred forty-nine SLORs were analyzed from 140 applicants. Grade inflation and limited variability in scores were evident. Higher scores correlated with the length of the relationships between letter-writers and applicants and with female letter-writer gender. There was no applicant gender or ethnicity bias detected. CONCLUSION: Despite score inflation, the MSDO SLOR allows for differentiation between fellowship applicants. Future studies are needed to further evaluate the reliability of the SLOR and find ways to improve its content.

Outcomes of Mohs Micrographic Surgery at the American Society for Dermatologic Surgery International Traveling Mentorship Program International Mohs Fellowship Recognition Units: A Retrospective Survey of 5889 Cases From South Africa, Romania, and the Netherlands.

BACKGROUND: The American Society for Dermatologic Surgery (ASDS) International Traveling Mentorship Program (ITMP) has initiated an International Mohs Fellowship Recognition Program, with 3 centers accredited to date. OBJECTIVE: To describe and compare the outcomes of Mohs micrographic surgery (MMS) at the three units. METHODS: From patient files, we extracted demographic information, as well as tumor type, location of tumor, tumor histology, stages of MMS, and outcomes. RESULTS: At the 3 units, 3,899 patients were treated with MMS over a 5-year period in the South African unit, and 1,141 cases in the Romanian unit. Over a 3-year period, 849 cases were treated in the Netherlands unit. Basal cell carcinomas (BCCs) constituted 78.9% (South African unit), 79% (Romanian unit), and 97.2% (Netherlands unit), and squamous cell carcinomas (SCCs) 17.7% (South African unit), 19% (Romanian unit), and 0.7% (Netherlands unit) of the tumors treated. The recurrence rate following MMS was low, at 0.1% (South African Unit) and 0.17% (Romanian Unit) of cases at the end of the study period, with a median follow-up time of 2 years. CONCLUSION: Mohs micrographic surgery is an effective treatment modality for removing BCC and SCC at ASDS ITMP-recognized International Mohs Fellowship units.

Micrographic Surgery and Dermatologic Oncology Fellowship Selection Criteria.

BACKGROUND: Obtaining a fellowship position for Micrographic Surgery and Dermatologic Oncology (MSDO) is becoming very competitive. Applicant qualities desired by MSDO fellowship directors have not been previously explored in a systematic way. OBJECTIVE: To characterize the prevailing practices of selecting MSDO fellows. METHODS AND MATERIALS: Cross-sectional study based on an anonymous online survey of MSDO fellowship directors. RESULTS: There were 34 completed surveys. Selection criteria with the highest importance to fellowship directors were the ability to work well and get along with others, interview, work ethic, and letter of recommendation from the Mohs micrographic surgery director at the applicant's residency. The criteria with the lowest importance were advanced degrees, medical licensing examination scores, and membership in Alpha Omega Alpha. Specific applicant factors that were looked upon most positively by fellowship directors include applicant from own institution and applicant's personal reasons and circumstances, whereas factors that were most unfavorable include applicant's desire to practice in the same city/area as the fellowship location and graduate of foreign medical school. CONCLUSION: Although variations existed, MSDO fellowship directors collectively placed greater importance on criteria that reflect interpersonal skills than on objective measures of academic performance, which highlights the importance of "fit."

Web App- and Text Message-Based Patient Education in Mohs Micrographic Surgery-A Randomized Controlled Trial.

BACKGROUND: Consent and wound care (WC) videos are used for education in Mohs micrographic surgery (MMS). Postoperative text messaging is poorly studied. OBJECTIVE: Develop and evaluate perioperative resources for MMS patients-video modules (DermPatientEd.com) and postoperative text messaging (DermTexts.com). MATERIALS AND METHODS: A study was conducted on 90 MMS patients. Patients were randomized 1:1:1:1 to videos with text messages, videos-only, text messages-only, or control. Primary outcomes included preoperative anxiety and knowledge of MMS and postoperative care. The secondary outcome included helpfulness/preference of interventions. RESULTS: Patients experienced a 19% reduction in anxiety as measured by a visual analog scale after the MMS video (p = .00062). There was no difference in knowledge after the WC video (p = .21498). Patients were more likely to report the WC video "very helpful" when compared with the pamphlet in understanding postoperative WC (p = .0016). Patients in text messaging groups were not more likely to report the service as "very helpful" when compared with the pamphlet (p = .3566), but preferred to receive WC instructions by text message for future visits (p = .0001). CONCLUSION: These resources proved helpful and effective in reducing preoperative anxiety. Patients prefer text message-based WC instructions over pamphlets after experiencing the service, but do not find them more helpful.