PracticalDermatology

A new debate is sweeping through our specialty that could have a major impact on current and future dermatologists. The issue at hand is board certification for Mohs surgery and, specifically, whether dermatologists should be required to be certified in order to perform this essential surgery.

Presently, Mohs surgery specialization is not subject to a singular certification process. Instead, it is a training process that includes a compendium of other helpful techniques and ancillary surgical procedures. Some dermatologists go through the process via hands-on experience with a trained Mohs surgeon while others attend a classical fellowship. The recent call for a unified certification process has resulted in a debate between the American Society for Mohs Surgery and the American College of Mohs Surgery (the two societies for Mohs surgeons), with the latter endorsing a board certification process. Sadly, as with any contentious issue, the winners will likely be ‘none of the above.’

While the idea of a unified board certification process is attractive and sells well to the public and medical establishment, the mechanics of achieving it are difficult. If the certification process is adopted, a series of domino events will likely produce a scenario in which physicians’ options for training and certification will be severely limited, ultimately creating significant hardship on innumerable patients due to less opportunity for access to necessary treatment. For example, if existing Mohs surgeons choose not to certify under the new system, will they be ineligible to work for certain insurance companies or hospitals despite years of experience performing quality Mohs surgery for countless skin cancer sufferers? Will malpractice carriers adopt a stringent policy based on one committee’s interpretation of what is ‘best’ for the Mohs community?

One of the most concerning aspects of the dialogue that’s unfolded so far has been the anti-competitive tone of the argument favoring certification, i.e. Mohs certification could effectively discourage residents from pursuing other fellowships (laser, procedural, etc.) where they might receive valuable valuable training but not qualify for a ‘Mohs’ certification at the end. Furthermore, this could even discourage those who are in favor of certification from engaging in educating or training those who are not planning a fellowship since they may become future ‘uncertified’ competition. This could lead to a significant reduction in the availability of Mohs surgeons in a given area, especially less densely populated areas where a full time Mohs surgery practice would not be practical. It may also result in the potential for malpractice liability or insurance-contracting issues for dermatologists who are currently performing Mohs surgery without having pursued a fellowship.

It would be naïve to think that the current training model for Mohs specialization isn’t in need of some changes. However, the current proposal’s bifurcation of training (either a pathway of Mohs fellowship/certification or no alternative opportunity to perform Mohs) would seem to be the wrong way to go about introducing such change. It will only serve to create a new generation of dermatologists who may want to treat skin cancer but can’t go beyond simple treatments without a fellowship-training program. This new generation would be undertrained and ill-equipped to treat all but the simplest skin cancers since they would also not be trained in the more complex surgical repairs that should be a part of every training program.

We are facing an epidemic of skin cancer along with a paucity of training to effectively meet the demands of treatment. It would be prudent to bring together the two Mohs communities and have a more serious and engaged discussion about how to address the internal issues of our specialty. Perhaps future discussions between the Mohs College and Mohs Society will yield cooperation that allows for both improved training in residency and standards for post-training surgery without tearing apart the two post-residency paths to competence.

—Joel Schlessinger, MD

Chief Cosmetic Surgery Editor