PracticalDermatology

Despite two previous failed attempts to achieve subspecialty certification (SC) in Mohs surgery through the American Board of Medical Specialties (ABMS), the American Board of Dermatology (ABD) is once again trying to force a contentious division on dermatology. In the midst of an uproar concerning onerous maintenance of certification (MOC) requirements, the ABD is planning a SC that will create the ultimate rift in dermatology.

A 2017 AAD Member Survey found members ambivalent regarding Micrographic Surgery and Dermatologic Oncology (MSDO) subcertification. Note: 53 percent of respondents practiced Mohs surgery; AAD data indicate only 20 percent of AAD members practice Mohs surgery.

In announcing its plan for SC, the ABD cited its desire to “recognize the efforts” of those dermatologists who have completed a post-residency fellowship in micrographic surgery (MS). Given unwavering lack of support for this SC within the dermatology community, one wonders if there is also a good reason to divide dermatology, and to do so while vesting additional authority in an unaccountable organization like the ABD. Doing so has far reaching implications for the training of future dermatologists and their perceived scope of expertise. If this SC becomes a reality, future generations of dermatology residents will be perceived as less competent to treat skin cancers, unless they invest in what may be an unneeded post-graduate fellowship (the presumed true rationale for this SC).

Make no mistake about it, SC will completely eliminate the right of all but those with SC to perform Mohs and potentially other surgical treatments. It will also give those who have this as their goal, and until now have professed so loudly, the rationale to restore the secrecy that once surrounded Mohs training. In the name of creating a monopoly, future dermatologists will have minimal exposure to this and other surgical treatments.

Mohs Surgery is a Single Procedure

Despite the complexity of treating some skin cancers, the proposal on the table is to certify a single procedure. It would be unprecedented, in all of medicine, to grant SC to a single procedure. Since its description by Frederick Mohs, MD, a general surgeon who never had fellowship training, dermatologists have been demonstrating that their level of training in cutaneous surgery and pathology is more than adequate to learn the Mohs technique and to eventually master it. It is pure mythology that this procedure requires fellowship training. With the exception of the introduction of immunohistochemistry for the treatment of melanoma (a controversy in itself), micrographic surgery has not changed at all since the introduction of the fresh tissue technique in the early 1970s.

ACGME accreditation of dermatologic surgery fellowships only began in 2004. Earlier fellowships, such as that initiated by Perry Robbins in 1966, were designed to ensure adequate teaching of the technique. The first truly formal fellowship did not exist until 1997. At that time, formal site visits, slide quality, and diagnostic proficiency were first accessed by the predecessor of the American College for Mohs Surgery (ACMS). Prior to that, fellowships never had the consistent requirements and quality control that we often think of. Despite that, they produced some of the most prominent surgeons working today.

The barrier to learning Mohs surgery was never the difficulty of the concepts or technique, all of which are within the skill set of any board-certified dermatologist. The success of the technique pushed the procedure closer to the center of dermatology training and increasingly it became clear that most dermatologists had the requisite skills to perform Mohs. The best data available indicates that there are no known quality differences between dermatologists practicing micrographic surgery without fellowship training and those with fellowship training (JAMA Dermatol. 2017 Jun 1;153(6):565-570). Today’s state of open knowledge and excellence in MS is an unmitigated success.

Why Not Pursue SubCertification?

In short, we should not pursue subcertification because it will fracture our specialty into smaller factions for no appreciable good reason. In a set of talking points curiously released on the same day as the ABD announcement (the vote was said to be a secret prior to the announcement), the ACMS prompted its members to point out that that SC would not prevent non-certified dermatologists from performing Mohs. Of course, insurance carriers will relish the chance to apply a false rationale to prevent the appropriate use of Mohs. This is happening now in the VA system and comes up frequently with insurance companies, which offer no true rationale for denying coverage other than lack of fellowship training.

In today’s reimbursement environment, third-party payers will do almost anything to increase profits. One way to do so is to restrict the number of providers eligible to bill for a given procedure. SC provides such a pretext. If it becomes a reality, insurers will wield it like a weapon and use it to cut off providers without SC. Restrictions will spread to flaps and grafts; SC will shrink our specialty. Today we have well qualified dermatologists with varied backgrounds in training, performing at the highest level. If the ABD succeeds in having the ABMS certify MDS as a subspecialty, in the absence of bonafide evidence that there are quality issues with the dermatologists practicing Mohs surgery today, dermatology and the flexibility of practice we enjoy today will be irrevocably damaged.

Resisting the Threat to Divide Dermatology

The version of dermatologic surgical SC proposed prior to MDS was called Micrographic Surgery and Dermatologic Oncology (MSDO). The AAD polled its members, not including trainees and international members, in 2017 regarding potential support for an MSDO subspecialty certification. We should carefully review those results as an indication of whether there is significant support for dividing dermatology among those that voted in the poll. With a response rate of 20 percent, 51.2 percent supported the MSDO subspecialty and 48.1 percent did not. (Fig. 1) Dermatologists practicing Mohs surgery were significantly overrepresented in the poll and ACMS members were further overrepresented in that group. Fifty-three percent of respondents practiced Mohs surgery, whereas AAD data indicate that only 20 percent of AAD members practice Mohs surgery. Notably, those responding to the poll and not practicing Mohs surgery opposed the subspecialty 51 percent to 49 percent. None of the data support our profession’s overwhelming (or even lukewarm) support for SC. In fact, it is clear that we are divided over this issue.

While it is true that the ABD certifies subspecialties in dermatopathology and pediatric dermatology, the comparison to Mohs is not parallel. Subspecialties in dermatopathology and pediatric dermatology are necessary in the ABMS certification system. In the case of dermatopathology it is due to the overlap of competencies between two member boards, the American Board of Pathology and the ABD. With regard to pediatric dermatology, ABMS member boards generally certify pediatric subspecialties (as an aside, pediatric dermatology does not have ACGME certified training programs, so the ACGME fellowship argument appears inconsistent). Each of these subcertifications covers an entire specialty, with thousands of diseases, rather than the proposed single procedure.

Can We Trust the ABD?

Initial board certification by the ABD is undoubtedly one of the great professional crowning achievements of a dermatologist. Unfortunately, those who control that board have taken the authority that comes from the support of the profession and used it unwisely. They have demonstrated themselves to be unresponsive in the debate over MOC, initially just ignoring dermatologists until it became clear that the board was at risk of losing legitimacy. Despite engaging in nominal discussion, the leaders of the ABD remain aloof, with its Executive Director recently dismissing my objections by telling me that the ABD board would do “as it sees fit.” Remarkable. Not “what is best for patients or dermatologists,” but as it sees fit. What can only be described as bizarre, he did so after denying that the ABD conducted a survey on SC in Mohs. He did so in front of the entire AAD Advisory Board; in front of many who participated in the survey.

The ABD decided to conduct its own survey after the previously described AAD poll poured cold water over their idea of SC. In the aforementioned ACMS talking points, that group’s leadership misleads its membership by overstating that the approval was well over 50 percent. Presumably they are talking about the 51.2 percent who said that they approve of SC (many of whom were their own members). The ABD, through its Executive Director, has stated that they have no plans to release their survey data on SC. Given their push for SC, it seems likely that their data did not indicate support for it.

What is supported by data is the financial gain that is in store for the ABD should the SC be implemented. Conservative estimates call for an initial group of 3,000 dermatologists to take this exam. If there is a $1,000 charge, revenue is $3 million. One could imagine a cost of double that. This incredible war chest could be used to further subjugate dermatologists. For decades, initial board certification was sufficient for our patients to understand our expertise. We cannot allow a board, that answers to no one, to dictate all aspects of the practice of dermatology.

What Can You Do?

Prior to approving any SC, the ABD must apply to the ABMS for approval. In the coming months the ABMS will hold a comment period. It is essential that all who oppose this superfluous and potentially damaging SC should send comments directly to the ABMS by contacting the ABMS through their website: ABMS.org

The more our colleagues from other specialties hear that the MDS subspecialty certification does not represent the desire of dermatologists to have their specialty fragmented, the less likely it is that the SC will to come to fruition.

Andrew Weinstein, MD, FAAD is in practice at Boyton Beach Skin in Boynton Beach, FL. He is a Fellow of the American Society for Mohs Surgery, of which he is also President.