Save Us

“Those who know what’s best for us…must rise and save us from ourselves”

—“Witch Hunt” from Rush, Moving Pictures side B

Having just completed my 20-year board-recertification exam, I am amazed how much I have learned, and, even more, how much I have forgotten. Isn’t that a bumper sticker testimonial for taking time to prepare? And yet when I think about the syndromes and conditions I may never see in this lifetime, at least the nuts and bolts of my daily patient care were part of the mix, otherwise it would be hard to objectively call me “certified.” I have been referred to as a Greek diner of dermatology, lots on the menu but not one stand-out item (or “done well” according to some).

The flip side to this is somewhat intriguing: I still see children and elderly patients, I read my own dermpath slides, I perform surgical procedures to remove benign and malignant tumors from the skin, I perform aesthetic procedures, and I participate in clinical trials to bring new medications into dermatology practice. Freezing a wart, doing a shave biopsy correctly, or even using a comedone extractor were not part of the test…is there a measure, in my now 20^th year of practice, that I am doing these procedures to an acceptable standard? Or should I have to leave practice, perform fellowships to specialize in each of these procedures, and meet a mythical level of proficiency that allows me to pay for certification to prove I can do what I have been doing for years? What’s next, the KOH Fellowship?

To now have a motion on the table to have to be recognized as “certified” to treat skin cancer should be concerning to the rank-and-file dermatologist. Even more concerning, as discussed by American Society for Mohs Surgery (ASMS) President Andrew Weinstein, MD in a recent issue of Practical Dermatology® magazine, is to mandate a certification to perform a single procedure, Mohs Surgery, which is part of basic training at many residency programs and, as demonstrated by its general surgeon pioneer from Wisconsin, can be performed by those who train with proficiency. (Read the article at practicaldermatology.com/2018/04.) As Dr. Weinstein summarized, the American Board of Dermatology (ABD) intends to mandate that any board-certified dermatologist who wants to perform Mohs Surgery for treating skin cancer be up to date in an even more dedicated MOC, demonstrate “experience” in the subspecialty by either completing the ACGME-approved fellowship out of residency or during an initial five-year practice pathway eligibility period, then passing the certification examination.

If one does the math, this means leaving practice for a year, impacting patients, overhead, employees, and income, in addition to competing with residents for a spot in the fellowship process, and probably having to demonstrate proficiency to someone who has been practicing for less time. As was pointed out to me by ASMS executive James A. Schiro, MD, many more ASMS Mohs surgeons practice in rural areas compared to those who are ACMS-fellowship trained, which would create a significant access issue for a specialty already perceived to not provide availability to patients. Ironically, as the article explains, since Mohs fellowships have been accredited starting in 2004, many of those practicing today would have been proficient long before a certificate was even available.

I have a hard time making sense of this. Quality assurance is one thing, demonstrating proficiency in our daily practice to assure best patient outcomes is inherent, and taking an exam once every 10 years to prove that we are better physicians than Dr. Google is fine and an understood necessity. However, we cannot let insurance companies, medical credentialing boards, the media, or even our patients, create unnecessary restrictions on us that sabotage our livelihood. We have become very proficient at taking an extra layer out of our own specialty—it should not be left up to those with no concept on how to construct the repair. Just think how many bean counters will be undercutting us—no pun intended—when Average Joe Derm, not board-certified to perform surgery by his own governing agency, won’t get paid for work done or will have to send patients miles away for months-long waiting lists to be treated. (Ah yes, I hear “O Canada” in the background as I write this.)

This is not the time to turn on each other—there is enough of that already at advisory boards and on social media—or to engage in the turf wars about who should read slides or cut out skin cancer. Unfortunately our track record for advocating for ourselves is not great—we average about 30 percent voter turnout despite 100 percent complaining turnout, and we average less than that for completing surveys that matter or showing up at legislative conferences, the open Advisory Board at the AAD, or any other opportunity to represent our specialty. Dr. Weinstein pointed out that when the AAD sent out a 2017 survey about the MSDO subspecialty certification, there was a response rate of 20 percent, and within that it was 51.2 percent in favor vs 48.1 percent against. How is this what we want for ourselves? A test for quality assurance is one thing, stopping the bus and going back to school is another…and a lot to ask.

If we start here—even though only 20 percent of us perform the Mohs Surgery procedure—what are we going to do next to choke our already suffocating specialty? Don’t we have our hands full with those who already try to do what we do without any training? Don’t we have enough headaches from the social and antisocial media, the bureaucrats who want to poach our incomes and integrity, and the sabotage from critics, aka patients? We don’t need another certificate—what we need is to support our specialty.

Those who know what’s best for us…should be us.

—Neal Bhatia, Chief Medical Editor