Fellow-in-Training Perspective
Advice from Early-Career Mohs Surgeons on Building a Successful Mohs Practice
By Callie Hill, MD, Fellow-in-Training Board Observer
As we approach the final months of fellowship, I find myself wondering “How can I transition from training to building a Mohs practice?” To answer this question, I had the privilege of interviewing three talented early-career Mohs surgeons who shared their experiences in academic and private practice Mohs surgery. Dr. Basia Michalski-McNeely (Mohs Fellowship: Cleveland Clinic, 2022) is an Assistant Professor in Mohs Surgery and Cosmetic Dermatology at Washington University in St Louis, MO. Dr. Rachel Kyllo (Mohs Fellowship: Northwestern, 2019) is the co-founder of Meramec Dermatology in Arnold, MO. Dr. Blake Phillips (Mohs Fellowship: University of Alabama at Birmingham, 2017) practices Mohs surgery at Total Dermatology in Birmingham, AL. From clinic management pearls to tips on establishing a relationship with referring providers, these surgeons shared applicable advice on navigating practice outside of fellowship.
In your first few years since fellowship, what practice pearls have you acquired that promote efficiency and flow in your Mohs surgery clinic?
Dr. Michalski-McNeely: “Communication is key to promoting effective teamwork. Clear and respectful communication with members of your Mohs team fosters a collaborative work environment and improves efficiency.”
Dr. Rachel Kyllo: “Adequate staffing with superior medical assistants and histotechnicians. Seeing a high volume of patients requires a ‘well-oiled machine’ with staff who are well trained and extremely capable to keep things running on schedule. Take time to cultivate a positive staff culture centered around excellence in patient care. Not all medical assistants that you hire will ‘make it’ - culling the bad apples from your team earlier rather than later is important to avoid other staff members from becoming disillusioned.
“During the first one to two years out of fellowship, you'll learn a ton about yourself as a surgeon and how you prefer to operate outside of training. Listen to your gut feelings those first couple of years and hone your schedule to fit how you want to practice.”
Dr. Blake Phillips: “When starting out a career, sacrifice surgical volume for optimized staff training. Grow slowly and avoid mistakes. Establish clear staff expectations from day one. Spend as much (or more) time improving your team dynamic and staff training rather than improving your personal surgical pace. You should be willing and capable of performing any tasks on the surgical team, but should avoid the potential pitfall of routinely stepping in to complete the tasks when tasks are not performed to your taste (much better to give feedback). It is very difficult to change the expectations of your staff once practice patterns are established. If there are tasks that you would optimally delegate in a high-volume practice, begin delegating them as early as you have the staff in place to do so.”
What is one leadership pearl you have learned through managing staff and a Mohs practice?
Dr. Michalski-McNeely: “Set expectations early - it’s important to establish clinic preferences early on to foster an environment where everyone understands their role.”
Dr. Rachel Kyllo: “There will always be stressful and difficult days. No amount of preoperative planning or discriminative scheduling will prevent bad days from happening. Staff will look to you and mirror your behaviors and attitudes on the most difficult days. Try to always maintain a positive attitude - the focus of your team should always be on delivering excellent care to your patients. The rest will follow.”
Dr. Blake Phillips: “Choose employees based on work ethic and trainability, rather than experience. Reward them well and promote from within, if possible. Your staff determines a good deal of your surgical outcomes and patient experience. Good staff come up with innovative ideas and catch potential errors on your behalf. Allow them to speak freely and promote a culture where they can approach you without feeling intimidated. Ultimately, your name and reputation are on the line for the outcomes from your clinic. Turnover is a costly and difficult problem.”
What is one challenge you faced in your first one to two years of practice—what did you learn and what advice would you pass on from this?
Dr. Michalski-McNeely: “One challenge I encountered early in my practice was managing the balance between clinical, administrative, research, and teaching responsibilities. From this challenge, I learned the importance of prioritization. My advice to others is to embrace time management strategies and don't hesitate to delegate tasks when necessary to maintain focus on patient care.”
Dr. Rachel Kyllo: “We opened our practice 3 months before the COVID19 pandemic hit. It was a very scary time, not knowing whether we would be able to make payroll with clinics essentially closed. We chose not to furlough any employees and guaranteed 40 hours per week of pay to our medical assistants. Our staff was very appreciative of this, and I think it cultivated a sense of loyalty. We knew that eventually the clinics would fully re-open and there would be skin cancers needing treatment. So, I guess the advice I would give is try to keep your long-term strategy in mind always. What's best for your practice in the long term may be uncomfortable in the short term, but that’s OK.”
Dr. Blake Phillips: “I worked at a facility that initially had limited capacity for medical photography. Photography for biopsy site identification/confirmation is crucial for a modern derm practice. Keep a hand mirror in the room to show patients the circled operative site. This ensures that all parties are on the same page, before incision. You will be amazed how often patients point to an incorrect location and require proof from a prior photo. On hairy scalps, look for the shorter hairs to confirm the site.”
Any tips on how to build relationships and market yourself to referring providers when first starting out?
Dr. Michalski-McNeely: “I highly recommend reaching out to local dermatologists, introducing yourself, and sharing information on how to easily refer patients. Additionally, actively participate in local medical and dermatological societies as these will allow you to establish connections. Finally, and most importantly, prioritize patient care. Build a reputation for providing exceptional patient care and you will naturally earn the trust and respect of referring providers.”
Dr. Rachel Kyllo: “Meet with potential referring physicians in person. When you are first out of training, your schedule will be lighter, and you will have time for in-person visits. Bring dessert or lunch for their entire office. Be nice to every staff member you come into contact with. We held an open house and invited all local dermatologists to come see our office when we first opened. Give your referring docs your personal cell phone number and let them know they can reach out to you anytime with questions about your mutual patients.”
Dr. Blake Phillips: “Nothing comes for free. Be willing to take any crappy non-Mohs cases that Mohs referrers want to punt to you. You will gladly excise that atypical nevus on an edematous ankle and hold their hand while it heals for months. You will do the smoker with 15 cheek cysts. Always send folks back to their primary dermatologist and provide timely records for review. I sent hand-written thank you cards to new referrers for the first couple of years.”
What is one piece of advice you can give this class of fellows as we enter the final stretch of fellowship training?
Dr. Michalski-McNeely: “Use these last few months of fellowship to envision yourself operating independently as an attending. Take ownership of all aspects of patient care, from reading slides to designing and executing complex flaps. Begin identifying elements of your fellowship practice that you intend to integrate into your future practice, such as Mohs maps, note templates, and scheduling protocols, to seamlessly transition into your first year out of fellowship.”
Dr. Rachel Kyllo: “If you’re thinking about opening an independent practice, do it! Opening a private practice has been the best decision I’ve ever made. It is definitely possible to do right out of training. There are a ton of resources from the ACMS, AAD, ASDS to help, as well as social media groups to connect with other dermatologists who are independent. Feel free to reach out to me with any questions!”
Dr. Blake Phillips: “Master the skill of technically-excellent layers. Your histotechs will love you, your stages will have fewer false-positives and your turnaround time will improve. Spend more time on mastering pathology than very advanced repairs. Reconstruction is the shiny object of everyone's interest, but the basics of Mohs are skills that remain unique to our subspecialty and critical for cure rates. Don't be the guy that meticulously repairs wounds with positive margins.”
Thank you, Drs. Michalski-McNeely, Kyllo, and Phillips for your words of wisdom. I am encouraged by these leaders and many others, who continue to set high standards in patient care and surgical excellence. To my colleagues finishing fellowship training in the coming months—congratulations and best wishes in your exciting careers ahead!