Mohs Around the World
Mohs Surgery in Turkey: An Interview with Dr. Gonca Elcin
By Christie Regula, MD, FACMS
Dr. Gonca Elcin is a dermatologist, Mohs surgeon, and professor of dermatology at Hacettepe University in Ankara, Turkey. ACMS member Dr. Christie Regula interviewed Dr. Elcin about Mohs surgery, training, and challenges for dermatologic surgery in Turkey.
How did you become interested in Mohs surgery?
It was after finishing my dermatology residency training at Hacettepe University in 2000. I had my dermatologic surgery training in Germany where I was a pupil of Ulrich Hohenleutner at the University of Regensburg in 2001. He was the head of micrographic surgery. I had the chance to operate on a large number of skin tumors with the Munich method of micrographic surgery and read the horizontal cut fresh frozen slides with him. I was astonished by the power of micrographic surgery especially when a clinically well-circumscribed, just ordinary looking tumor demonstrated margin positivity under the microscope. I knew for certain that the naked eye was not enough for cancer removal.
Can you tell us a little bit about your training in Mohs surgery?
When I returned to Turkey at the end of 2001 and was appointed as a faculty member at Hacettepe University, I had the mission to establish dermatologic surgery and micrographic surgery in my department.
Although I knew that the Munich method of micrographic surgery was superior to standard excision in terms of achieving tumor clearance, I was always dreaming of a shift to the classical Mohs technique. The Munich method does not use “flattening of the tissue” before freezing. When flattening of the tissue is not applied, then horizontal frozen sectioning must be done from the bottom to the very top of the tissue, and even if you cut vigorously, 100% margin control for the lateral margins can never really be achieved. Mohs was promising 100% margin control with only one slide, but only if I could capture that “flattening.” I was reading again and again in every book about Mohs surgery, and I was watching every video about Mohs surgery trying to capture “flattening,” but I couldn’t until in a dermatology congress in Turkey I listened to Sumaira Aasi. No, the “click” did not happen because of her speech, but the “click” happened in my visit to her Mohs unit at Stanford. I observed her Mohs histotechnician with admiration while he did the flattening of the tissue. It was a magic moment when a three-dimensional structure beautifully laid down on a microscopic slide with only two dimensions. Real magic.
This “click” happened to me in 2012. And in 2013, we left the Munich method (tchüss) and utilized Mohs micrographic surgery in the way it is done in the states. Soon after, in October 2014, I was certified as a micrographic surgeon by the European Society of Micrographic Surgery.
What is the state of Mohs surgery in Turkey?
To understand the state of Mohs surgery, we shall look at the state of dermatologic surgery in Turkey first. In Turkey, there is no dermatologic surgery fellowship program. The only way for Turkish dermatologists to have subspeciality training is to go abroad.
The authority to establish a subspeciality is given by law to the Board of Medical Specialization of Turkish Ministry of Health. Although I believe it is a medical and an educational issue, decisions whether or not to establish a subspeciality are made by political bodies. It is very clear that to have dermatologic surgery as a subspeciality for dermatology remains the most important step in the improvement of the state of Mohs surgery in Turkey.
The Turkish Board of Dermatology and all its commissions are very actively involved in these issues with strong support from the Turkish Society of Dermatology. Yet the problem is not solved.
When you're practicing in Turkey, do you work by yourself? Do you have other physicians that work with you?
I'm proud to tell you that since 2013, I have been able to utilize Mohs micrographic surgery for 10 continuous years, alongside my colleagues Özay Gököz and Serdar Özer in the departments of pathology and ENT respectively, with very good harmony.
Dermatologists in Turkey are not allowed to sign a pathology report. For really complex closures and whenever general anesthesia was necessary, we enjoyed having our ENT colleague with us.
What are the biggest challenges that you feel like you face practicing?
Educating the Mohs histotechnician has been my biggest challenge, and I had to do it more than once. Due to a shortage of personnel employed in the university, I had to train our phototherapy technician as a Mohs histotechnician. And then when she got pregnant, I had to train our cosmetology technician. It was only in our second or third year that we had a real pathology technician specifically hired for this job.
The second big challenge was the nurse. Because dermatology in Turkey is not considered a surgical branch of medicine, it was not easy to employ a nurse with surgical background in the department. A surgery nurse is a real game changer. I was lucky to work with a surgery nurse in only some of my Mohs years, and despaired not to be able to work with one in the remaining years.
Share a little bit about your personal life and your future plans.
There have been life changing events in my personal life very recently. My husband started working at Springfield College in Massachusetts. He became an assistant dean for interprofessional education in the Health Sciences Center. We moved to the states in September 2023. We have a 21-year-old son who is studying theatre at the University of Ottawa, Canada, and a daughter who is 15 and was admitted to the national team for Husky Volleyball. We live in Wilbraham now, and I am retired at least for the present. Surprise: Open to work.
Is there anything else that you would like our membership to know?
I would like to greet every member of the ACMS. It was a memorable experience to be interviewed in the Mohs around the World section of the newsletter. I’ll make a new year’s wish that the ACMS and ESMS come closer to each other, and for the sake of skin cancer patients all around the world they go on applying diversity, equity and inclusion when they are giving scholarships to young dermatologists. I hope the number of scholarships increases. I hope that I may be able to be a “guest” member for the website of the ACMS, at least to read the newsletter. Happy 2024 to all of you.