Viewpoints with Michael J. Albom, MD

The following is provided by Michael J. Albom, MD, Clinical Professor of Dermatology and Former Head of the Surgery Section at the Charles C. Harris Skin and Cancer Unit within the Ronald O. Perelman Department of Dermatology at New York University Medical Center. Beginning in July 1974, Dr. Albom completed a one year Mohs surgery fellowship with Dr. Perry Robins, who was then the Head of Mohs Surgery in the Department of Dermatology at NYU Medical Center.

1. What sparked your interest in Mohs surgery?

Through the auspices of the Department of Dermatology at Boston University Medical Center, my professor, Dr. Larry Norton, and I, as a third year dermatology resident, provided dermatologic evaluations and care at Pondville Hospital in Massachusetts. This hospital was devoted to advanced cancer patients. We were asked to consult with two patients with basal cell carcinomas of the head who had direct invasion into the brain. These were recurrent lesions secondary to surgery and radiation therapy. In those days, most dermatologists did D & Cs of BCCs. Any lesions larger than a centimeter, especially on the face, were referred to surgeons. Many of the patients with advanced lesions were not followed by their original dermatologists and, as a result, most dermatologists did not see these advanced horrific cases. I asked Larry if he was aware of any other methods of treatment beyond standard surgical excision and/or XRT that could have been offered to these two men before they ultimately developed and succumbed to these incurable advanced BCCs. He knew of Dr. Fred Mohs, but was of the understanding that Fred had a very limited training program, perhaps about 6 weeks in duration. He suggested that I contact Dr. Perry Robins at New York University. Timing is everything in life. I called Perry who told me he was finishing his interviews the next day for the fellowship of 1974-75. I came to New York the following day and was fortunate to be chosen as his next fellow.

2. Tell us about your current practice.

My practice is primarily devoted to Mohs Micrographic Surgery. Over the years, I have performed most aspects of dermatologic surgery including laser surgery, liposuction, hair transplantation, wire-brush dermabrasions, and Botox and fillers. I was the first physician in New York State to use intradermal collagen as a filler substance. As I do very advanced cases of Mohs surgery, I had to have IV sedation available to a subset of patients. I believe I was the first dermatologist in New York City to utilize a board-certified anesthesiologist in an office-based surgical setting. Unfortunately, the in-office services of an anesthesiologist are no longer available to my Medicare patients. The reason for this is the anesthesiologist's reimbursement was so inadequate that it didn't even cover the cost of his IV medications. Except for Botox and fillers, the majority of my practice is devoted to Mohs Micrographic Surgery.

3. What do you enjoy most about your practice?

I still enjoy the interaction with patients. I consider each patient as one who has a cutaneous carcinoma occurring within the context of his or her own unique medical and psychological problems. Also, several patients have significant personal issues that have dramatically impacted their daily existence. This personal history often evolves over time as the patient begins to trust us. In some instances, it has allowed me to have the discussion with patients to consider ways to remedy their personal problems. As Mohs surgeons, we need to always remind ourselves that patients are not simply persons with a skin cancer, but are complex individuals who have a multitude of issues of which we need to be aware in order to optimize communication and maximize management.

4. What do you enjoy least about your practice?

The paperwork is endless and new regulations by government have become very intrusive. Private insurance companies are about as problematic when it comes to documentation and reimbursement issues.

5. Clinically, what do you find challenging at this point?

Many cases are challenging from a unique pathophysiologic standpoint. Many are challenging because the tumors are invading critical underlying vital anatomic structures. I often work with head and neck surgeons, plastic surgeons and radiation oncologists as part of my extended Mohs surgical team. Over the years, it has been very gratifying to have successfully treated many patients who were considered by others to be hopeless cases.

6. What challenges do you foresee the Mohs College and its members facing in the future?

To date, the Mohs College provides the best education for our members regarding the latest advances in our specialty. I believe our high quality Annual Meeting will remain iconic for years to come. Our members are comprised of the finest surgeons from both academia and private practice. All of their efforts continue to make us very relevant in the world of cutaneous cancer. The biggest challenge to our members will be related to the long term viability of our specialty. There are continuing efforts by government and private health insurers to limit or reduce the criteria for doing Mohs surgery as well as their ongoing maneuvers to reduce reimbursements. We will have to remain vigilant and be proactive to protect the long term viability of Mohs surgery.

7. What advice would you give fellows just starting practice?

Look for venues in which to practice that will allow you the most opportunities to develop meaningful experience. That often means starting in an academic center where you will have access to multiple specialists involved with the management of cutaneous cancers. The venue might also be a large multi-specialty clinic. Spend time in the operating room with head and neck surgeons, plastic surgeons and ophthalmic plastic surgeons who can upgrade your knowledge about "living" anatomy especially with regard to structures as the facial nerve, deep muscles and vasculature, anterior orbital structures, etc. Spend time reviewing slides with excellent dermatopathologists especially when you work on complex cases of unique tumors as DFSP, AFX, angiosarcoma, undifferentiated squamous cell carcinomas, etc. Visit an excellent radiation oncologist to actually see how cases are managed with XRT. Prepare for untoward events and have an established plan of action for management. Make every effort to establish a system for long term follow-up. I have attended courses where the Mohs surgeon shows photos of a case with absolutely no follow-up, yet says the patient healed well and was delighted with their results. This is gratuitous nonsense and worse, it is worthless to the education of the audience. Try to standardize your photography and take multiple views of the operative area from close-up to distance with frontal and ¾ views at the very least. Show your problem cases as well so that residents and fellows don't get misled that complications don't exist and that you are the only surgeon who has never had a complication. As the old saying goes, surgeons who say they have no complications are either confabulating or don't do any surgery. Take your work seriously but don't take yourself too seriously. Try to enjoy time out of the office with family and friends. I have yet to meet a Mohs surgeon who has been in practice for over 30 years who wished that he or she spent more time at the office. Good luck on your journey.

8. What do you enjoy doing outside of work (professionally)?

I still enjoy giving lectures and teaching in seminars.

9. What do you enjoy doing outside of work (personally)?

I especially enjoy time with my family. I have a passion for reading, mostly non-fiction. I enjoy music of all kinds because in my earlier life I played the trumpet semi-professionally. Traveling has helped me to appreciate, first hand, the unique aspects of people from a vast array of cultures.

10. What would people be surprised to know about you?

I used to teach ballroom dance. One of my greatest experiences of all time was working with my mother to teach blind teenagers how to dance.

Jeremy S. Bordeaux, MD, MPH