Annual Meeting Recap

The View from the Back of the Room

"The past is never where you think you left it." ~ Katherine Anne Porter

"The past is a foreign country; they do things differently there." ~ L.P.Hartley

Attending twenty-five straight Mohs College annual meetings is a bit like being married to the same person for a quarter of a century–you must look closer and harder and with considerable charity to discern the new and exciting. Despite accomplishing this attendance feat, I hate to advertise the fact. Seems I've arrived at the age and stage called "veteran Mohs surgeon." This status, I've discovered, situates me more often than I like in a peer group prone to pontificate via the "retrospectoscope." Perhaps I'm too sensitive. However, once the "back in the ole days" discussion gets rolling, I flinch. Don't get me wrong, my colleagues and I had a great ride. But our younger members face far more complex times with uncontrollable variables that were unimaginable when I cut my first layer. We older members probably do new members a disservice by rendering a past doctored with equal amounts of revisionist history and sentimental myth.

Two years ago I wrote an essay on the annual meeting as seen through the eyes of a first time attendee. This year I thought my new prescription glasses–graduated lenses no less–might be just the ticket for a fresh view. Alas, during the first session I found myself in the back of the huge Fairmont hotel auditorium vainly bobbing my head hoping to magnify the speaker standing in the distance–I gave up, headed to a TV monitor located in the back, and found myself standing among old friends and colleagues. These long time attendees–lots of grey or absent hair here–offered an interesting but muffled commentary while leaning against the back wall. I was hearing a simulcast of our college's current "best and brightest" with those that held that honor in the past. The latter viewpoint is not often heard at College meetings: The OF view (standing, of course, for the Old Fogies.)

My, how things have changed. The total attendance at my first College meeting was smaller than the early morning breakfast session I attended. Trying to hear and see 2012 speakers had more in common with watching a Knicks game from the cheap seats-a TV experience. At this rate of College growth I can imagine a JumboTron in our future.

In those old days you really didn't need a program and there were precious few exhibitors. The meeting was more like a seminar led by Dr. Mohs. There were few members and the speakers were mostly Dr. Mohs' early trainees. When a speaker presented, the other speakers would occasionally interrupt and reliably comment at length during the discussion. The discussion would end when Dr. Mohs ambled to the microphone and gave the definitive opinion. To be honest, there was little basic science and few presentations that would pass current muster. Those of us who were the "young guys"-there were only 11 fellowships the year Fred Fish and I finished our training-were expected to be seen and not heard. Casting my eye about this year's annual meeting did suggest one huge improvement from the past "not so great days." Somewhere along the way we Bozos wised up and started training women.

Reconstruction was rarely a topic at those early meetings. The OF's in the back of the room, many of whom headed academic training programs and mentored fellows, were on the cutting edge of developing new and aesthetically elegant reconstructions, visionaries re-creating our specialty into one that did "full-service" cancer treatment. In those early meetings the boasting was like listening to fish stories, a type of, "Guess how big a cancer I took out." These days the discussion has morphed into the complexity and number of flap maneuvers done for a single closure. In the back of the room the very people who championed reconstruction at past meetings showed admiration for many of the demonstrated repairs. But I also frequently heard, "Yes, I know you can do that, but is that much surgery really necessary?" It seems that reconstruction, as with all techniques, is a tension between pushing the envelope and the wisdom of knowing when to limit or not to do a procedure at all.

I was surprised how much attention the "back of the room" crowd paid to the pathology talks. These folks had been looking at slides for a quarter of a century yet stopped their conversations and studied the speaker's projected H&Es. As one OF surgeon said, "The easy ones are just as easy as they always were, but the hard ones just get more difficult." I heard a universal wish for the perfect special stain that would identify the squamous cell needing another layer or the melanoma that had secretly sent off its deadly care package. As one colleague put it, "These people in my practice are friends, I worry more now when I take off a tough one than I used to."

So I ended up sitting with the old guys in the back of the room that, oddly enough, was where I sat for my first ten years. Looking around, we shared those back rows with a lot of new members, members who weren't yet "fellows of the College." Seems each generation of surgeons starts in the back and then gradually moves forward to the speaker's table-only to return to the back of room.

Talking to these new folks I was impressed and surprised. Despite the "clamors of doom" occasionally echoing from the podium, these new members seemed undaunted about government intervention, EMR's, or specialty competition. They simply wanted to know how they could get better, how they could take better care of their patients, how they could make a difference. They were, on the whole, a cocky, smart, ambitious lot (which is pretty much how I would have described those I sat with during my first Mohs College meetings) but these new fellows are starting their careers with far better training and preparation.

It turns out that this year's meeting, notwithstanding its size, diversity of sex and age, and large number of exhibitors wasn't so different from my first. New members still want to know more, learn the newest techniques, and push the envelope and the older members still urge them to seek wisdom. A hopeful sign I think.

David P. Clark, MD