President's Message
Dear Fellow Mohs College Member,
The first thing I would like to do before going any further is to acknowledge and thank Brett Coldiron for a terrific job not only as our past president but for all the work he has done for the ACMS. His hard work, desire, and passion to make sure that we are fairly reimbursed for our efforts have been nothing short of outstanding. I personally thank Brett and I look forward to his ongoing involvement with the ACMS. No doubt, I will turn to him on a frequent and regular basis for his thoughts and insights. If you were unable to attend the annual meeting in Chicago or unable to attend the business meeting on Friday afternoon, I had the opportunity to present what I refer to as the "ACMS Top Ten Checklist for Success," which I hope will be the cornerstone for my presidency this coming year.
1. Vision and Self Inspection
I think it is important for us to ask where we have been. What is our future direction and how should we rework our strategic goals? We need to focus on the important issues, which are quality patient care and a fair value for the work that we do. It is imperative that we prioritize the needs of our members and be proactive and responsive, ready for any uncertainty and surprises that may occur.
2. Effective Communication
A key concept is to keep our membership informed of what is going on. Currently we have a quarterly newsletter, which has been an excellent addition to providing on-going information to our membership. We also have a recently updated website which I hope all of our members utilize because of the tremendous amount of information that is available. In addition, we recently created a member list serve which will allow members to discuss in real time with other members important issues that may arise, including challenging patient cases or significant political and economic issues. An email message will be sent to you in the near future describing the list serve and how to utilize it. In the meantime, please add the email address: ACMSmember@list.mohscollege.org to your safe senders list as this will be the account that the list serve emails will generate from.
3. Education
One of the things that the ACMS does best is educate our members. Lifelong learning is key to being a competent Mohs surgeon. It is equally important for us to make sure that we also teach the next generation. Our yearly meeting is a great venue and that is why we always have a very good attendance. However, I think that we can add more educational endeavors in addition to our annual meeting. One concept would be to consider smaller regional meetings. These would be scheduled over a weekend with specific topics that allow more audience interaction and participation. Smaller meetings have the potential to be more intimate and to cultivate creative interaction.
The other areas in the realm of education would be webinars and on-line courses. In point of fact, we recently posted talks from the 2012 Mohs meeting on our website, which you may access and review. Preceptorships are also being considered with the ability to open our office to others. I certainly recall what an educational experience it was for me when I would review other fellowship training programs just to see how other Mohs surgeons ran their offices and what they did surgically. In particular, preceptorships for our younger members aligned with a more mature (hate to say "older"), established member could be an excellent combination.
Finally, it will be important to consider lining up support for eventual board certification. I know many of us were disappointed when this did not occur the first time and we ran into some political issues that prevented the support from other dermatologists. However, it is very clear to me - and most of our members - that board certification for ACGME-trained and fellowship-trained Mohs surgeons is what we need for the future success of the AMCS. I am not sure what the appropriate timing for this will be, but already we have set our sights on making sure that we work on gaining the appropriate support.
4. Promotion
We need to drive home the importance of the current skin cancer epidemic and the role of fellowship-trained Mohs surgeons as experts in the care of skin cancer. We are the best trained cutaneous oncologists and surgeons to treat skin cancers and we need to make the public aware of this as well as to educate our fellow health care colleagues. This may require a more substantial marketing effort. Marketing was looked at a number of years ago and was felt to be an expensive endeavor, but there are probably some less expensive ways to get our message across. We need to increase press coverage, so that not everything in the media is always about cosmetic dermatology. We need more press coverage about the skin cancer epidemic and how patients should be diagnosed and treated. With the recent acceptance of appropriate use criteria we can clearly market the fact that Mohs surgery is appropriate, is cost effective, and is performed most competently by fellowship-trained dermatologists.
We have started this process by adding a "Resource Page" on the mohscollege.org website, and an "In the News" page on the skincancermohssurgery.org website. Additionally, with the help of our web marketing team, we have developed a press release relating to the aforementioned topic which has been distributed to local and national media (http://www.mohscollege.org/members/resources.php). We plan to continue with this process and build on it in the coming year.
5. Advocacy
Currently we have a very active public policy committee headed by Brent Moody who is doing a terrific job. We have a lobbyist who is keeping us well-informed and appears to be responsive to our needs. It is my hope that in conjunction with our upcoming meeting in Washington, D.C. we can organize ourselves in a concerted fashion as the pre-eminent skin cancer experts to clearly make the message known about the skin cancer epidemic and the importance of dermatology and Mohs surgery.
6. Research
It is important that we continue to develop new knowledge about skin cancer epidemiology, treatment, diagnosis, and prevention, as well as the creative reconstructive and surgical techniques that we perform. We are beginning to emphasize the need for research in areas of appropriateness of Mohs surgery, cost effectiveness of Mohs surgery and the utility of Mohs surgery for select cancers. We will continue to look at potential interfacing with the Dermatology Foundation but we will strongly support on-going research for the ACMS.
7. Unity
The ACMS is a small group within a small specialty. It is important for us to continue to work with other groups, including the American Academy of Dermatology, the American Society of Dermatologic Surgery, the Association of Professors of Dermatology, as well as patient groups, and local medical and state societies. We have been very fortunate to have a number of our members serve as presidents of the AAD. Ron Moy just finished his presidency, Dan Siegel is our current president and Brett Coldiron will be our president in two years. Having those College members in that position can only help in our effort to work on a united front.
8. Member Engagement
There are a lot of very smart and talented people who are members of our College whom I have yet to meet, and I want to help you be as involved in our organization as you wish to be. I am looking for new ideas so that the ACMS will stay strong and vibrant and meaningful. There are any number of committees that our members can serve on. I am open to any ideas for new task forces or committees. I think it is very important for all members to consider in what fashion they plan to be involved in giving back to the College.
9. Leadership Development
It is important for us to begin now to train the future leaders of the ACMS. This includes supporting our younger members, providing appropriate networking capabilities, and even considering formalized mentorship programs. As the membership gets larger, it will become more and more important for us to support and engage our younger members as we prepare them to be the future leaders of the College.
10. Listen
I will do my very best to figure out what our members need and want. Specifically, what can the ACMS do to help? My goal is to ensure that our members feel that the ACMS provides value and that they are satisfied and proud to be members. I can be reached any time at (585) 737-6892. My office number is (585) 275-9208, and my e-mail is PresidentBrown@mohscollege.org. Below are our officers and board members. Please feel fee to contact any of them at any time.
Vice-president: Scott W. Fosko, MD
Secretary/Treasurer: J. Ramsey Mellette, Jr., MD
Immediate past president: Brett M. Coldiron, MD
Board of Directors:
Sumaira Z. Aasi, MD
Murad Alam, MD
John G. Albertini, MD
John A. Carucci, MD, PhD
Frederick S. Fish, III, MD
Christopher B. Harmon, MD
Gary P. Lask, MD
Tri H. Nguyen, MD
Allison T. Vidimos, MD
Have a great summer, work and play hard!
Sincerely,
Marc D. Brown, MD
President, American College of Mohs Surgery
ACMS Happenings
Photos from the 2012 Annual Meeting are now available on our website!
Congratulations to the newly slated ACMS Executive Committee & Board of Director Members
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| Secretary/Treasurer: J. Ramsey Mellette, Jr., MD (2012-2013) |
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Directors: |
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| Murad Alam, MD (2012-2015) |
Allison T. Vidimos, MD (2012-2015) |
John A. Carucci, MD, PhD (2012-2015) |
Congratulations to the following 2012 ACMS Award Winners
Distinguished Service Awards
The Distinguished Service Award honors individuals who devoted extraordinary time and effort to a particular College-related project, activity, or initiative. This year we thank three members who were instrumental in establishment the Appropriate Use Criteria (AUC).
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| Michael J. Fazio, MD | Allison T. Vidimos, MD | Mark J. Zalla, MD |
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| 2012 - Richard G. Bennett, MD |
Frederic E. Mohs Award for Career Achievement
Richard G. Bennett, MD
The Mohs Award Committee members independently rate candidates for excellence in the following areas:
- Teaching
- Clinical Practice
- Innovation
- Mentorship
- Promotion of Mohs Surgery
Theodore Tromovitch Award
Christopher W. Weyer, DO
Abstract: 'Investigation of Hyfrecators and their In Vitro Interference with Implantable Cardiac Devices'
Congratulations to the Newest Fellow Members of the ACMS
| Michael Abrishami, MD Ayad Abrou, MD Erin Allen, MD Gina Ang, MD Nicole Annest, MD Otter Aspen, MD Brian Baker, MD Jeremy Banky, MD Natalie Bene, MD, PhD Alexander Berlin, MD Sachin Bhardwaj, MD Kelly Bickle, MD Megan Bogart, MD Jeremy Bordeaux, MD, MPH Stephanie Braun, MD Carmen Campanelli, MD Lisa Campbell, MD Ross Campbell, MD David Carlisle, MD Dafnis Carranza, MD Angela Casey, MD Minsue Chen, MD Susannah Collier, MD Bryce Cowan, MD Tejas Desai, DO Michelle Draznin, MD Jeffrey Ellis, MD Amin Fazeli, MD Wade Foster, MD Greg Fulchiero, MD Jorge Garcia-Zuazaga, MD Christopher Gasbarre, DO David Gaston, MD Jason Hansen, MD Robert Hayes, MD Marissa Heller, MD Todd Holmes, MD |
John Huber, MD Eva Hurst, MD Angela Hutcheson, MD M.Amanda Jacobs, MD Joseph Janik, MD Christine Kannler, MD Andrew Kontos, MD David Kouba, MD, PhD Bradley Kovach, MD Heidi Kozic, MD Jessica Krant, MD, MPH Richard Krathen, MD Thomas Langei, MD Brian Leach, MD William Lear, MD Aimee Leonard, MD Ross Levy, MD Linh Lu, MD Mathew Ludgate, MBChB, FRACP Cathy Macknet, MD Kimberly Maino, MD Adam Mamelak, MD Margaret Mann, MD Jason Marquart, MD Paul Martinelli, MD Juan-Carlos Martinez, MD Sheetal Mehta, MD Wendy Mitchell, MD Neil Mortimer, MBChB FRCP FRACP Girish Munavalli, MD, MHS Michael Murphy, MD Ann Neff, MD Julie Neville, MD Steve Obermok, MD Thornwell Parker, MD Brent Pennington, MD Clifford Perlis, MD, MBe |
Greg Persichetti, MD Justin Plasecki, MD Chad Prather, MD Larisa Ravitskiy, MD Kelley Redbord, MD Brandon Rhinehart, MD Steven Ritter, MD Hudson Rogers, MD Amy Ross, MD Ritu Saini, MD Hakeem Sam, MD, PhD Faramarz Samie, MD, PhD Andrew Satchell, MD Aradhna Saxena, MD Carl Schanbacher, MD Jared Scott, MD Lindsay Sewell, MD Monika Srivastava, MD Daniel Stewart, MD, PhD Michael Swann, MD Priya Thakker, MD Valencia Thomas, MD Marta Van Beek, MD George Verghese, MD Justin Vujevich, MD Suneeta Walia, MD Steven Wang, MD Aaron Westphal, MD Robert Willard, MD Andrea Willey, MD Courtney Woodmansee, MD Siegrid Yu, MD Priya Zeikus, MD Ross Zeltser, MD Matthew Zipoli, MD |
Congratulations to the Newest Associate Members of the ACMS
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Robert Anolik, MD Cynthia L. Bartus, MD Priya Batra, MD Todd C. Becker, MD, PhD Andreas Boker, MD Diana Bolotin, MD, PhD Susan L. Boone, MD Navid Bouzari, MD Christopher M. Buckley, DO Michael Campoli, MD, PhD David R. Carr, MD Todd V. Cartee, MD Joanna Chan, MD Jennifer Chwalek, MD Robert H. Cook-Norris, MD M. Laurin Council, MD Hyland Cronin, MD Antonio P. Cruz, MD Aerlyn G. Dawn, MD Krisinda Clare Dim-Jamora, MD Matthew Donaldson, MD Tobechi L. Ebede, MD Kimberly M. Eickhorst, MD Mark Philip Eid, MD Abdel Kader El Tal, MD Scott Freeman, MD Alisa A. Funke, MD Juber Hafiji, MB ChB, MRCP (UK) |
Mandy Harting, MD Aton M. Holzer, MD Kyle Horner, MD Omar A. Ibrahimi, MD, PhD Adam Ingraffea, MD Hooman Khorasani, MD June Kim, MD Nancy H. Kim, MD Brian A. Kopitzki, DO Fiona Larsen, MD Frances K. Lawhead, MD David A. Lee, MD Kristyna H. Lee, MD, MPH Rosemarie Liu, MD Wilfred A. Lumbang, MD Jared Lund, MD Jillian Macdonald, MD Matthew J. Mahlberg, MD Holly H. McCoppin, MD Joseph W. McGowan, IV, MD Jamie E. McInturff, MD Jill McKenzie, MD Tara Miller, MD Mohsin Mir, MD Saira B. Momin, DO Stephanie Myracle, MD Michelle Pennie, MD Anthony Petelin, MD |
Matthew Petrie, MD Theresa L. Ray, MD Ilya Reyter, MD Liliana J. Saap, MD Seema S. Sheth, MD Nicholas R. Snavely, MD Cylburn E. Soden, Jr., MD, MA Michael Sorace, MD Novie Sroa, MD Chadd J. Sukut, MD Cristina I. Tarantola, MD Chad W. Tingey, MD Hien Thanh Tran, MD, PhD Jane Unaeze, MD Rajat Varma, MD Molly M. Warthan, MD Christopher W. Weyer, DO Lucile White, MD Oliver J. Wisco, DO, FAAD Yaohui G. Xu, MD, PhD Molly Yancovitz, MD Christopher B. Yelverton, MD, MBA Jeremy Youse, MD Yue Yu, MD, PhD Alexandra Zhang, MD |
I'm an Associate Member of the College-Now What?
When & How to Apply for Fellow Status of the ACMS
An Associate member of the College in good standing for at least three (3) years is eligible for membership as a Fellow. However, as an Associate member, you can submit your application materials at any time, and the College will hold your application until you are eligible for Fellow membership.
To apply, submit a completed Fellow Membership Application & case log containing 300 cases completed since your fellowship training to the College administrative office at: 555 E Wells Street, Suite 1100 Milwaukee, WI 53202.
Application materials can be found at: http://www.mohscollege.org/acms/membership/joinfellow.php
The deadline for Fellow Membership Applications is August 1st (annually) for review by the Membership Committee. Application review takes place in the winter, and new Fellow members are voted in during the Membership Business Meeting at the College's Annual Meeting.
Highlights from the Literature
Population-Based 20-Year Survival Among People Diagnosed with Thin Melanomas in Queensland, Australia. Adele C. Green, Peter Baade, Michael Coory, Joanne F. Aitken, Mark Smithers. J Clin Oncol 2012; 30(13): 1462-7.
As the incidence of melanoma has increased, and our ability to detect early melanomas has improved, the number of thin melanomas diagnosed each year has also grown. While the prognosis for patients with thin melanomas is considered to be excellent, the specific survival rates and determinants have not been well-studied, and the 20-year survival rates for patients with thin melanomas were actually unknown–until now. The purpose of this study was to determine 20-year survival rates for patients diagnosed with melanomas less than or equal to 1 mm, and to determine the main prognostic factors for those patients.
The authors compiled all available clinical and histologic data from the Queensland Cancer Registry for all patients diagnosed with a single thin invasive melanoma from 1982 to 2006, and matched them against national death registration data. Melanoma-specific survival estimates to December 31, 2007, were assessed, and subgroup differences in prognosis were analyzed using multivariate Cox proportional hazard models.
Included in this analysis were 26,736 patients, aged 15 to 89, with thin invasive melanomas less than or equal to 1 mm, out of a cohort of 44,031 patients with invasive melanoma. Overall 5- and 10-year melanoma-specific survival rates to 2007 were 98.7% and 97.4% respectively, while the 15- and 20- year survival rates were 96.7% and 96.0%. Females had better survival than males overall (98.5% vs. 96.5% at 10 years). Survival generally decreased with increasing age, such that melanoma-specific survival at 10 or more years was below 96.1% for patients aged 65 to 89 at the time of diagnosis. Patients with scalp and neck melanomas had lower long term survival than those with melanomas of the trunk and extremities. Level of invasion below the upper papillary dermis, thickness greater than or equal to 0.75 mm, and acral lentiginous and nodular subtypes were also associated with reduced long-term survival. The impact of ulceration or mitoses could not be assessed, as these features were not routinely included in pathology reports at the time of data collection.
This study constitutes the largest series to date, with the longest follow-up, of patients with thin melanoma. Its significance is enhanced by the fact that its data were derived from a population-based prospective melanoma registry, which is probably more representative of survival outcomes than studies from major melanoma centers with a greater proportion of higher risk patients. The authors have succeeded in stratifying patients with thin melanoma into two groups, low-risk and high-risk, on the basis of two major features: tumor thickness (associated with a four times increased risk of death in patients with melanomas >0.75 mm as opposed to <0.25 mm), and age at the time of diagnosis (associated with a three fold risk when comparing patients younger than age 25 vs. those older than age 65). These results are important because they improve our ability to counsel thin melanoma patients about their long-term outlook. While their chance of long-term survival is very high, a small subset of patients will require greater vigilance in their follow-up, since they are at greater risk of dying of their disease. It may be that we will ultimately recommend sentinel lymph node biopsy for patients with thin melanomas exhibiting more aggressive features, although formal clinical trials will be necessary to define their optimal course of management. As the authors themselves point out, these data provide even more solid justification for continuing efforts to improve early melanoma detection through clinical surveillance and public education, and to reduce melanoma mortality by shifting the thickness distribution of these tumors towards systematically thinner lesions.
Désirée Ratner, MD
Columbia University Medical Center
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
Practice Tips & Efficacy Corner
As of May 2, 2012, the ACMS officially purchased a Leica SCN400 slide scanner which is considered a fast, reliable and flexible way to scan and digitize Mohs slides. Dr. Fred Fish, III, a member of the Board of Directors (2010 - 2013), spearheaded the campaign to purchase this machine due to the benefits that it will provide the ACMS and all of its members for a long period of time.
Dr. Fish allowed us the opportunity to ask him a few questions about the slide scanner to relay to the membership.
1. What was your main drive behind proposing that the ACMS purchase a slide scanner?
The Mohs College has been involved with slide review for a number of years, and we have been looking for a way to streamline and improve the process. The technology has finally arrived so that high quality images can be produced for review by slide scanners. The slide scanner allows for remote review of the slide material once it is scanned in. It permits tremendously greater efficiency and uniformity of review. All reviewers will have the same images to examine, and review can occur either via a conferencing option or individually. The scanner will also provide a platform for developing a teaching library as well as CME programs and educational modules.
2. Describe how the Board vetted and ultimately chose this slide scanner.
The ACMS Board of Directors looked at several brands of slide scanners available on the market. Ultimately, we chose the Leica SCN400 based on its technology, extensive software options and ease of use. In Chicago, while at the ACMS Annual Meeting, we were all give the opportunity to see and view the machine in person and meet with the sales representatives for Leica to make the final arrangements for purchase. Aside from the scanner itself, the Board approved purchase of additional software that will benefit in other areas aside from just basic slide scanning.
3. What do you anticipate being the short-term uses of the slide scanner?
In the short term, at next year's annual meeting, we anticipate having a portion of the DQC exam be computer-based. Ultimately, we will look to phase out the slide/microscope viewing entirely and move to an all-electronic version of the DQC exam.
The slide scanner will be housed in the administrative building of the ACMS (Executive Director, Inc. in Milwaukee, Wisconsin). Once the machine is in place, we will work on establishing training, both for staff and member users. We plan on having several opportunities for training and general overview for College members as to the uses of the slide scanner and how to go about sending in slides, etc. This is very user-friendly technology, which we feel will benefit all members in the long run.
4. What do you anticipate being the long-term uses of the slide scanner?
After the initial education phase, we anticipate there will be a number of long-term uses. We are planning to work with the ACGME and the RRC to establish a slide review program for the ACGME fellowship programs.
Secondly, with the establishment of the Centers of Excellence Program, under Dr. Tom Stasko, the slide scanner will be put to use as an element of establishing a center for excellence. It will allow for a larger volume of slides to be reviewed in an efficient manner with easy access to high quality images for the reviewers.
Thirdly, ACMS is in the processes of becoming CME certified, meaning in the next few years, we will no longer have a third party accreditation service for our meetings and other educational services. This will allow for year-round CME opportunities, not just once-per-year at the Annual Meeting, and we can use the slide scanner to assist in setting up quality control reviews and exams to gain CME credits on an ongoing basis.
Fourthly, an ultimate goal of the slide scanner is to build a teaching library, accessible to all ACMS members. The slide scanner will solve the problem we had in previous attempts to create a slide library, which is decaying stains and compromised slides after a few years in storage. Scanning and storing the slides online will allow for review of slides long after the original slide is no longer able to be interpreted. Additionally, this could open the door for members to send in slides of difficult cases, to be reviewed by a group of peers online.
Fifthly, we hope to work with the RRC and ACGME fellowship programs to develop teaching modules for fellowship training. This will ensure a consistent element of training in pathology across all fellowship training programs.
Last, but not least, we foresee the ASMH (American Society for Mohs Histotechnology) being able to utilize the slide scanner for their MTQA (Mohs Technology Quality Assurance) program. Currently, this program is all manual and is not held as often as it should ideally be.
5. What do you anticipate to be the main benefit for the ACMS having the slide scanner on hand?
The all-encompassing benefit of the slide scanner will be providing the ACMS membership with cutting-edge technology that will facilitate slide review and serve as a platform for improving slide quality, while educating our membership about new discoveries and techniques in pathology that are pertinent to Mohs surgery. This cutting-edge technology will help to ensure that the Mohs College and its members continue to be at the forefront of Mohs surgery.
Fiona Zwald, MD
Emory University
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
Hot Topics of Interest: AUC & RUC Reviews
Where the money comes from, and notes from the reimbursement battlefield.
Most Mohs patients have insurance, and therefore someone else is deciding what you get paid for what you do. That payment is determined by two numbers, and two numbers only: the RVU (relative value unit) and the CF (conversion factor). The RVU for any given CPT code is ultimately determined by CMS (the Center for Medicare and Medicaid Services). The conversion factor is determined by either the government or private insurers, and translates the RVU into a dollar amount. Almost all private insurers use the RVU value as determined by CMS.
Here's the secret, and the reason you should care. CMS gets advice (and usually takes it) on RVU's from a private American Medical Association committee called the RUC (the Resource-based relative value system Update Committee). So, for the most part, one unpublicized committee determines how much you get paid for any given code, relative to all other codes.
So who is this "RUC"?
The RUC is comprised of 31 members, with 21 of those appointed by major national medical specialty societies, and it meets 3 times a year. At these meetings, existing code values are reviewed and refined and new codes are assigned a value. The RUC determines work RVU's, determines practice expense RVU inputs, and comments on professional liability insurance (PLI) costs. CMS takes the work RVU, converts the practice expense inputs into an RVU value, and determines a PLI RVU value. These are added together to produce the total RVU for the code (so work RVU + practice expense RVU + professional liability insurance RVU = total RVU). It is important to note that the RUC does not define codes (that is the job of the AMA CPT committee) nor determine whether codes are paid or not paid (that is the purview of CMS and private insurers). The RUC is the only portal that physicians have for direct input into payment guidelines. More importantly, Dermatology has one of the RUC seats.
Dermatology codes have been called before the RUC recently for review, and the values have been refined (i.e. changed). Recently, the following codes were reviewed: lip biopsy (40490), eyelid biopsy (67810), ear biopsy (69110), regular and frozen section pathology (including 88304, 88305, 88331, 88332), intermediate linear closures (12031 through 12057) and malignant lesion destruction (17260-17286). In addition, other codes of importance to Mohs have been looked at this year. Value recommendations suggested by the RUC to CMS are confidential until CMS publishes any changes in the federal register, and thus can't be discussed. There were also some proposed refinements in the definitions of some of these codes (such as the eyelid biopsy having to include a portion of the lid margin, which is that portion of the eyelid between the lash line and the palpebral conjunctiva), but it is unknown at this point whether CMS will accept the proposed refinements.
Additionally the Federal Register indicates that the actinic keratosis destruction codes (17000-17004) and the Mohs codes (17313-17315) are scheduled for review soon. And here is an important bit about all of this. In general, codes values don't tend to go up. This is because the work RVU component of the code value can only go up if certain RUC standards (known as compelling evidence) are met. Compelling evidence includes such things as a technology change in the procedure, a different specialty doing the procedure now, versus when it was last valued, a change in the patient population, or evidence that the existing value is incorrect (such as having failed to include certain components of physician work). Rarely is compelling evidence met. However, values can also go up or down when practice expense is refined. Practice expense includes both the supplies and staff needed to do any given procedure.
Codes are valued at the RUC using survey data. Likely, you have been asked to participate in a RUC survey. If asked, participation is critical (we need to have a minimum of 30 completed surveys) and the more surveys we have, the more robust and valid our data is assumed to be. As you might imagine, careful completion of the survey is critical, as the data is looked at quite closely. Good surveys do not always mean good values, but bad surveys always lead to bad values. In some cases, the surveys are good and merely show that there is less work in the code than previously thought. In other cases, the surveys appear good but the RUC determines that the values are not believable. But whatever values are ultimately accepted by the RUC may not be accepted by CMS.
The Mohs codes have been a particular challenge when previously looked at by the RUC. Other specialties have difficulty conceiving of the surgeon and the pathologist being the same person. Mohs surgeons get paid to both remove the tumor and repair the defect, which is not true of all similar codes. Due to the outpatient nature of the procedure, there are no operating room logs to refer to. And lastly, utilization of the Mohs codes is increasing every year. While this is at least partially explained by increasing skin cancer incidence, there is concern about "indication creep". While the RUC can't control this, it can try to moderate utilization increases through valuation decreases. In fact, it would be fair to say that CMS and many at the RUC view consistent increases in usage as indication of an overvalued code based on the thinking that if doctors find a code that is relatively lucrative relative to other codes they may use it more.
This is why the recently published Mohs Appropriate Use criteria are so critically important. For the first time Dermatology has taken a public and proactive step based on a well-vetted methodology to insure that utilization of this procedure is consistent with published studies. Hopefully this is a first step toward moderating that portion of the utilization increase that can be moderated. This is critical not only for the good of medicine in general (and Mohs specifically) in a resource limited world, but also to pull the Mohs codes off of CMS screens for procedures that show significant utilization increases. This preserves the Mohs codes for the challenging cases in which Mohs surgery is absolutely needed.
Scott A. B. Collins, MD
ACMS Congressional Briefing
Mohs College Educates Congress on Skin Cancer
More than 40 congressional leaders, legislative staff and advocates learn about the growing skin cancer epidemic.
On May 17, 2012, as part of Skin Cancer Awareness month, the American College of Mohs Surgery (ACMS) sponsored a congressional briefing - Winning Against the Skin Cancer Epidemic - to raise awareness about the growing skin cancer epidemic and explore opportunities to address this escalating health issue through prevention, treatment and public policy. A crowd of more than 40 congressional leaders, including Representatives Scott DesJarlais (R- TN- 4) and Jim Cooper (D- TN- 5), legislative staff, and other advocates, gathered in the Rayburn House Office Building to discover that skin cancer is the most common form of cancer in the United States, impacting more than two million Americans each year, and that more new cases of skin cancer are diagnosed each year than the combined incidence of cancers of the breast, prostate, lung and colon.
Ali Hendi, MD, describes various skin cancer treatment modalities, including Mohs Micrographic Surgery.
Ali Hendi, MD, a private practicing Mohs Surgeon in Washington, DC and Clinical Assistant Professor of Medicine at Georgetown University Medical Center, provided a detailed look at available skin cancer treatment options, including Mohs Micrographic Surgery. Michel McDonald, MD, a practicing Mohs surgeon in Nashville, TN and President of the Nashville Academy of Medicine, followed with statistics on the increasing incidence of skin cancers in the United States, with a focus on growth in the Medicare population. Dr. McDonald also discussed costs associated with various skin cancer treatment modalities and how each treatment compared in term of cost, quality and effectiveness. Brent Moody, MD, a practicing Mohs surgeon in Nashville, TN and Chair of the ACMS Public Policy Committee, concluded with the Mohs surgical community's response to the growing epidemic through high-quality, cost-effective treatment to eliminate skin cancers. Dr. Moody also discussed recent scrutiny by public and private payers and efforts by the Mohs College to educate medical directors, regulators and policy makers on the growing skin cancer epidemic and the value of Mohs Micrographic Surgery in addressing skin cancers.
Members of the audience engaged in a brief dialogue following the informational session, asking about the difference between various skin cancers and sharing personal stories about their experiences and exposure to skin cancer.
The Mohs College continues to educate members of Congress, their staff, and policy makers at the local and national levels, raising awareness to the epidemic of skin cancer and ongoing efforts of the Mohs surgical community to address skin cancer through prevention and high-quality, cost-effective treatment.
Brent Moody, MD and Michel McDonald, MD discuss recent scrutiny by public and private payers on growth in skin cancer treatments with Rep. DesJarlais.
The Occasional Reader
Summer's here. And, judging by the conversations I overheard at the recent Annual Meeting regarding Medicare, Obamacare, family-care, and staff-care, all of you need a vacation–preferably a long one far away from the Internet or Smartphone coverage. The summer edition of the Occasional Reader traditionally suggests reading material with stories good enough to hold attention during long evenings at a rustic cabin or while camping with the lions on the Serengeti. Of course, you don't need me to suggest that you pack Suzanne Collins' successful "Hunger Games" trilogy. You can hardly get through an airport without tripping over a display of those popular paperbacks and frankly, you could do worse, much worse. However, as usual, I will suggest some books, old and new, that remain, "off the beaten path."
First is one of my all time favorite reads. David James Duncan is, in my estimation, one of the most skilled living writers. Many of you may have read or heard of his long novel about family and baseball, The Brothers K. Although I liked The Brothers K, I thought his earlier book, The River Why, was a masterpiece. Written in 1983, the book is, on the surface, simply a fishing story. Frankly, I am not an angler so initially I approached this read with more than a little skepticism. Duncan is a hilarious writer who quickly converted me. While the author has much to say about fishing and rivers and conservation, his "laugh till you cry" insights into families and people are powerful without resorting to sentimentality. I teach this novel in courses pitched to college students and adults and it habitually gets the highest reader approval. (And they are a tough crowd.)
The second suggestion is a more recent novel that has not gotten much press. David Mitchell's Cloud Atlas is fascinating read with an unusual structure. Be forewarned, this is not a novel with a standard Nora Roberts plot line. In the first half of the novel Mitchell tells six stories separated in time from the 1850's to the present. Although the stories are somewhat related, the interrelationship becomes clearer when in the second half of the novel the stories are followed up in reverse order. Complicated? Mitchell's prose style is so strong that each of the chapters could stand alone as a strong short story. Although I like some of the stories far more than others, this book came as a surprise to me–a delightful non-traditional surprise.
I, as I would suppose many of you did, read Willa Cather's O Pioneers in junior high or early high school. This early 20th century author often gets labeled as a "younger person's author" or is simply forgotten in the shadow of her contemporaries Hemingway, Fitzgerald, and Katherine Mansfield. I recently re-read her novel, Death Comes for the Archbishop, following a medical mission trip to Central America. The story concerns the first Bishop of Santa Fe. However, in addition to a wonderful introduction to the New Mexico of 1850–a time when the Spanish territory came into American jurisdiction–Cather explores the clashes of culture. I found her insights current and thoughtful. As I discovered while serving the indigenous people in Guatemala, even coming into another culture with the best of intentions is fraught with difficulties. Cather's book is a delightful read and a reminder that good writing does not go out of style.
Finally, I will make a strange suggestion: this summer, try some poetry. I am not a poet but have come to appreciate a growing number of new writers who are committed to writing poetry that is not the distant, obtuse stuff of my freshman college English class or the province of so-called experts. This is not to say that these new poets write poetry that is trivial or superficial–just the opposite is the case. However, I find that when I slow down, read and ponder, these are words that cut to the heart.
We live in world so crammed with communication that in a numbed state of Google search I forget that facts are not meaning and efficiency rarely presages happiness. These days it is the spare and well crafted word that attracts my attention, a word deftly describing a thing's essence. And it is by such poetic word choice that I am brought up short, and the spell of my well-intentioned tedium is broken. As the poet Elizabeth Bishop says, these are words, "cold deep dark and absolutely clear" which echo throughout my day and are remembered. Take one of the poetry volumes listed below and "waste a few hours" reading by a quiet lake or in the sun dappled woods. Take a deep breath and dwell for time in these poet's keen observations of people and places and issues of their heart. These are not bullet point lectures and you won't know any more about coding or dengue when you are done. Often the poet takes you on a meandering walk seeing what others ignore, wondering where others conclude-trust me, slow down and see the images between the words and you will be challenged and refreshed. Vacations are meant to refresh by slowing down so that the picture can be re-focused. Poetry forces you to slow down and use different ways to see things, different ways to think. Try it, you might like it.
I list some of my favorite poets whose work seems most accessible to first time explorers, in no particular order:
Jeannie Murray Walker: A Deed to the Light or Night Tracks
Mary Oliver: Why I Wake Early
Susanna Childress: Entering the House of Awe
Dana Goia: Pity The Beautiful
Scott Cairns: Philokalia
Anne Doe Overstreet: Delicate Machinery Suspended
Daniel Bowman: A Plum Tree in Leatherstocking Country
Have a great summer and keep reading.
David P. Clark, MD
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