President's Message
Dear Fellow Mohs College Member,
What a year it has been. We are closing 2012 with change and some uncertainty, but as an organization, the ACMS is still strong and thriving.
In five short months, we will be convening in our Nation's Capital for the 45th Mohs College Annual Meeting. Aside from the outstanding educational program that always comes together, thanks to our Scientific Program Committee, there are several new things to look for at the meeting.
On Saturday night, we will host our first annual ACMS Capital Gala. After discussions with many of you, and responses in our membership needs surveys, we determined that members were looking for more opportunities at the Annual Meeting to socialize and enjoy the time "outside of the classroom" with their colleagues. Be sure to look for this event when registering for the meeting and pack your dancing shoes for D.C. You won't want to miss this evening of fun.
Since we will be in the Nation's Capital, it will allow us a front seat to visit with our advocates and plan meetings with decision-makers on the Hill. Details are still forming relating to the activities that ACMS members may be involved with relating to advocating in the Annual Meeting, but it will certainly play center stage to the meeting as a whole. We will not miss out on this opportunity to promote 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.
As you may recall from the previous newsletter, the ACMS recently purchased a Leica SCN400 Slide Scanner to scan and digitize Mohs slides. One of the uses for the slide scanner will be to digitize the DQC exam instead of using microscopes. The DQC and Teaching Library Committee believes it best to ease into this switch, therefore at the upcoming meeting you will find a portion of the DQC exam computer-based. Ultimately, the DQC and Teaching Library Committee look to phase out the slide/microscope viewing entirely and move to an all-electronic version of the DQC exam.
Lastly, the CME and Education Committee is diligently working on the 2013 Annual Meeting CME in conjunction with the Accreditation Council for Continuing Medical Education's initial application to become our own accredited body by 2014. Since the upcoming meeting will find us in the rigorous accreditation process, you will notice minor changes to the final program as the ACMS fulfills policies and procedures required by the ACCME.
On the topic of meetings, another endeavor that recently passed Board approval is an ACMS regional meeting. Our first regional meeting will likely take place late fall 2013 on the west coast. Our goal is to hold regional meetings on alternate coasts from the current year's Annual Meeting and to provide you with another educational opportunity if you are unable to attend the Annual Meeting. The regional meetings will not count toward your one-meeting-per-three-year guideline to maintain membership in the ACMS, but will offer CME credits for attendance. These meetings will be designed to be smaller, more intimate, with active audience participation. Topics on reconstruction, oncology, pathology and coding will be presented via case presentations, tumor boards, panel discussions, and controversies discussions. Be sure to look for more information relating to the regional meeting in early spring 2013.
As we end this year, the Mohs College has grown another year older and another year stronger through the hard work and dedication of each member. I thank you all for your contributions this and every year. Without you, we wouldn't be where we are today.
Enjoy a great holiday season. All the best to you and your families.
Sincerely,
Marc D. Brown, MD
President, American College of Mohs Surgery
ACMS Happenings
ACMS Fellowship Training Transition to the ACGME Update
History
In 2004, the ACGME approved the dermatology Residency Review Committee's (RRC) request to accredit a new fellowship program that would focus on surgical dermatology. The new program, currently named Procedural Dermatology, is a subspecialty of dermatology that is concerned with the study, diagnosis, and surgical treatment of diseases of the skin and adjacent mucous membranes, cutaneous appendages, hair, nails, and subcutaneous tissue. Applicants to the Procedural Dermatology programs must have completed an ACGME-approved residency in dermatology. Procedural Dermatology fellowships are one year in length.
In October 2007, the ACMS Board of Directors voted to transition the approval and oversight of American programs to the ACGME. This transition was staggered depending on the dates of approval of the program. It began in July 2010 and will be completed July 1, 2013. If an existing ACMS fellowship program has not been ACGME approved by 2013, it will not be recognized by the ACMS and its fellows-in-training will not be eligible to apply for ACMS membership.
ACGME Procedural Dermatology Programs-at-a-Glance
Currently there are 50 fellows-in-training enrolled in 55 ACGME accredited Procedural Dermatology programs (2012-2013). Sixteen ACMS-only accredited programs remain approved through June 30, 2013, 5 of which are international.
ACGME accredited programs are evaluated at least every five years. The period of accreditation or cycle length, is granted by the Residency Review Committee (RRC) and can vary from one to five years, depending on the strength of the program. The average length of accreditation for procedural dermatology programs for 2012-2013 is almost 4 years (3.93).
Role of the ACMS in the Fellowship Training Program
The ACMS remains dedicated to assisting directors and fellows in maintaining the training programs. Of paramount importance is slide quality. To that end, ACMS recently bought a slide scanner to facilitate slide review. ACMS supports an annual meeting of program directors, at which the directors receive current information from the RRC and the ACGME, and are able to have a robust discussion about requirements and their implementation. Information obtained from surveys of directors and fellow-in-training is presented at the meeting. The ACMS also supports and maintains the matching program through San Francisco Match. For the fellows-in-training, ACMS serves as an information source and maintains a formal Grievance Committee set up per ACGME guidelines. Additionally, ACMS still accredits international fellowship programs.
ACGME Resources for Program Directors
A comprehensive visit to the ACGME website is the most important first step for a Procedural Dermatology program director.
Additional Info:
ACGME Dermatology Webpage
ACGME Program Directors "Virtual Handbook"
The American Board of Dermatology, Inc.
American Academy of Dermatology
Suzanne M. Olbricht, MD
Chair, Fellowship Training Committee
ACMS AMA Update
The American Medical Association will be convening for its Interim Meeting in Honolulu, HI from November 10-13, 2012. Delegates from the American College of Mohs Surgery, Drs. Michel McDonald and Divya Srivastava, along with representatives from the American Academy of Dermatology, American Society for Dermatologic Surgery, and Society for Investigative Dermatology will be advocating for Dermatologists' and Mohs Surgeons' interests within the House of Medicine.
It is certainly an interesting and dynamic time for the profession of medicine. With the re-election of President Obama, the country will see the Patient Protection and Affordable Care Act take effect. The AMA delegates will be discussing policies on developing meaningful tools to assess the success of ACA in taking care of patients. Also, innovative ways and resources to expand Medicaid funding and ensure the strength of Medicare in the future will be discussed. In addition, the delegates will explore options for Medicare patients who wish to seek care from non-enrolled physicians.
Several resolutions up for debate are aimed at easing regulatory burdens currently placed on physicians. Some of these policies that pertain to our subspecialty include opposing Medicare penalties for non-adoption of electronic health records, eliminating ICD-10 in favor of moving directly to ICD-11, and opposing Recovery Audit Contractor audits of E+M Codes.
Monika Srivastava, MD
2013 Annual Meeting Preview
Go online in early January to view the following Annual Meeting info
http://www.mohscollege.org/annualmeeting/
- Online registration (opening January 10th)
- Hotel info & links to online booking
- Registration: including Early-Bird reduced registration (through February 18th)
- Preliminary programming for the 2013 Annual Meeting
Planning is well underway to offer an impressive 2013 Annual Meeting
Thanks to the hard work of Chair, Dr. Howard Rogers and the rest of the Scientific Program Committee, there will be numerous additions to the breakfast and general sessions, as well as guest speakers featured at the Annual Meeting.
Several new plenary sessions have been added including Photodynamic Therapy and Mohs for Hard to Access Sites. Also, a variety of new breakfast mini-session topics will be introduced this year: Challenging Cases for the Laser Surgeon in Cutaneous Oncology, Mohs Surgery of the Genitalia and Perineum, The Forehead Flap and Two Stage Nasolabial Interpolation Flap, The Great Patient Experience, and Fine-tuning Your Surgical Scars After the Fact. Sign up early, as all morning mini-sessions will fill up fast.
Friday
- Jack Resneck, Jr., MD, Associate Professor and Vice-Chair of Dermatology at the University of California, San Francisco (UCSF), who specializes in health policy research including examining health system reform, the future of the dermatology workforce, and access to outpatient specialty care, will be a guest speaker in the session, Healthcare Reform Symposium.
Saturday
- Rosalie Elenitsas, MD, Professor of Dermatology and Director of Penn Cutaneous Pathology Services, the dermatopathology laboratory at the University of Pennsylvania, will be joining Dr. Christopher Miller in the session, Dermpath Challenges: Difficult Cases from U Penn, and will be a guest panelist in, Mohs Frozen Section Challenges.
- Kevin Shumrick, MD, facial plastic and reconstructive surgeon from Cincinnati, OH, will be a guest speaker in the session, Nasal Reconstruction of Mohs Surgical Defects and a panelist in the session, How Would You Reconstruct It?
This is shaping up to be an Annual Meeting that you won't want to miss!
The abstract submission deadline is just around the corner
The submission deadline is Tuesday, January 15, 2013 at 11:59 pm PST.
To make your submission visit the ACMS abstract submission website at http://owpm.net/abstracts/ACMS/ for detailed instructions on how to proceed. Only electronic submissions will be considered for review.
For research abstracts to be considered, research must be underway at the time of submission and completed in advance of the meeting. Industry, institution, and author(s) names must not be used in the title or body of the abstract(s). Importantly, all accepted abstract authors and presenters must disclose commercial conflicts of interest in the application. Failure to do so will result in forfeiture. Use of institution names will disqualify the abstract for consideration, as this compromises blinded review. For more information regarding the ACMS abstract rules and processes view the 2013 Call for Abstracts online at: http://www.mohscollege.org/annualmeeting/2013/2013-call-for-abstracts.pdf
For those fellows-in-training: don't forget to apply for the prestigious Tromovitch Award at the time of submission on the ACMS abstract submission site. The award is available only to current fellows-in-training or those who have completed their ACMS approved fellowship within the past year. The recipient(s) of the Tromovitch Award must submit an article suitable for publication in the Journal of Dermatologic Surgery by March 2014. Upon receipt from the Journal of the submitted article, the recipient(s) of the Award will receive complimentary membership dues for his or her first year of membership in the College and free registration at the 2014 Annual Meeting.
We look forward to your contribution.
Highlights from the Literature
Sirolimus and Secondary Skin-Cancer Prevention in Kidney Transplantation. Euvrard S, Morelon E. et al. NEJM 2012; 367:329-39.
The substantial risk of developing cutaneous squamous cell carcinoma (cSCC) in organ transplant recipients (OTRs) is well known, but whether sirolimus is useful in preventing secondary skin cancers has not been systematically assessed until now.
This phase 3, multicenter, randomized, open-label trial included renal transplant recipients with stable kidney function who were receiving calcineurin inhibitors (cyclosporine or tacrolimus) and had at least one invasive post-transplant cSCC. Patients were randomly assigned either to transition to sirolimus or to continue receiving calcineurin inhibitors. The primary endpoint of the study was survival free of new cSCCs at 2 years. Secondary endpoints included the time to onset of new cSCCs, occurrence of other skin and non-skin tumors, and graft function.
From March 2004 to March 2009, 290 cSCCs were diagnosed in 120 patients, of whom 55% had one lesion and the remainder had multiple lesions (average 4.2, range 2-15). 68% of patients developed a total of 274 other lesions, including 68 BCCs, 27 KAs, 90 SCC in situ, and 89 AKs. New cSCCs developed in 14 patients (22%) in the sirolimus group after a median interval of 15 months and in 22 (39%) in the calcineurin-inhibitor group after a median interval of 7 months. The difference between cSCC-free survival in the sirolimus vs. the calcineurin inhibitor group was significant for patients with a single cSCC but not for those with more than one cSCC. cSCCs developed in 6 patients after sirolimus withdrawal, after a maximum exposure of 4.1 months. Metastatic cSCC developed in one patient in the sirolimus group, 6 months after conversion.
Of the 86 patients who completed 2 years of treatment, skin cancers developed in 20 patients (with 71 lesions) in the sirolimus group and in 31 (with 191 lesions) in the calcineurin-inhibitor group (47.6% vs. 70.5%). During the study period, the SCC:BCC ratio decreased from 3.9 to 1.4 in the sirolimus group and from 1.8 to 1.0 in the calcineurin inhibitor group. No episodes of graft rejection occurred. There were 60 serious adverse events in the sirolimus group as compared with 14 in the calcineurin inhibitor group, including edema, acne-like lesions, aphthous ulcers, proteinuria, respiratory symptoms, hematologic abnormalities, and arthralgias.
Importantly, switching from calcineurin inhibitors to sirolimus not only decreased the risk of new cSCCs, but also delayed cSCC occurrence in this transplant population. This antitumoral effect was more pronounced when sirolimus was introduced after the first cSCC occurrence, as opposed to when it was introduced after multiple cSCCs had arisen. Serious adverse events were significantly more frequent in the sirolimus group, but the number of cSCCs in this group was lower by a factor of 3.4. The SCC:BCC ratio decreased in both groups but was more significant in the sirolimus group; the authors speculate that close follow-up ensured removal of premalignant lesions before they became invasive in both populations. Metastases of skin cancers (one case each of SCC, melanoma, and Merkel cell carcinoma) occurred in patients who received calcineurin inhibitors, either initially or after switching back from sirolimus.
The authors postulate that there may be a specific antineoplastic activity of sirolimus, rather than a lower degree of immunosuppression, that explains the decrease in new skin cancers in this population of patients. mTOR inhibitors interrupt the PI3K-AKT pathway, which plays a critical role in regulating cell proliferation, survival, and mobility. They also inhibit growth of endothelial cells and progression of neovascularization, and have been shown to reduce the vascularity and thickness of cSCCs. Since the E6 oncoprotein activates the mTOR1 pathway, it is also possible that sirolimus might act on skin cancers through antiviral mechanisms as has been demonstrated with CMV and HHV-8.
In conclusion, the results of this study suggest that the earlier that the conversion from calcineurin inhibitors to sirolimus occurs after an initial cSCC diagnosis, the greater the efficacy of this regimen in decreasing the risk of subsequent skin cancers in kidney transplant recipients. These findings have important implications for organ transplant patients, and suggest that we should be able to help these patients to decrease their skin cancer risk, not only through the use of sunscreens and sun protective behaviors but also through careful management of their immunosuppressive regimens after transplantation.
Désirée Ratner, MD
Columbia University Medical Center
Viewpoints with Dr. Perry Robins
The following is provided by Perry Robins, MD, Professor Emeritus of Dermatology and former Chief of the Mohs Micrographic Surgery Unit at New York University Medical Center. A pioneer in Mohs Micrographic surgery, he has performed more than 40,000 Mohs surgical procedures. An accomplished educator in his field, Dr. Robins was the first to offer one-year fellowships in Mohs surgery and was also the first to train dermatologists from other countries in the Mohs technique. Dr. Robins is the founder and president of The Skin Cancer Foundation, founder/president of the International Society of Dermatologic Surgery, and former president of the American College of Mohs Micrographic Surgery.
1. What would people be surprised to know about you?
I feel extremely fortunate that I was able to shape and develop the Mohs College to become a worldwide prestigious organization. If it were developed at a later time, it would not be as prestigious and distinguished as it is today.
From the beginning, Dr. Frederic Mohs allowed doctors to come and observe his technique. With no formal instruction, he allowed doctors to spend from a few days to a week observing his technique and after completing the clinic, he would send doctors home with a booklet and a container of zinc paste. After passing through his practice, doctors passing through his clinic would call themselves chemosurgeons.
In 1965, I had established the first professional Chemosurgery Unit and training program at New York University Medical Center, where it was my academic responsibility to train future chemosurgeons in a one-year training program that included anatomy, physiology, anesthetics, oncology, dermatopathology, surgery, prosthetics, and wound repair.
Those that completed a one year training program were well trained and extremely competent to do the procedure, while unfortunately many of those who received superficial training began to give the specialty a bad name through reports of mistakes and misdeeds, which were numerous.
In 1965, I was appointed the first Secretary-Treasurer of a new society formed in Munich, West Germany, during the annual meeting of the International League of Dermatological Societies. This new society was the American College of Mohs Chemosurgery, which is the predecessor of today's American College of Mohs Surgery, and was intended to professionalize the specialty.
In the years following its formation, doctors such as Ted Tromovitch trained residents in chemosurgery, Frederic Mohs continued to run a revolving door training program, which he adamantly refused to close. It was not until the late 1970's that he conceded to train doctors passing through his clinic for a minimum of six months.
With the number of doctors trained by myself and my protégés for periods of one year or more, we were able to create a new minimum baseline of training that has since become standard to the society. At the same time, we also eliminated third year residents from doing the program, as it allowed them to enjoy their third year without making a commitment of an additional year.
By insisting that all trainees have a rigorous year of training, we were able to uphold the high standards that are expected of Mohs surgeons today. If the revolving door which Dr. Mohs insisted on was able to persist (as Mohs wanted to make it accessible to ALL doctors), many doctors would have been unprepared for the challenges in doing skin cancer surgery.
I am proud to see the 1000 members we have in the specialty are well trained and competent to do the procedure.
2. What sparked your interest in Mohs surgery?
In the early 1960's, very few had heard of chemosurgery as a treatment for skin cancer. After reading a few articles by Dr. Frederic Mohs, at my personal expense, I decided to observe Dr. Mohs at his clinic for a month. I felt strongly that his technique should be available at NYU to treat the horrendous skin cancers that were presented at medical conferences held there.
It is also fortunate, that a plastic surgeon, Dr. Hugh Brown, from the United Kingdom travelling on a Fulbright Fellowship, was assigned to our unit, who assisted us in refining our techniques for one year.
3. Tell us about your current practice.
After treating 47,000 patients, I turned my practice over to a young Mohs surgeon, Dr. Ritu Saini, who has done a truly outstanding job in caring for my patients.
4. What do you enjoy most about your practice?
I enjoyed receiving patients from other specialties: plastic surgery, otolaryngology, oncology, and hand surgeons, who have been unsuccessful in treating their patients (some as many as ten times!). It has been extremely rewarding to save appendages, including fingers, thumbs, and genitals, which had scheduled for removal (penectomy).
5. What do you enjoy least about your practice?
I least enjoyed the paperwork . . .
6. Clinically, what do you find challenging at this point?
The greatest challenge is trying to provide a reasonable standard of healthcare to all people in need of it.
7. What challenges do you foresee the Mohs College and its members facing in the future?
I think it is inappropriate to allow vagabond doctors to migrate from office to office to do Mohs surgery. This is forbidden in the plastic surgery field and does less to allow us to maintain the professional standard expected in our field.
8. What advice would you give fellows just starting practice?
For fellows starting a practice, I suggest going to a geographical area in dire need. It will be more rewarding to treat large numbers of patients, than competing in a metropolitan area that has an overabundance of Mohs surgeons.
9. What do you enjoy doing outside of work (professionally)?
Over the life of my professional career, I've started three journals, the Journal of Derm Surgery (which I owned for twenty years), the Journal of Drugs in Dermatology, and the Skin Cancer Foundation Journal; played a role in forming several societies, including the Skin Cancer Foundation, the International Society for Dermatologic Surgery, and the Mohs College; and lectured extensively in over 40 countries in four languages. Today, I continue to run leadership roles in the dermatologic surgery world, as well as Co-Chair the Orlando Dermatology, Aesthetic, and Clinical conference, and editing the Journal of Drugs in Dermatology.
10. What do you enjoy doing outside of work (personally)?
In my personal life, I continue to enjoy philanthropic endeavors outside of dermatology, having founded the Foundation for Children with Learning Disabilities. I continue to participate in outreach programs between the Skin Cancer Foundation and the International Society for Dermatologic Surgery, training doctors and treating patients with skin cancer worldwide in underprivileged areas.
The views expressed above are the personal beliefs of Dr. Robins.
Jeremy S. Bordeaux, MD, MPH
Practice Tips & Efficacy Corner
In recent years dermatology practices, including surgical practices, have seen a shift in their makeup. More and more dermatology practices have integrated midlevel practitioners into their framework to help make their medical practice more flexible and responsive to the needs of patients. According to the American Academy of Dermatology, approximately 30% of dermatology practices have physician assistants or nurse practitioners on their staff. The majority of physician extenders in dermatology practices are physician assistants.
Physician assistants practice medicine with physician supervision. They can perform physical exams, diagnose and treat medical conditions, provide patient counseling, prescribe medication, and assist in surgical procedures including biopsies, excisions, repairs, and Mohs surgery.
In my practice, I routinely work with physician assistants with general dermatology patients, as well as Mohs surgery patients. The physician assistants help evaluate new patients, perform biopsies, perform cryotherapy, prescribe medications, write consultation letters, document the visit, and provide all necessary explanation to patients. They will often see follow-up acne, wart, and eczema patients with minimal supervision. The key to successfully delegating these responsibilities is training. During the first 3-4 months of employment, the physician assistants are extensively trained in the 10-15 most common diagnoses that we encounter in our practice. They are taught how to recognize these disorders, evaluate them, and treat them. Physician supervision is always present and available.
The physician assistants also increase the efficiency of our Mohs practice. Routinely, the physician assistants anesthetize the site after the surgeon confirms the site and they provide hemostasis after Mohs layers are taken. The physician assistants also help with wound closures. This allows the physician to concentrate on removing the cancer, evaluating the pathology, and suturing more complicated wounds.
Other practices utilize physician assistants in different ways. Adding a physician assistant can help to open up regular dermatology slots on days when the physician is performing Mohs surgery. This allows patients to be seen on a more timely basis and may lead to the identification of new skin cancers. Physician assistants can also help with clinical research projects in practices engaging in these types of activities. Again, the key to increased efficiency and productivity is training physician assistants to meet your specific practice needs.
When training physician assistants, it is important to know state regulations. Physician assistants must always practice within the scope of the supervising physician, but may not be able to perform all procedures that the physician does i.e. laser surgery, Botox administration, etc. These rules and regulations vary from state to state.
Medicare and most private insurance plans reimburse physician assistants 75-85% of the rate bestowed to physicians.
In conclusion, well-trained mid-level practitioners, including physician assistants, can help increase the flexibility, productivity, and efficiency of a Mohs surgery and dermatology practice.
Monika Srivastava, MD
Hot Topics of Interest
The Mohs College, Public Policy, & You
Brent Moody, MD, FAAD, FACP, Chair, ACMS Public Policy Committee
William Patrick Davey, MD, MBA, FACP, ACMS Public Policy Committee
Emily L. Graham, RHIA, CCS-P, Vice President, Regulatory Affairs, Hart Health Strategies
Introduction
Now more than ever, the Mohs College recognizes the value of a Washington presence to monitor and influence policies that impact Mohs surgeons and the patients we serve. Toward that end, the ACMS Public Policy Committee (PPC), under the direction of the Board of Directors, has ramped up efforts over the past 18 months to engage with policymakers and regulators, providing the Mohs surgeon's perspective on key issues, such as Medicare coverage and reimbursement, implementation of the Patient Protection and Affordable Care Act (PPACA), and efforts to limit Mohs surgeons ability to effectively diagnose and treat skin cancer.
Impact of the Presidential Election and the Affordable Care Act
Though not by landslide proportions, President Obama defeated Mitt Romney in the Presidential race last month. As a result, it will be challenging to counter the perception that voters have, on the whole, endorsed "Obamacare." The newly reelected President Obama is unlikely to change course on his landmark health care reform law, as the Administration produces mountains of regulations in the upcoming months.
Nonetheless, the impact of the election on Mohs surgeons cannot be overstated. Implementation of the law will continue, including provisions of utmost concern to the Mohs College, such as the Independent Payment Advisory Board (IPAB) and the Value-based Payment Modifier.
The Mohs College continues to take action, proactively addressing the challenges posed by this sweeping health care system reform both in the legislative and regulatory arenas.
Overview of Efforts
Collaborating with our Washington consultants at Hart Health Strategies, we have had some notable impact and successes on Capitol Hill and in the federal regulatory arena. Below, we highlight a few of our most significant accomplishments.
Congressional Briefing on Skin Cancer. On May 17, 2012, as part of Skin Cancer Awareness month, the Mohs College sponsored a Congressional briefing on Capitol Hill – 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.
ACMS PPC Chairman and members, Brent Moody, MD, FAAD, FACP, Ali Hendi, MD, and Michel McDonald, MD, provided a detailed look at available skin cancer treatment options, including Mohs Micrographic Surgery, followed by statistics on the increasing incidence of skin cancers in the United States, with a focus on growth in the Medicare population, and concluded with the Mohs surgical community response to the growing epidemic through high-quality, cost-effective treatment to eliminate 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 with and exposure to skin cancer.
Congressional Skin Cancer Caucus. Working with Reps. DesJarlais and Cooper, the Mohs College initiated the registration of a new Congressional Member Organization (CMO), or "caucus," that would focus on skin cancer issues.
According to the Members' Congressional Handbook, CMOs exist to affect public policy, either directly through policy advocacy for a region or an issue, or indirectly by attracting media attention, or through the socialization and orientation of its members. Nearly all CMOs serve as a forum for the exchange of information.
Despite existing Congressional caucuses with a focus on cancer, the Mohs College maintained that skin cancer had yet to gain the level of attention needed to prompt action in the legislative arena. Given the epidemic growth in skin cancer incidences, a new legislative platform focused exclusively on skin cancer was essential. Members of Congress agreed.
On October 1, 2012, the Congressional Skin Cancer Caucus was approved by the House Committee on Administration. The caucus will serve as a forum and resource for Members of Congress working to address the growing skin cancer epidemic. The caucus will support legislative activities and promote public policies that raise awareness about skin cancer, foster effective skin cancer prevention outreach and education, increase screening and early detection of skin cancer, and improve access to skin cancer care and treatment.
The Mohs College, along with other like-minded organizations and stakeholders, will use this new forum to ensure skin cancer continues to receive the increased recognition in Congress, and higher priority on the Congressional agenda, that it deserves.
Medicare Local Coverage Decisions. Looming Medicare pay cuts and steep penalties for failing to participate in Medicare quality improvement programs sit high on ACMS' list of concerns at the national level. Locally, however, Mohs surgeons face increasing scrutiny by Medicare Administrative Contractors (MACs) about perceived overutilization of the Mohs surgical procedure. Those concerns translate into local coverage decisions (LCDs) that limit Mohs surgeons' ability to effectively diagnose, treat and manage beneficiary skin cancers.
In the northeast, ACMS members coalesced around a draft local coverage decision (LCD) issued by Highmark Medicare (now Novitas Solutions), the MAC responsible for administering the Medicare program in Pennsylvania and other states, that aimed to limit beneficiary access to Mohs surgery on the trunk, arms and legs.
The Mohs College activated members in the region, equipping them with the tools and information necessary to change this course of the unfavorable coverage policy. Mohs surgeons and the local dermatology association engaged in a dialogue with the Contractor Medical Director and dermatology representatives on the Contractor Advisory Committee (CAC), educating them on the growing skin cancer epidemic and the value of Mohs Micrographic Surgery in addressing skin cancers, regardless of body area. Action by this grassroots effort proved successful, as Highmark Medicare's final coverage policy included changes advocated for by the Mohs College. Beneficiary access to the gold standard in skin cancer treatment was preserved thanks in part to the Mohs College and its members.
Value Based Purchasing and Quality Improvement. Over the past several years, public and private payers have been moving toward value-based purchasing, linking provider payments to improved performance. Improved performance is being measured by cost and quality metrics developed and endorsed by a variety of public and private entities, including the American Medical Association (AMA) Physician Consortium for Performance Improvement (PCPI) and the National Quality Forum (NQF). The Mohs College has recently gained a seat at these important tables to provide input on the measures that will eventually be used to determine our "cost and quality" scores, and, ultimately, our Medicare reimbursements.
Alliance of Specialty Medicine. To help further the message of specialty care providers like Mohs surgeons, the Mohs College has joined the Alliance of Specialty Medicine (the Alliance). The Alliance is a broad coalition of national medical societies representing specialty physicians in the United States. This non-partisan group is dedicated to the development of sound federal health care policy that fosters patient access to the highest quality specialty care.
As a small sub-specialty, we recognize that joining forces with other specialists will help us advance our mutual message on a variety of issues, including the Medicare physician payment, regulatory reform, and access to specialty care. The Mohs College maintains that our collective voices as specialty physicians will become a stronger, more powerful tool for influencing legislation and regulation that impacts the specialty physician community and the patients we serve.
Surgical Caucus of the AMA. The Mohs College recently joined the Surgical Caucus of the AMA. According to the American College of Surgeons (ACS), the Caucus provides a forum at each session of the AMA House of Delegates for discussion and recommendations concerning professional and socioeconomic issues of interest to surgeons. Delegates to the AMA from the Mohs College will participate and engage in the surgical caucus, representing and sharing the Mohs surgeon perspective on the important issues and concerns shared with the broader surgical community.
Mohs on IPAB
Among other efforts, the Mohs College has been very active in supporting repeal of the IPAB.
Created under the health reform law, the IPAB authorizes 15 unelected, unaccountable government bureaucrats to develop proposals aimed at containing growth in Medicare expenditures without impacting coverage or quality. Recommendations are unlikely to come until 2018, but it should be noted that most Part A providers, such as hospitals, are out of the IPAB's reach until 2020, making physicians more vulnerable to cuts. Additionally, IPAB recommendations automatically go into effect unless blocked by a Congressional three-fifths supermajority. IPAB members are prohibited from engaging in any other employment; therefore, no practicing physicians may serve on the board. The law further clarifies that a majority of the IPAB must be non-providers.
In March 2012, the Mohs College urged House members to vote "yes" on H.R. 452, the Medicare Decisions Accountability Act of 2011, which would have repealed the IPAB. Shortly thereafter, the Mohs College applauded passage of H.R. 5, the Protecting Access to Health Care Act, which used savings from medical liability reform to fund IPAB repeal.
The American College of Physicians (ACP) has voiced support for the general concept of an independent body developing recommendations to implement payment reform that helps to effectively maintain the fiscal integrity of the Medicare system. Rather than repeal IPAB, ACP has advocated for several modifications, including a requirement that a physician who provides primary care services be allowed to serve.
Unlike ACP, the Mohs College opposes the IPAB in its entirety and supports its repeal. However, the reality is that IPAB may be here to stay. To have any impact on this body, we must look to other options. Toward that end, the Mohs College has identified a potential IPAB nominee: a near-retirement physician with vast experience in both clinical practice and health policy, willing to take on this role.
ACMS' PPC continues to vet a strategy for this option with its leadership and other physician organizations.
How Can Individual Mohs Surgeons Help?
In May 2013, as part of the Mohs College Annual Meeting in Washington, DC, ACMS members will have an opportunity to meet with their Members of Congress and staff as part of a half-day advocacy conference.
To assist Mohs surgeons in their efforts, both in Washington and in their districts, we have prepared a Grassroots Advocacy handbook, full of helpful advice on how to be an effective advocate for your specialty, your practice, and your patients. You can download this colorful and informative brochure from the Government Relations webpage on the Mohs College website.
In addition to hill visits, Mohs surgeons will hear from Congressional leaders and top agency officials about potential modifications and the ongoing implementation of the health reform law.
Conclusion
Our best efforts to influence policy are only that; the Mohs College cannot be successful out its own. We look to you, the membership, for assistance in addressing the critical issues that continue to impact our practices and our patients. Asking busy surgeons to take time out of their day to learn the issues and engage lawmakers in these discussions is never easy, but it is essential if we seek meaningful change in the direction of our nation's healthcare and our ability to continue providing high-quality, cost-effective skin cancer care.
The Occasional Reader
Looking Westward: The Prose of Wallace Stegner
As a result of writing this column my colleagues often corner me at meetings and ask, "How is it you read so much outside of medicine?" My short answer is, of course, that I enjoy reading. However, as with any skill worth mastery, reading genres beyond the technical necessities of our demanding specialty requires an intentional discipline. Perhaps a better question might be, "Why make the effort"? Oscar Wilde once observed, "It is what you read when you don't have to that determines what you will be when you can't help it."
In past columns I have suggested books not found on popular newspaper best-seller lists or prominently displayed at the local Barnes & Noble store–I judge you, my readers, quite able to find these sorts of books. Rather, I desire to perform the function of the now almost extinct local bookstore owner or wise librarian who, like an able diagnostician, carefully listened to the reader's desires and interests before prescribing a reading cure, a cure located in some obscure or out-of-print or overlooked tome. I venture into this Don Quixote-like-quest in the belief that the faculties of imagination and memory and creative association are formed in large part by the stories we read.
Wallace Stegner (1909-1993) ranks both as one of the finest American writers and one of the least well known. Although not nearly as famous as his contemporaries, F. Scott Fitzgerald and Ernest Hemingway, Stegner's prodigious output of graceful, insightful and award-winning prose is at least as great. In addition to producing novels, short stories, novellas, and nonfiction works for over fifty years, Stegner taught Creative Writing at the University of Wisconsin, Harvard, and Stanford. His students included such now well known writers as Wendell Berry, Larry McMurtry, Edward Abby, Gordon Lish, and Sandra Day O'Connor.
One reason Stegner is overlooked may be because he is often categorized as a regional writer. It is true that many of his stories and interests are situated in the American West. Stegner's family homesteaded on the Montana-Canadian border and his early years were spent in what is now considered the last wild frontier of the lower 48 states. Although his writing deals with stories and history situated in the west, Stegner deals with the universal issues of place, meaning, and memory as well as the tension between rugged individualism versus our human need for cooperation. A larger concern found in many if not most of his works involves a consideration of what might be defined as courage or heroism in a less demanding locale or setting that becomes simply a common "way of life" in other more rigorous places or situations.
The author's best known and available works are his Pulitzer Prize winning novel, Angle of Repose (1971), and the 1987 novel Crossing to Safety. However I would suggest that readers enter Stegner's prose by reading Wolf Willow.
Wolf Willow is an intriguing and hard-to-classify weaving together of four individual stories, individual narratives that meld history and autobiography. The author combines a childhood memoir, a haunting coming-of-age novella set in the terrifying Montana blizzards of 1906-07, an adult reflection about returning to a childhood home, and a well-documented history of pre-1920 Montana, in order to give the book a vivid and nuanced view of frontier life in the early portions of the 20th Century.
Book publishers and bookstores find Wolf Willow difficult to categorize due to its use of subjective and objective viewpoints and melding of fiction and nonfiction genres. What is not difficult to apprehend is Stegner's careful and lyrical descriptions of place and persons. This is a master wordsmith's excavation of his memory, a reconstructed geography of a life and world that was hugely formative for the author and remains an ever-present reality still; however this reality remains fugitive, malleable, and provisional.
Stegner writes of the Montana prairie, "Desolate? Forbidding? There was never a country that in its good moment was more beautiful. Even in drought or dust storms or blizzard it is the reverse of monotonous, once you have submitted to it with all your senses. You don't get out of the wind but learn to lean and squint against it. You don't escape sky and sun, but wear them in your eyeballs and on your back. You become acutely aware of yourself. The world is very large, the sky even larger, and you are very small. But also the world is flat, empty, nearly abstract, and in it flatness you are a challenging upright thing, as sudden as an exclamation mark, as enigmatic as a question mark."
C.S. Lewis once said that we read because, " . . . we want to see with other eyes . . . to feel with other hearts, as well as our own . . ." Even now as I re-read Stegner's words in Wolf Willow while looking out on a mountain valley, I feel again the endless wind pushing and shouldering against my face just as when I first stood waist deep in a swirling Kansas wheat field as a teenager. This is prose well worth your time.
Stegner was also a master of the short story, winning the "O Henry prize for the Best Short Story" on three occasions. His Collected Stories (1990) remains the best way for readers to sample his pithy shorter work. My personal favorite novel is the short work, The Spectator Bird (1976). This novel was awarded the National Book Award for fiction in 1977 and can be read in its entirety on a long rainy day or during a day of air travel.
Finally, history lovers might be interested in Stegner's study of John Wesley Powell's explorations and mapping of the American West. His book, Beyond the Hundredth Meridian: John Wesley Powell and the Second Opening of the West (1954) remains a definitive and well-written history of the first white man to explore the Colorado River and Grand Canyon.
Wallace Stegner wrote many other prose gems, but this list should suffice for now. As always, I hope at least one of these suggestions captures your fancy.
Happy reading.
David P. Clark, MD
Volunteerism Survey
Attention ACMS Members:
The ACMS Board of Directors is recognizing members who have volunteered for causes related to the field of dermatology within the past year.
Members will be recognized during the ACMS Annual Business Meeting on Friday, May 3rd in Washington, D.C. as well as in the ACMS newsletter.
Please visit this survey to submit your volunteer activities
ACMS Classifieds
Please contact: info@mohscollege.org to submit a classified for the ACMS Membership Bulletin at no cost to ACMS members. ACMS Classifieds material must be pertinent to the practice of Mohs Surgery and Cutaneous Oncology to be eligible.
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