Using Initial Biopsies and Vertical Sections to Improve Trainees' Confidence in Performing Mohs Surgery

BACKGROUND

Tissue preservation and tumor clearance are hallmarks of Mohs micrographic surgery, but no standardized method currently exists to guide trainees on how to balance the two.

OBJECTIVE

The authors provided residents and fellows with additional histologic information to enhance their surgical decision-making without changing the standard methodology of Mohs surgery.

METHODS AND MATERIALS

Trainees were provided initial biopsy slides (IS) and frozen vertical sections (VS) of the first Mohs layer. All Mohs layers were excised in standard fashion, and vertically oriented sections were taken from the layer without disturbing the surgical margins to obtain VS. Surveys were used to assess trainees' confidence in performing Mohs surgery with and without these tools.

RESULTS

Trainees reported increased confidence in performing Mohs surgery when they reviewed IS before surgery and viewed VS of the first layer.

CONCLUSION

Reviewing IS and VS improved trainees' confidence in performing Mohs surgery. This additional histological information was obtained while maintaining the usual steps of Mohs surgery. Objective information obtained from IS and VS may explain why trainees' confidence increased using this technique. Both IS and VS can be valuable teaching tools that may enhance trainees' ability to perform Mohs surgery.

Education and Perspectives on the Use of Oral Skin Cancer Chemoprophylaxis: A Cross-Sectional Survey of Current Fellows in Mohs Micrographic Surgery & Dermatologic Oncology

BACKGROUND

According to the curriculum guidelines of the Accreditation Council of Graduate Medical Education and the American Board of Dermatology, Mohs micrographic surgery & dermatologic oncology (MSDO) fellows must demonstrate competency in the use of oral skin cancer chemoprophylaxis. The current level of education in this area is unknown.

OBJECTIVE

To characterize oral skin cancer chemoprophylaxis education for acitretin and nicotinamide among current MSDO fellows and to compare the clinical indications felt most appropriate for prescribing to a previously published expert consensus.

METHODS

An electronic survey was distributed to all active MSDO fellows by the American College of Mohs Surgery.

RESULTS

Responses were received from 63 (69.2%) MSDO fellows. Twenty (31.7%) and 37 (58.7%) fellows reported receiving fellowship training on acitretin and nicotinamide, respectively. Fifty-seven (90.5%) intend to prescribe chemoprophylaxis after training. Sixteen (28.1%) and 43 (75.4%) report feeling very comfortable prescribing acitretin and nicotinamide, respectively. Fellow concordance with a previously published expert consensus opinion on appropriate prescribing indications is variable. Forty-one (65.1%) indicated that additional education would increase the likelihood to prescribe after training.

CONCLUSION

Although most MSDO fellows intend to prescribe oral skin cancer chemoprophylaxis, a standardized curriculum may promote increased use and concordance with expert consensus recommendations.

Medical Student Decision-Making: Standard Surgical Excision or Mohs Micrographic Surgery to Manage Basal Cell Carcinoma

Context

As future physicians, osteopathic medical students will play a critical role in helping patients make informed decisions regarding treatment options.

Objective

To examine the influence that the time, cost, and cosmetic effects associated with treatment options for basal cell carcinoma (BCC), along with students' demographic characteristics, have on treatment decision-making. The influence that different sources of information have on students was also studied.

Methods

Medical students were recruited from the Nova Southeastern University College of Osteopathic Medicine for this cross-sectional study. Students were presented with a case scenario in which they were a patient with primary nodular BCC in a low-risk zone, and they were asked to select standard surgical excision (SSE) or Mohs micrographic surgery (MMS) as a treatment option. They also completed an anonymous survey that assessed the way that factors associated with the treatment options (time, cost, and cosmetic effects) influenced their treatment choice, along with the influence that different sources of information have. Measures of central tendency, frequencies, and other descriptive analyses were used to define the characteristics of the sample. χ2 analysis, correlational analysis, and t tests were used to examine the associations between the treatment decision, treatment-related factors (time, cost, cosmetics), and year in medical school. Statistical significance was set at P≤.05.

Results

A total of 450 students completed the survey and were included in the bivariate analysis. Three hundred forty-five students (76.7%) selected MMS as a treatment option and 105 (23.3%) selected SSE. Significant differences were found in the influence of time, cost, and cosmetic effects associated with treatment between students who selected MMS and those who selected SSE (P<.001). Cost played a more influential role in treatment decision-making for students who selected SSE than for those who selected MMS. Time and cosmetic effects played a more influential role in treatment choice for those who selected MMS. The most influential sources of information were health care professionals and medical literature, with 398 (88.4%) and 313 (69.6%) students, respectively, indicating that these sources were highly influential when making medical treatment decisions. The internet had a low influence over students' treatment decision-making (238 [52.9%]).

Conclusions

This study represents an initial step toward understanding factors that influence patients' treatment decision-making in a situation in which there is no medically preferred treatment option. The findings point to the importance of time, cost, and cosmetics as influential factors for patients choosing between different treatment options.

Academics or private practice? The future of dermatologic surgery education

BACKGROUND

The career choices of Mohs fellows have important implications for ensuring the quality of dermatologic surgery training during residency. No published data examine the career choices of fellows in Mohs micrographic surgery.

OBJECTIVE

To determine the number of Mohs fellows entering academics and to examine the influence of fellowship characteristics, scholarly activities, and personal background on career decision.

METHODS

A voluntary survey was distributed by mail in June 2004 to all Mohs fellows-in-training during 2003-2004.

RESULTS

Twenty-nine percent (12 of 42) of the fellows chose jobs in an academic or university setting. The practice setting of the fellowship, personal factors, and scholarly activities prior to fellowship did not correlate with career decision. By contrast, increased scholarly activities during fellowship and an interest in teaching did correlate with the choice to enter academics.

CONCLUSIONS

A significant percentage of Mohs fellows pursued academics. Increased academic productivity during the fellowship and an interest in teaching correlated with the decision to pursue an academic career. Fellowship directors interested in encouraging academic careers may find these data useful to structure their curricula and to mentor fellows inquiring about academic careers.

Dermatologic surgery training in residency

BACKGROUND

Dermatologic surgery is an integral part of dermatology residency training.

OBJECTIVE

To characterize the current level of surgical training in dermatology residency programs.

METHODS

A survey was mailed to the 112 dermatology residency programs in North America and Puerto Rico.

RESULTS

A total of 71 residency programs (63%) responded. All programs offer training in surgical excisions, 97% of programs train residents in at least one cosmetic procedure, 92% of programs offer Mohs micrographic surgery, and 90% of programs train their residents in laser surgery.

CONCLUSION

Surgical training in dermatology residency varies widely, with a trend toward more cosmetic procedures when compared with prior studies.

On dermatological surgery, registrars and residents

Training in aspects of skin surgery is now a requirement of general dermatology registrars and residents in the UK and USA, respectively. We compare this component of the training programmes at St John's Institute of Dermatology in London and at New York Medical College in New York City. Because of their understanding of cutaneous pathology, dermatologists are often best qualified to assess patients for skin procedures and should therefore be involved, directly or indirectly, in their surgical management. In our view, the curricula should be changed to place more emphasis on the supervised assessment and treatment of patients with skin tumours as well as to reflect the growing importance of laser treatments and the demand by patients for cosmetic interventions.