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December 2015 e-Newsletter

President's Message

Dear Colleagues,

I hope everyone had an enjoyable Thanksgiving. Among my many blessings, I count the Mohs College and so many of you who inspire, educate, mentor, innovate and advocate on my behalf and that of the entire ACMS membership. I was reminded of this once again recently at the third Regional Meeting in Napa, CA. Drs. Michel McDonald and Tom Stasko developed a terrific program that included multidisciplinary colleagues in radiology, head and neck surgery, and dermatopathology; a tumor board with cases submitted by attendees; practical pearls with interactive learning formats; a networking luncheon that matched junior and senior members in academics and/or private practice; and even TED-style talks complimented by food and wine!

Preceding the meeting itself, I was fortunate to participate in the Fantastic Flaps course, directed brilliantly by Dr. Deb MacFarlane. A highlight of the hands-on workshop was the incredible head and neck anatomy presentation by Mayo Clinic anatomist Nirusha Lachman, PhD, which included 30 minutes of narrated video of fresh tissue dissections. I concur with several very senior colleagues who described it as the best anatomy lecture they had ever seen. Dr. Lachman is married to a current Mohs fellow-in-training, attended the entire Regional Meeting, and truly understands what we do and how we do it.  She will be an amazing resource for us for years to come. To that end, she has agreed to produce a webinar with the ACMS in early February so all our members can view and access this surgical anatomy material to improve patient care and outcomes. More details will be coming.

Also preceding the Regional program, the Board of Directors held its semiannual meeting. I would like to update you on some key outcomes of that meeting, particularly those Board actions responsive to the Membership Survey, which we examined comprehensively. In addition to demonstrating an unparalleled degree of engagement by our members, the survey also elucidated various levels of understanding or confusion and commitment or indifference to current and proposed strategic initiatives. The Board remains committed to the Strategic Plan and to you, the members, while continuing to adapt to a shifting landscape.

Regarding Public Relations, the Board has approved preliminary funding for Dr. Tom Rohrer’s PR Committee to work with an experienced, committee-vetted PR firm to further develop campaign strategies and determine which short-term tactics might be most appropriate. We will proceed deliberately and thoughtfully, with additional communications prior to any potential assessment or significant financial outlay. But, clearly the membership is anxious for action on the PR front and we have heard this message. Other more immediate communications initiatives that you will see in early 2016 include:

  • The launch of an email and online news brief similar to the AMA and AAD Daily Briefings, but that will be sent less frequently and include those stories and news updates most relevant to Mohs surgeons.
  • A revised and more robust interactive online Job Board for Mohs surgeons, locums, and histotechs.
  • Continued engagement with a company that provides search engine optimization (SEO) to ensure our ACMS website statistics are continuously improving.
  • Development of a state-of-the-art Mohs surgery animation video that can be used to educate patients, colleagues, referring physicians, regulators and legislators about Mohs surgery, its value, and our unique skill set. After showing a fascinating demo to the Board in Napa that Allison Vidimos dubbed “way cool,” Dr. Kenny Omlin generously agreed to collaborate with local Silicon Valley computer animators to facilitate production in concert with the PR Committee.

Our National Registry and Outcomes (NRO) Committee continues to be led skillfully by Dr. Oliver Wisco, and staff member Tammy O’Connell has quickly integrated into her role as coordinator of these quality efforts. The Board is committed not only to ongoing education and communication about the project itself, but also to the critical necessity of data to demonstrate our value in the new health care paradigm.

While the membership survey generally showed strong support for the Registry project, I definitely appreciated some confusion surrounding it and the uncertain downstream benefits, as well as concerns regarding potential costs in both time and money. I would submit that a neutral third party could readily view our fundamental mantras of “fellowship trained,” “highest cure rates” and “best cosmetic results” as self-serving and poorly substantiated. Unless data-proven, I don’t believe we will ever sate the voracious appetite for profit by insurance companies (by restricting access to our care) or for cost containment by government agencies (by reducing indications, reimbursement or case volumes). The Board believes our best path forward involves some method to substantiate our claims of quality, particularly relative to others who may lack any such data. Therefore, I am pleased to report several successes in the last 6 months:

  • Authoritative articles on both Mohs complications and Mohs recurrences will very soon be published that define essential quality metrics, having been developed by the NRO Subcommittees led by Drs. Ian Maher and Justin Leitenberger.
  • Drs. Sarah Arron and Howard Rogers have begun a Phase 1 “Data Field Test” as a preliminary pilot study of the inputs themselves, how easily and accurately the data is actually collected, and how the metrics defined so far withstand these real world conditions in both an academic and private practice setting. The NRO Committee and Board of Directors are firmly committed to a registry that provides the best data with negligible disruption to one’s normal efficient operations. These preliminary test results will be analyzed, adjustments made, and we anticipate a larger, modified Phase 2 “System Pilot” study later next year.
  • A Request for Proposal (RFP) is being developed to determine the optimal final registry solution, which could be an outsourced IT vendor, an internal proprietary ACMS system, or collaboration with the AAD’s DataDerm project. Only then can we begin to develop an accurate budget for the project and further engage in a membership dialogue regarding priorities and capital needs.

As always, there is much to be done as we keenly survey the horizon and anticipate the challenges ahead. But, now is also a time to reflect on the past year: to celebrate achievements, address our shortcomings, fortify our resolve to remain united in our mission, and to express gratitude. I would like to thank our vastly talented and dedicated collection of volunteer members, as well as our highly committed and experienced ACMS staff.

I wish everyone a safe and peaceful holiday season and I look forward to a productive, successful 2016 for the Mohs College.

Yours in service,


John. G. Albertini, MD, FACMS
ACMS President, 2015-16
president@mohscollege.org


2015 Regional Meeting Highlights

Dear Colleagues,

I’m proud to say that the 2015 ACMS Regional Meeting held November 13-15 in beautiful Napa Valley, which combined a richly informative scientific program with numerous opportunities for interaction in and out of sessions, was a resounding success.

Preceding the meeting was a day-long hands-on flap workshop led capably by Dr. Deb MacFarlane, designed for members at least several years out from fellowship training. Guest speaker Dr. Nirusha Lachman, a professor and anatomist from Mayo Clinic, guided participants through anatomical danger points and facial anatomy, while nearly a dozen ACMS member faculty demonstrated skin flap techniques and relevant reconstructive tips. A number of attendees said it was the best anatomy lecture they’ve seen!

Among the meeting highlights was a multidisciplinary session that focused on management of complex cases, not just complex repairs. This session featured Dr. Pedram Gerami, a dermpath expert from Northwestern, who discussed gene expression profiling for prognosticating melanoma; and Dr. Vasu Divi, a head and neck oncology specialist from Stanford, who discussed best practices for collaboration between Mohs surgeons and Head and Neck surgeons in patients with aggressive tumors.

Another highlight was the Grand Rounds, which saw attendees submit in advance a challenging case for discussion. These included a recurrent pleomorphic tumor of the scalp, a spindle cell tumor, and two basaloid tumors.

I know I’m not the only one who genuinely enjoyed the networking lunch on Saturday, during which junior ACMS members had the opportunity to interact with more senior members around table questions that generated meaningful discussion about the future of our specialty.

I want to extend thanks to committee members, Drs. John Albertini, Tom Stasko, Allison Vidimos, Christopher Miller and Jerry Brewer for their support and contributions in planning the meeting. Special thanks also go to the ACMS Officers, Board of Directors, and staff for an incredible job organizing the meeting. 

To view a gallery of photos from the meeting, visit the ACMS Flickr page.

See you in Orlando in April!


Michel McDonald, MD, FACMS
Chair, 2015 Regional Meeting Program Committee


2016 Annual Meeting Call for Abstracts

ACMS members are invited to submit an abstract for consideration of an oral or poster presentation at the 48th ACMS Annual Meeting taking place April 28 – May 1, 2016 at the Rosen Shingle Creek Hotel in Orlando. The meeting will include two categories of abstracts:

1. Scientific abstracts: Original research that addresses the most urgent needs of our patients and the ACMS. Scientific abstracts with a primary author who is a fellow-in-training or who is in his or her first year of practice after completing a fellowship in Micrographic Surgery & Dermatologic Oncology will be eligible for the Tromovitch Award Competition.

2. Rapid Pearls abstracts (NEW!): Two-minute anecdotal pearls regarding Mohs surgery technique, frozen section pathology, reconstructive surgery, or practice management.

See details in the Call for Abstracts

The deadline for abstract submissions is 11:59 pm PST on Wednesday, January 13, 2016.

In addition to abstract submissions, fellows-in-training are invited to submit a case for the Clinicopathologic Case Competition: fellows-in-training may submit clinicopathologic slides and photographs of Mohs cases that have uncommon or rare pathology or that illustrate prototypical diagnostic challenges and keys to diagnosis or tumor detection. These case submissions must be received by the ACMS office by March 1, 2016.  

View the following information on the 2016 Annual Meeting website:

  • Call for Abstracts
  • Welcome letters from the President and Program Committee Chair
  • Program at a Glance
  • Guest speaker biographies
  • Preliminary list of exhibitors

Call for Mohs Award Nominations

The ACMS Board of Directors is requesting nominations for the Frederic E. Mohs, MD Award for Career Achievement.

This award, which was first presented in 2004, is named in memory of the esteemed physician who developed the micrographic surgery technique and founded the College, Frederic E. Mohs, MD. The objective of this prestigious lifetime achievement award is to honor individuals who promote Mohs surgery throughout their career with their teaching, clinical practice, scientific contributions, innovation, mentorship, or service to the organization, in the spirit of Dr. Mohs. The award will be presented at the Business Meeting taking place Friday, April 29, 2016 during the Annual Meeting in Orlando.

Nominations for this award may be submitted by completing the designated spaces in the questionnaire linked below. You can re-enter the questionnaire at any time to update your responses, however nominations must be completed on or before Friday, January 22, 2016.

Enter the nomination questionnaire

If you have any questions, contact Becky Brandt at the ACMS office at (414) 347-1103 or rbrandt@mohscollege.org.


Facial Anatomy Webinar for Mohs Surgeons

Navigating Superficial Anatomy of the Face for Mohs Surgeons
Wednesday, February 3, 2016
7:00-8:00 pm CT
1.00 CME Credit Hour
Webinar will be recorded and materials archived for future access.
Registration opens Monday, January 4. Members will be notified via email.

The webinar will cover facial anatomy relevant to the dermatologic surgeon, highlighting anatomical danger and safe zones through an interactive live lecture supplemented by video footage of dissections of un-embalmed cadaveric specimens. Objectives include:

  • Appreciate the four principle fascial planes of the face
  • Understand how the muscles of facial expression are arranged and attach to the dermis
  • Understand how the SMAS is continuous with platysma, superficial parotid fascia, galea and superficial temporal fascia
  • Review the facial nerve as a principal motor supplier of the mimetic muscles and follow its course in innervating muscles from their deep surfaces
  • Review the trigeminal nerve branches as they exit supra-orbital, infra-orbital and mental foramina on a trajectory toward the skin where they lie within the sub-cutaneous fibro-adipose layer
  • Review course and relations of facial and superficial temporal arteries as the run along a superficial course to cross palpable bony boundaries

SPEAKER: Nirusha Lachman, PhD, is associate professor in the Department of Anatomy, College of Medicine with joint appointment in the Department of Surgery, Division of Plastic Surgery at Mayo Clinic. Her primary focus lies in integrating anatomy education for everyday practice, and she is one of few clinical anatomists in the world who works collaboratively on a daily basis with clinicians in a practice-based setting. In her 20-year career as a clinical anatomist, Dr. Lachman has contributed at least 57 scientific publications in peer reviewed journals, 16 book chapters and numerous abstract publications and national and international presentations.

Related Reading: A Conceptual Framework for Navigating the Superficial Territories of the Face: Relevant Anatomic Points for the Dermatologic Surgeon (Christensen KN, Macfarlane DF, Pawlina W, King M, Lachman N)


Biweekly News Bulletin Coming in Early 2016

In January, the ACMS will begin delivering a new version of the Membership Bulletin e-Newsletter in order to provide important internal news more frequently, alongside the latest news in the field of Mohs surgery.

The current Membership Bulletin e-Newsletter has been sent three times a year, in April, August and December. Because of its infrequency, this delivery model severely limits the inclusion of valuable, real-time news most relevant to busy Mohs surgeons.

Delivered bi-weekly via email, this new ACMS bulletin will serve as a scannable, easily digestible source of news and updates, with short teasers that provide quick summaries of more detailed content available on the ACMS website or elsewhere.

The bulletin will also be available on the newly created News & Notes page of the ACMS website at www.mohscollege.org/news, including highlighted recent or trending articles and a searchable archive containing all past issues. Members can subscribe to an RSS feed if they choose, and can share articles of interest with colleagues via email and social media.

The bulletin will continue to feature, on a semi-regular basis, the same columns you’ve grown accustomed to seeing in the e-Newsletter, including:

  • Practice Tips and Efficacy
  • Viewpoints
  • Highlights from the Literature
  • Hot Topics
  • The Occasional Reader

Internal content will continue to be planned and written by ACMS staff and members of the Newsletter Committee, led by David Clark, MD, MFA, FACMS. The Bulletin will be published in partnership with MultiBriefs, the leading digital media provider for trade and professional associations.

We look forward to your feedback.

NOTE: The bulletin will be sent as an email from acms@multibriefs.com. You are encouraged to whitelist this domain to ensure these messages don’t get caught in your Spam filter.


Updated MohsCollege.org Homepage

In response to feedback from the PR Committee and a desire to better market the ACMS, its members, and Mohs surgery to non-member website visitors, the ACMS developed an updated home page for www.MohsCollege.org that went live last week.

A user can hover over any of the sliding images to stop the rotation if a slide advances too quickly. A button was also added that links to the newly created News & Notes page, which includes short bits of important information and will soon link to the new ACMS Bulletin and archive. Check this page often for important updates.

NOTE: The ‘What Fellowship Training Means’ and ‘Mohs Surgery: The Gold Standard in Skin Cancer Treatment’ images are available for member download here.

 

 


In Memoriam: Georganne Dixon

Former ACMS Executive Director Georganne B. Dixon passed away December 4. She was 70. Dixon retired in 2011 after serving as Executive Director for eight years.

“I have often thought about her since my presidency,” said David Brodland, MD, FACMS, past ACMS president who worked closely with Dixon. “My fond memories include my Monday afternoon teleconferences with her to ‘put out the fire of the day,’ her fierce loyalty to the College and her love of a good laugh. She was an earnest worker, sincere, loyal, likable, and just plain and simply one of the nicest and goodest [improper suffix intended] persons around. She will be missed.”

Leonard Dzubow, MD, FACMS, another past president of the ACMS, said “Georganne was a wonderful and warm human being, and a strong advocate for the Mohs College.”

“Georganne and I worked together on a variety of client executive activities over the years and I always enjoyed it,” said ACMS Executive Director Rebecca Brandt, CAE. “Many of the policies and procedures the ACMS has are a result of her hard work.”

Dixon, who lived in Grafton, Wisconsin just north of the ACMS office in Milwaukee, is survived by her children Andrea Iravani, Sean (Peggy) and Adam (Nikki). She was “Grandma Georganne” to Tanner and Riley and “Nonna” to Virginia, William and Annabelle. She was the sister of Greg (Georgene) Berad, Catherine Berad, Bernadette Berad and Dolores (Steve) Nochese. She is further survived by nieces, nephews, other relatives and friends.

Read her obituary here. The ACMS will be sending a flower bouquet in her memory.


Highlights from the Literature:
Summary of Literature Regarding Electronic Brachytherapy

By Eva Hurst, MD, FACMS

In the July 2015 issue of JAMA Dermatology, Linos et al expressed concern regarding the significant increase in use of electronic brachytherapy (EBT) to treat non-melanoma skin cancer (NMSC).1 While I’m sure many, if not most, of you have been solicited to some degree by the makers of these devices, if you’re like me, at least some of you are wondering just what is the scientific evidence for the use of EBT? I thought in this brief commentary I’d review for you the very limited publications on its use for skin cancer. I also want to emphasize that this represents my personal interpretation and opinion of the literature.

First, what is electronic surface brachytherapy (EBT)? EBT was developed in the last decade and was first used to treat other cancers such as breast and endometrial, and more recently skin cancer. Its advantages include a shorter treatment schedule (40 Gy in eight fraction delivered twice weekly) and the fact that it does not require radioactive isotopes, thus negating the need for dedicated treatment vaults. For physicians, current reimbursement ranges from $16,000 to $24,000 for one skin cancer. A radiation oncologist must be officially involved in the care, and the companies that make the devices recommend that dermatologists contract with a radiation oncologist to administer treatments in the office and submit the claims.

There are to date only three papers reporting on data of EBT for treatment of NMSC.2,3,4 However, two of the papers are actually studies involving the same patient cohort, just expanded in time to include more patients and longer follow-up times.2,3 In his second paper, Bhatnagar reported a mean follow-up of 10 months (range 1-28 months) of 171 lesions in 122 patients with a mean age of 73 years. They reported no recurrences during the time of the study. The authors also assessed “cosmesis,” reporting 93% (of 46 lesions at one-year follow-up) had “excellent” outcomes. Paravati et al just published the results from 154 lesions in 127 patients.4 Median follow-up was 16 months (range 3.4-35). They reported two (1.3%) recurrences and excellent cosmetic outcomes in 94%. Of interest, 22/154 lesions involved sclerosing variants of BCC, and at 26 months of follow-up, one (4.1%) recurred. 

And that’s it for the supportive data! No other long-term follow-ups, and we know from other studies that recurrences in NMSC can often occur four to five years after conventional therapies. Also, no biopsies were done to assess pathologic clearance following treatments; just clinical observation of “clearance” was documented. In the September 2015 JAMA Dermatology, three fellows of ASTRO (American Society for Radiation Oncology) wrote a brief editorial echoing the concerns of Linos et al and calling for more study of this treatment modality.5 In the same issue, we find the first published case report of a recurrence and ocular complication following EBT for a basal cell carcinoma of the left lower eyelid.6 The patient had recurrence 10 months after treatment, as well as conjunctival contracture and lower eyelid ectropion.

As we all know, standard electron-beam radiation therapy provides a viable non-surgical option for NMSC, particularly in the elderly population. Its disadvantages are that it is costly and inconvenient, requiring multiple trips over six weeks. While we all want convenient and safe treatment options for our patients, current long-term efficacy is lacking for electronic surface brachytherapy. Its increase in use is likely at least partially related to the high levels of reimbursement, which far exceed the cost of Mohs micrographic surgery. In addition, the company marketing targets younger patients with touted “painless treatment” for those who “don’t have time for surgery” and want excellent cosmesis.

As more and more patients get treated with EBT for non-melanoma skin cancers and follow-up times increase, I’m sure many of you will see recurrences and/or complications. I encourage you all to collect that data and report or publish it so that we can accumulate more publicly available information regarding this treatment modality in order to educate ourselves, as well as our patients.

References


Practice Tips and Efficacy:
How to Keep Expenses Down, Revenue Up, and Patients Happy

By Joshua P. Spanogle, MD

Running a practice is not easy. With the changing reimbursement climate, keeping margins to a sustainable level can be a challenge. Below, I’ve compiled a list of “quick hits” to keep expenses down, revenue up, and patients happy. Many thanks for tips from Dr. Neil A. Shah of Clarus Dermatology in St. Anthony, MN and Ms. Kajal Shah (no relation), regional manager of Advanced Dermatology and Cosmetic Surgery in Jacksonville, FL.

Staffing

Contract-to-hire
Apple and other companies use this. Try before you buy with employees. For example, offer a 30-day (or 60-, or 90-day) contract employment. If somebody isn't a good fit, the practice doesn’t risk an unemployment filing for termination. The potential hire isn’t offered a permanent position until the temporary contract is up. This allows for flexibility in hiring, i.e., it allows the practice to test for those individuals who will be a good fit. Consider making a big deal when the individual is brought on for a permanent position (embroidered scrubs, key for the door, email account).

Histotechs
No matter the quality of the Mohs surgeon and support staff, a histotech can make or break your day, both in terms of efficiency and quality of care offered. Insist on well-trained techs. Consider contract-to-hire or, at least, a working interview before bringing someone on permanently.

Don’t skimp on staff
At times, practices can be “penny wise and pound foolish.” It can be tempting to skimp on staff to save overhead. As a physician, your job is to see patients and provide excellent patient care. It is not your job to fill out paperwork and compile notes. A little bit of math can help to clarify the situation. Ask yourself how many more patients a day you would need to see to justify hiring an additional medical assistant (probably not many). Also ask yourself how much smoother your day would be if you could just sign paperwork or computer charts and not fill them out. By way of example, Dr. Shah employs 3.5 CMAs for each physician. 

Empower staff
Often, staff spend more time with the patients than the physician does. Additionally, because of the social structure inherent in the physician-patient relationship, staff have a different perspective on the patient experience. A comment or complaint that would never reach the physician may be communicated to a medical assistant, for example. This can be very useful and actionable feedback. Staff can also have unique perspectives on workflow. Is room turnover too slow? Perhaps the staff have suggestions (since they are the ones turning over the room). The key here is that the staff feel empowered. Not only can this make for a more efficient practice and a better patient experience, it can also improve morale. Numerous studies demonstrate that feeling valued is more important than monetary compensation.

Financials

Fee estimates
Provide patients with fee estimates well in advance of their surgical appointment. Make sure prior authorization has been obtained. The last thing you want is to fill the schedule, only to find that patients are cancelling at check-in due to financial reasons. Not only do such cancellations void a surgical slot (which will never be filled), a patient who is blindsided by cost will likely be upset, which is bad customer service. 

Timely submission of claims
Submit claims on the day of service. Simple, right?

Credit card on file
As deductibles increase, practices are getting a higher percentage of the total payment from patients themselves (see “Fee estimates” above). Having a credit card on file helps to ensure payment. An alternative can be that the patient leaves a deposit. Storage of the credit card information can be an issue, but more EMRs are offering this. Besides EMRs, there are other secure vaults for storing credit card information. (SecureNet from Wells Fargo is one example; Stripe is an online vendor offering a similar service). Note that the practice can still work with individuals to break up payments. Overall, having a credit card on file can make collections much easier. 

Scheduling

Referring providers
For Mohs surgery, referring providers are vital. Visit them often. Solicit their feedback. Provide updates on shared patients in a timely manner. Make referrals easy.

Scheduling templates
Check templates in advance of appointments. Make adjustments to accommodate patient wait times. Do you have five cancers on the nose scheduled for Tuesday, and mostly cheeks and foreheads on Thursday? Double-checking the template and making adjustments may make for a more pleasant patient experience and a more pleasant day for the surgeon.  

Reminder calls
These should be placed the day before the appointment, not 2-3 days out. People forget.

Patient experience

Lunch
Consider providing lunch for patients. The Mohs day can be a long one. A sandwich platter can be ordered for patients at the cost of a few additional suture packs. Feeding hungry patients can go a long way towards establishing goodwill.

Empathy
This seems simple, but it can be hard to remember during a busy day. I try to instill in my staff that the patient is most likely having the worst day of his or her week, if not month. It may be routine for us to cut a cancer out of someone’s face, but it is a singular (and stressful) experience for many patients.


Viewpoints:
Challenges for the Newly Minted Mohs Surgeon

By Ashley Wysong, MD

I sat down with several leaders in Mohs surgery at the recent ACMS Regional Meeting in Napa to ask what recent Mohs fellow graduates (<5 years out) should know about the future of Mohs surgery.

When asked about the challenges that face the young Mohs surgeon today, Dr. Marc Brown, Professor at the University of Rochester and a past ACMS president, pointed out that we are currently living in “the most unsettled time” in the history of Mohs surgery. Specifically, he explained that the current payment structures are changing with the expansion of the Affordable Care Act and HMOs as well as with the decline in the number of small private practices.

Dr. Brown anticipates that we will see an increase in large groups/multi-specialty practices and that academic practices, venture capital groups, and large health care systems will continue to acquire smaller practices. He expects that in the long-term there will be “strength in numbers” which is reflected by recent data reporting that less than 5% of recent graduates from ACGME dermatology programs are entering solo practice.

Dr. John Albertini, current president of the ACMS, agreed, stating that “the consolidation effect is real” and that having small, independent dermatology practices will become an increasing challenge in the coming years. Specifically, he observed that an increased size/scale is needed for leverage and negotiations with insurance companies in the era of narrowing networks. He also explained that access to patients will continue to be a challenge for young Mohs surgeons in that “you have to be big enough that insurance companies can’t ignore you.” This is becoming an issue of increasing importance as insurance companies pursue termination of network systems across the country.

As reported in the St. Louis Dispatch in June of last year, Dr. George Hruza, ACMS committee member and past president of the American Society of Dermatologic Surgery, was one of many physicians cut from Medicare Advantage plans by UnitedHealthcare. In addition to deficiencies in insurance coverage, Dr. Brown added that the geographic distribution of Mohs surgeons will continue to play a role in access to care, as “there are too many Mohs surgeons in certain parts of the country, while other areas remain underserved.”

Both Drs. Albertini and Brown recommend that all young Mohs surgeons “know yourself” and find a balance between taking care of patients and micromanaging your practice in the expanding “corporatization of medicine.”  In this ever-changing environment, Dr. John Carrucci, professor and director of Dermatologic Surgery at NYU, encourages young surgeons to “do the absolute best that you can and to make yourself invaluable” to the people with whom you work. Dr. Thomas Stasko, chairman of Dermatology at the University of Oklahoma and current vice president of the ACMS, adds “it [the changing practice environment] has been this way forever. However, now we can see the larger world around us easier and worry about it. We can’t worry about what happens tomorrow, we can only focus on the patient in front of us today.”


Survey Response Requested

The following short survey is being distributed at the request of ACMS members in good standing for the purposes of research/data collection, and has been reviewed and approved for distribution by the Executive Committee of the ACMS Board of Directors. Your responses are appreciated.

Practice Patterns and Job Satisfaction

This survey is part of a fellowship research project at the University of Missouri-Columbia Dermatologic Surgery program. Its purpose is to study practice patterns and job satisfaction among Mohs surgeons.

We aim to determine if there are gender-based practice patterns and factors that influence these patterns. We also aim to determine factors that influence job satisfaction among male and female Mohs surgeons. This study could provide the basis for further studies investigating whether enough Mohs surgeons are being fellowship-trained to meet population needs and what factors might influence trained Mohs surgeons to have longer careers.

The survey is anonymous and should take less than five minutes to complete. The University of Missouri IRB approved this study: IRB# 2003520 HS. For questions, contact the research team at (573) 882-4800,
or the MU IRB office at (573) 884-8596. Thank you for participating and contributing to the education of our fellows!

Sincerely,

Nita Kohli, MD, MPH
Fellow, Micrographic Surgery and Dermatologic Oncology
Department of Dermatology, University of Missouri

Nicholas Golda, MD, FACMS
Medical Director, Program Director
Department of Dermatology, University of Missouri


The Occasional Reader

By David P. Clark, MD, MFA, FACMS

I had the privilege of speaking about books at our Regional Meeting held in Napa, California. After the talk, some members who wield novels in addition to scalpels gathered around and we talked books with the same enthusiasm usually reserved for tumor-free planes and bloodless reconstructions. I made the observation that you could tell more about a reader by what books were on their nightstand than by those colorful tomes found on the coffee table. My companion’s logical question wasn’t long in coming: “Well then, David, what books are on your nightstand?”

What a great idea for a book column!

Before I disclose such intimate details, a few disclaimers are in order. As longtime readers of this column know, I attempt wide-ranging book suggestions; a distillation of my personal reading. But, I do winnow my choices to those well-written books I think might have wide appeal. However, examining the reading material on own nightstand, I wondered if I had contracted a form of literary ADD. Note well: The presence of a book next to my bed does not mean the book would be a usual candidate for The Occasional Reader.

No Ordinary Time: Franklin & Eleanor Roosevelt: The Home Front in World War II
by Doris Kerns Goodwin
This is a long (771 page) but very readable history of the Roosevelt White House during the war years. I am a child of a WWII veteran and have a soft spot for historical scholarship and novels from that period. Books of this length are not recommended in The Occasional Reader because busy surgeons are often put off by the commitment necessary to finish a Doris Goodwin book. However, her books are a joy to read and, for the most part, she has successfully negotiated the compromise between historical details and a narrative arc sufficiently concise for the tired bedtime reader to continue turning pages.

TransAtlantic
by Colum McCann
In a previous column, I reviewed Colum McCann’s award-winning novel Let the Great World Spin. TransAtlantic is McCann’s next novel, and continues this author’s string of excellent novels. In TransAtlantic, an imaginative exploration of connections between Ireland and the U.S., McCann makes use of disconnected stories occurring during different eras. This is a carefully braided novel that provides the reader thicker meanings via juxtaposition rather than explication. McCann is an Irish-born writer living in New York City whose novels explore the space were people of varied cultures are forced to confront each other. In TransAtlantic, McCann has chosen to probe this cultural dissonance through use of actual individuals separated in time (Sen. George Mitchell, Fredrick Douglass) as well as more traditional fictional characters.

McCann is a writer of rare ability and well worth reading. I cannot give away the conclusion of this novel because I haven’t gotten there yet, but I’m anxious to see if this master wordsmith can bring these many story strands to a successful conclusion.

52 Ways of Looking at a Poem: or How Reading Modern Poetry Can Change Your Life
by Ruth Padel
  
This unusual book is the effort of an award-winning poet and poetry critic. The book is counter-cultural. That is, like fine wine, the book needs to be consumed slowly. Padel instructs the reader to engage one short chapter containing a single poem each week. The short chapters are dense, defy skimming, and must be re-read. Often. I am not a poet and can only claim to be a “late to the party” lover of poetry. For those new to the art form, poetry can be off-putting. However, Padel’s effort is the best book I have found that explains poetic basics as well as explicating 52 wonderful modern poems, many by poets I had not previously known. Her commentary is both thoughtful and humbling. Padel clearly loves words and language. Her thoughtful and intelligent prose cannot help but make readers appreciate the poet’s art and our native tongue.

Wearing God: Clothing, Laughter, Fire, and Other Overlooked Ways of Meeting God
by Lauren F. Winner
Lauren Winner is a professor at Duke University, teacher of writing, Episcopal priest, and author of multiple academic and popular books. This book is her readable exploration of metaphor. The author looks at a few of the over 200 different Biblical metaphors for God. Winner points out current and past religious practices tend to utilize two or three particular metaphors in an attempt to describe an infinite God. Winner argues this exclusion of many other metaphors for God used by biblical authors provokes a false sense of control over ideas about God, a false sense that leads to theological distortions and errors.

This book is an intriguing discussion of seldom-heard metaphors for God. God as a laboring woman, God as bread, and God as laughter are only a few metaphors Winner explores with engaging humor and self-depreciation. This book is a scholarly discussion wrapped in delightful and accessible prose. Winner’s books will be provocative, disturbing, and absorbing for those who count themselves religious. But, those less interested in spiritual issues will still find Winner’s command and interest in language and text provides an absorbing read. 

The English Girl
by Daniel Silva
The last book on the stack is a detective/espionage thriller. Silva is a master of the genre, and this is the 13th in the series with “hero” Gabriel Allon as the protagonist. Allon is an Israeli assassin and art restoration expert who comes to the aid of the British government. No great literature here, but the novel is a good tale, well told.

The Mad Feast: An Ecstatic Tour Through America’s Food
By Matthew Gavin Frank
Food writing often places too much emphasis upon glossy images rather than useful advice. These irresistible glossies often enticed me to buy these books imagining in some alternative life I might have the time or skill to reproduce the suggested recipes. If I do try and reproduce the suggested recipes I often discover the author failed to describe the technique fully or failed to mention a key issue. Matthew Frank has taken the food writing path less traveled. This is first a food book of words; 50 erudite, lyric essays about food. Oh yes, there are 50 interesting recipes, but not a single photo.

The author has provided a single recipe for each state in the Union. But more than a simple iconic example of local cuisine, Frank tells the reader more than they could imagine about the local context for the food. From discussing Beaver Tail Stew in Arkansas to Hoosier Cream Pie, we learn bizarre, eclectic, and outrageous information about each food and locale. This is a book of fun prose and one of the most enjoyable and unique reading experiences I have had in recent years.    

So, there you have it. What are you reading? My holiday wish? Find a book out of your usual comfort zone and put it on your nightstand—it will provide you some moments of relief after a full day of surgery. The best of reading to all. 


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