Mohs Around the World
Mohs Surgery in Colombia
An Interview with Dr. Alvaro Acosta de Hart
By Arif Aslam, MBChB, FRACP, FACD
Dr. Alvaro Acosta de Hart is a dermatologist, dermato-oncologist, and Mohs surgeon at the National Cancer Institute and National University of Colombia. ACMS member Dr. Arif Aslam interviewed Dr. Acosta de Hart about Mohs surgery, training, and challenges for dermatologic surgery in Colombia.
1. Please tell us about your undergraduate training and early exposure to dermatology and skin surgery.
After graduating from medical school in Bogota in 1983, I completed a three-year dermatology residency at the National University of Colombia in 1988, and at that time, Mohs surgery was not available. As a resident, I also spent time in plastic surgery and then realized the crucial role of a dermatologist specializing in skin cancer and skin cancer surgery. In 1991, I travelled to Barcelona for a yearlong self-funded Mohs surgery fellowship with Dr. Antonio Vilalta Solsona. During that year, we completed 200 cases.
2. What did you do after your fellowship?
I returned to Colombia to work at the National Cancer Institute and the National University and at first encountered resistance from plastic surgeons. Despite this, in 1992 I began to perform office-based skin surgery, and it was not until 1997 that I treated my first patient with Mohs surgery. I vividly recall transporting my first section carefully through the entire hospital before reaching the pathology department where, at first, I was treated with caution as I was told it would be impossible to achieve good frozen horizontal Mohs sections. For a further 5 years, I worked in a private setting performing Mohs surgery and complex skin surgery. To refresh my skills and performance of Mohs surgery, I spent a short time in 1995 with Dr. David Lefell at Yale, and then in 1997 I spent time training in dermatopathology in Cambridge, Massachusetts.
3. What is your current work schedule and how do you divide your time between public and private work?
Between 7 am and noon every weekday, I am based at the National Cancer Institute, and the afternoons are spent in my private office. At the National Cancer Institute, I perform Mohs surgery (usually 4-6 cases per week) two days a week, with another two days of Mohs surgery in my private office, which can sometimes include Saturdays too. The rest of my week is spent in academia, multidisciplinary tumor board discussions, and complex skin surgery including teaching. I meet all of my patients prior to surgery who are mostly Colombian, but in my private office, I will see patients from other countries which include Ecuador, Peru, Venezuela, and the US.
4. What are the wait times for Mohs surgery in Colombia?
At the National Cancer Institute, it is four to five months for basal cell carcinomas, but we try to prioritize eye cases for within one month. Privately it can be offered within one to two weeks.
5. Tell me about your reconstructions and any collaborations that you have?
For the first five years, I performed all of my own reconstructions, but nowadays I am sending most of my cases out to plastic surgery or other surgical specialties. The reason for this is that the legislation has changed and does not allow surgical reconstructions to take place in a non-hospital setting, so the ones I choose to do myself are simple. Most of my referrals come from dermatologists with approximately 30-40% from a few loyal plastic surgeons.
6. What is the current landscape for Mohs surgery training and services in Colombia?
At the National Cancer Institute, we provide a certificate valid for two years for training in Mohs surgery with similar training for dermato-oncology and lymphoma. The population of my country is just over 50 million and we have 35 doctors offering Mohs surgery, most of whom have a background in dermato-oncology or dermatology. Colombian dermatologists collaborate regularly to agree upon our own guidelines to determine the risk categories for different types of skin tumors. We only perform Mohs surgery in Colombia on high-risk patients for whom we cannot perform conventional surgery.
7. What are your current challenges and research interests?
The greatest challenges I face, perhaps like many of my Mohs colleagues across the world, is the resistance from surgical specialists and then the lack of wider accessibility for Mohs surgery for those from underserved and poor regions. Another unique challenge I have is dealing with pathologists as legally I must double-read all my Mohs slides with a pathologist. My research interests in published work have been the utilization and safety of tumescent anesthesia and skin cancer surgery. I think this was good research as it meant that in Colombia, the plastic surgeons began to recognize my expertise.
8. Please share with us a little about your personal life and future plans.
I am now 66 years old and have been married for more than 30 years. We have a 25-year-old son, an economist. Time permitting, I try to exercise and enjoy running, cycling, and roller skating - but after an accident, I try to focus on running only. Travel is also a huge passion of mine, and I love to connect with others at international meetings where I try to spend an additional 3 days as a tourist.
Soon, I shall retire from the National Cancer Institute and National University but will remain an Emeritus Professor. Eventually, I shall also step down to a maximum of two days a week in my private office. The rest of my time will be devoted to improving my English and studying world history.