Fellow-in-Training Perspectives

Each annual Fellow-in-Training Board Observer also serves as a member of the ACMS Newsletter Committee in order to participate in discussion of, and provide valuable perspective on, College activities and news for other fellows-in-training. Below are their contributions.

Winter 2018: Use of Digital Patient Photography for Surgical Site Identification
Summer 2018: A Roadmap to Navigate the Year of Fellowship Training
Spring 2018: What Fellows-in-training Should Know About the Transition from Trainee to Independent Practitioner
Winter 2017: Staging of Melanoma and SCC in the AJCC 8th Edition Cancer Staging Manual
Summer 2017: Tools and Resources for Continuing Education
Spring 2017: Words of Wisdom: Advice from Successful Mohs Surgeons
Winter 2016: Did You Know? ACMS Resources Available to Fellows-in-Training

Winter 2018

Use of Digital Patient Photography for Surgical Site Identification

By Thomas S. Bander, MD • 2018-19 FIT Board Observer

Many fellows start their morning with the time-honored tradition of searching for an elusive biopsy site among a sea of actinic keratoses, biopsy scars, and lentigines. There are many reasons for patient misidentification of biopsy sites. Sometimes a lesion on the scalp or back is “out of sight, out of mind.” Other times, patients expect that their referring dermatologist will communicate with us to ensure a smooth consultation. Regardless of the reason, it is frustrating to be derailed from our normal workflows by biopsy site uncertainty.

A review of the literature reveals that patients misidentify their surgical sites about 9-29% of the time. A time interval of six weeks or more between biopsy and surgery, multiple biopsies at the same visit, and patient inability to see the biopsy site are risk factors for biopsy site misidentification. Many surgeons have turned to digital photography to prevent surgical postponement or more serious medical errors, such as wrong-site surgery. At our institution, every patient is asked to send a “selfie” at the time of their referral, which serves both to remind patients of the location and to capture an image of the site before it completely heals. Of course, not all patients are technologically savvy enough to send a photo, and we receive our share of blurry selfies. Nevertheless, we and our patients often gain valuable information from the photos.

In addition to verifying surgical sites, patient photographs are useful for monitoring concerning skin lesions over time, tracking surgical and cosmetic outcomes, explaining complex procedures, sharing interesting cases with colleagues, and even creating anatomically accurate Mohs maps. Many in our field agree that high-quality digital photography can make our practices safer and more efficient, but what makes a dermatologic photograph high-quality?

Over my first few months of fellowship, I’ve learned some guiding principles for optimal clinical photos from our medical photographer, Desiree Kingston. After sifting through our vast trove of photos for a recent resident lecture, I thought I’d take the opportunity to share what I’ve learned.


  • Obtain consent and ensure that your chosen storage system protects patient information.
  • Turn off overhead surgical lights to avoid unwanted shadows.
  • Utilize a contrasting solid background when possible. Consider standing patients against a blank wall or using a portable foam board for more flexible positioning.
  • Take photos with and without markings when possible. This is especially helpful for future presentations and lectures. It’s hard to present a reconstruction conundrum when the answer is given away on the photo of your Mohs defect!
  • Consider multiple photos per lesion, with close-ups to capture lesional morphology and regional photos to pinpoint location.
  • Be consistent. Take photos of each body part in the same position every time. Have the same staff member take photos when possible.

Pre-biopsy photos

  • Circle the lesion in ink and label with a letter or number, even if it seems obvious.
  • Consider marking nearby scars or landmarks.
  • Take photos before injections or other procedures like cryotherapy that may alter the lesion’s appearance or nearby landmarks.
  • Some site-specific recommendations:
    • Face
      • Take a straight-on view for lesions between lateral canthi.
      • Take a side view for lesions lateral to lateral canthi or on nasal sidewalls.
      • Include stable landmarks, such as medial or lateral canthi, oral commissures, or superior or inferior auricular attachments.
      • Consider including a ruler to measure the distance to anatomic landmarks.
    • Scalp
      • Include at least one anatomic landmark. We generally include ears for occipital or temporal scalp or nose for overhead photos of vertex and frontal scalp. Orient these photos the same way every time.
    • Extremities
      • Include at least one joint for context.

Post-operative photos

  • Clean the surgical site, removing body fluids and residual antiseptic (especially povidone-iodine, which can result in unwanted color alterations).
  • Remove drapes, surgical towels, gauze, and surgical instruments to reveal as many anatomic landmarks as possible and remove distractors.
  • Be sure to ask patients or family members if they are comfortable viewing graphic defects or intraoperative photos before displaying them in the room.

I hope you found these pearls as helpful as I have. I look forward to the opportunities afforded by our ever-improving photography hardware and software. It’s worth the investment to increase patient confidence in our surgical site identification and improve our communication with colleagues and other learners.


  • Nijhawan RI, Lee EH, and Nehal KS. Biopsy site selfies—a quality improvement pilot study to assist with correct surgical site identification. Dermatol Surg 2015 Apr;41(4):499-504.
  • Zhang J, Rosen A, Orenstein L, et al. Factors associated with biopsy site identification, postponement of surgery, and patient confidence in a dermatologic surgery practice. J Am Acad Dermatol 2016 Jun;74(6):1185-93.
  • MacFarlane DF and Wysong A. A schema using fixed anatomic landmarks for biopsy site identification on the head and neck. Dermatol Surg 2013 Nov;39(11):1705-8.

Summer 2018

A Roadmap to Navigate the Year of Fellowship Training

By Jeffrey Scott, MD • 2017-18 FIT Board Observer

Summer is an exciting time as incoming fellows settle into their new positions and recent graduates transition to independent practice. As such, we felt it timely to provide a roadmap to help new fellows-in-training navigate the upcoming year, maximize opportunities provided by the Mohs College, and adequately prepare to apply for Associate Membership in the ACMS next summer.

ACMS Resources
Fellows-in-training should create a profile on the ACMS website early on in order to receive ACMS correspondence, including the biweekly Cutting Edge News Bulletins and the monthly President’s Messages. A completed profile also gives fellows access to important materials located behind the ACMS firewall, including web pages related to the Mohs Surgery Career Center, Advocacy and Public Policy, past President’s Messages and Membership Bulletins, the annual Membership Directory, Online Bibliography, and information on membership, dues, and board certification. These pages contain important clinical resources for fellows to utilize throughout the year and are only available after creating a profile on the ACMS website.

ACMS Annual Meeting

A highlight of the fellowship year is the ACMS Annual Meeting, which will take place in Baltimore, MD from Thursday, May 2 to Sunday, May 5. Fellows-in-training should plan to register before March 30. Trainees are also encouraged to sign up for the Hands-on Cutaneous Flap Workshop held the day before the ACMS Annual Meeting.

Abstract submission begins August 9, 2018 and runs through January 10, 2019. Abstracts are considered for oral or poster presentation, and fall into one of two categories: 1) scientific abstracts describing original research that addresses topics relevant to the ACMS and Mohs surgery, and 2) rapid two minute pearls describing anecdotes from Mohs surgery, pathology, reconstruction, or practice management.

Abstracts submitted by fellows-in-training can also be considered for the prestigious Theodore Tromovitch Award. This prize is awarded to one fellow-in-training who presents original research performed during their fellowship year or first year of practice after fellowship. The fellow-in-training must attend the ACMS annual meeting and participate in the Tromovitch Award oral presentation session to be eligible for the award, and the abstract must include data analysis at the time of abstract submission.

Clinicopathologic Case Competition
Fellows-in-training may also submit an interesting case from their fellowship year for the Clinicopathologic Case Competition. These cases should involve rare pathology, illustrate diagnostic challenges, or highlight key teaching points for interpreting frozen section histology. The winner of the Clinicopathologic Case Competition will present the case at the Annual Meeting. Importantly, physical slides (not images) must be mailed to the ACMS, and the slides will be returned after the competition concludes. Fellows-in-training must also submit high quality clinical photographs with their case descriptions. The deadline for submissions for the Clinicopathologic Case Competition is February 15, 2019.

Application for Associate Membership

Fellows-in-training should plan to apply for Associate Membership to the ACMS at the conclusion of training. The deadline for submitting applications is August 1, 2019. Associate Membership in the Mohs College is the first step in becoming a Fellow of the ACMS, for which you can apply after you have been an Associate Member for three years.

ACMS Membership and Dues information

Supporting Documents
The Associate Membership application requires a number of supporting documents, including a letter of support from your Program Director, a complete case log, a final evaluation of the fellow-in-training, verification of submission of a scientific article, and a copy of your current ACLS card, along with a $75 application fee. Ideally, many of these documents should be obtained before you finish fellowship, including the letter of support and final fellow evaluation, both of which must be signed by the fellowship director. Additionally, don’t forget to keep your BLS and ACLS certifications up-to-date or you will be required to re-certify. You will need to provide a copy of your current ACLS card with your application (no camera photos).

Case Logs
Submit case logs in either ACMS/ACD or ACGME format. No handwritten logs will be accepted. The case logs should include detailed information on at least 500 cases (600 cases if you completed a two-year fellowship), with 50 cases clearly designated as complex. It is far easier to record your cases as you progress through the year rather than waiting until the end of each month or quarter to update the logs. Cases should include the date, a lesion identification, the diagnosis, whether the tumor is recurrent, the location, the total number of stages, whether the case was complex, the type of repair, initials of the supervising surgeon, and your role in the case (assistant or primary surgeon). Criteria for complex cases can be found on the ACMS website, but of note, histologically aggressive tumors, tumors other than BCC and SCC, and tumors requiring more than four stages are all considered complex cases.

Tips for a Successful Application from ACMS Staff
Fellows-in-training should provide a permanent email address and update their contact information at the end of training. This facilitates communication between ACMS staff and applicants after fellowship, particularly when changing institutions and switching mailing and email addresses. Fellows should also be careful tasking a program or office manager with completing and submitting the Associate Membership application. When a proxy fills out and submits the application on behalf of the fellow, the applicant may not read and be able to affirm the “Information/Liability Release Form,” which compromises the integrity and authenticity of the application process.

ACMS staff encourages fellows to reach out with questions and they are always available to help guide fellows through the application process.

Spring 2018

What Fellows-in-training Should Know About the Transition from Trainee to Independent Practitioner

By Jeffrey Scott, MD  • 2017-18 FIT Board Observer

The final three months of fellowship are a busy time for fellows-in-training. We are synthesizing knowledge, honing our surgical technique, refining our own personal style, and finalizing the details of our next jobs. We still have the direct supervision, support, and guidance from our fellowship directors, but within a few short months we will set out on our own as independent Mohs surgeons.

We thought it would be helpful to hear advice on this unique time from Mohs surgeons in the early stages of their careers. Mohs surgeons in a variety of practice types less than five years out from training discussed what fellows-in-training should know about navigating the transition from trainee to independent practitioner.

Common themes from the respondents emerged, including qualities to look for in a new practice, how to structure your time when first starting out, and how to think independently while still in fellowship. I thank these Mohs surgeons for providing their unique perspectives and hope that they will serve as a valuable resource for trainees in the home stretch of their fellowships.

Read each surgeon’s responses below:

Jeremy Etzkorn
Location: Philadelphia, PA
Completed fellowship: 2013
Practice type: Academics
Practice breakdown: 80% Mohs/excisions, 20% research

Here are some of the things that I remember wishing I had done better/known when starting independent practice:

  • Your first job may not be/is unlikely to be your last job. While it's important to try to get as much right as possible when choosing and negotiating for your first job, treat each transition as a learning opportunity. I started in private practice, transitioned to the VA, and then returned to academics. Each practice type has its unique advantages and disadvantages and it may take time to figure out exactly what you want from your professional life. Changing jobs is not 'failure' but an opportunity to find a better fit for both parties, employee and employer.
  • When negotiating for your job, a critical determinant of your success in practice is having adequate support to do your job as effectively and efficiently as possible. Make sure that your needs and expectations are clearly reflected in your contract. 
  • When you start your job, this is likely the 'least busy' you will be. It's a unique opportunity to spend extra time training your staff and establishing the culture of your practice. The time you invest up front will pay off handsomely as your staff trains new people in the future and your time is increasingly stretched thin.
  • Research 
    • Have your ideas vetted before starting any project. Seek out mentors who can help clarify your ideas and the questions that you want to ask. Before embarking on a project, seek out constructive criticism.  
    • Overall planning of research agenda/goals; I also encourage people to have projects that span short-, intermediate-, and long-term objectives.  Also, don't be too wedded to a single idea or research theme. Flexibility will allow you to continuously find new opportunities. However, before starting any project, make sure that it's worth the year(s) of your life that you will invest in it.

Michael Graves
Location: Austin, TX
Completed fellowship: 2015
Practice type: Private practice
Practice breakdown: 50% Mohs, 30% venous disease, 20% general dermatology

I was attracted to my current practice due to the excellent reputation and longevity of the practice as well as an established patient base. Practice consolidation, often fueled by private equity, has drastically altered the landscape of Mohs surgery through internalization of cases. As many practices refer internally, building a referral base is simply impossible in some markets.  The previous owner had been in practice for 40 years in the South Austin area. He provided excellent care with a constant focus on patients over profits, and many of his patients had come to trust him over the years. We worked out a slow transition where he would go to two days a week for a year, followed by one day a week for a year. Having the retiring physician's presence and endorsement was a massive benefit to everyone involved. It helped that we have similar practice styles and a continual focus on providing the highest level of care for each patient.

The structure of the day-to-day practice has been a natural evolution to a modern era. Many long-standing practices are using outdated systems for both clinical and front office workflow. Since taking over the practice, we have implemented an electronic medical records system, changed our practice management system, added an electronic patient outreach and appointment reminder system, updated to a modern benefits platform, along with hundreds of smaller changes to bring the practice to the modern day. These changes take hard work and a particular dedication towards constant improvement of one's practice. I often compare the changing of a practice to changing direction of an ocean liner - changes should be slow, carefully considered, and a few degrees at a time.

Most fellows do not understand the true economics and business of how the practice of medicine works. There are often unrealistic expectations of volume, available Mohs cases, and appropriate compensation. There is a huge deficit in our training of these business issues and some are unhappy with the reality as they enter into practice. I feel like a greater understanding of practice management would serve younger surgeons well, in particularly realizing that they cannot compare themselves to one who has had years to build up a patient base.

I had the benefit of joining a practice with an established Mohs flow and had no difficulty jumping into that flow. The vast majority of scheduling difficulties can be identified and addressed with appropriate diligence. Grading the difficulty of Mohs cases is an extremely useful technique to prevent a few cases from overwhelming the lab. Using time studies on yourself can help you identify how long it realistically takes to intake, counsel and take the first layer, as well as subsequent layers, time to read slides, and closure times. If I have a large, complicated flap that needs to be done in the middle of a busy Mohs day, I'll occasionally have the patient go to lunch for an hour or two and come back when things are slower. When I first started, suture removals were interfering with our Mohs flow substantially. I was able to dedicate a desk nurse to handle all wound care follow-ups to prevent the Mohs flow from being affected.

Kira Mayo
Location: Fairport, NY
Completed fellowship: 2016
Practice type: Private practice
Practice breakdown: 80% Mohs, 20% excisions and skin checks

I started the job search a few months into fellowship. Some characteristics that attracted me to my current practice included complete control over my schedule and practice space, and location. I also knew my future employer from my residency and knew we would work well together. I would advise fellows to consider location, colleagues, pay structure, and control over their work space and schedule before selecting a practice. I started Mohs at the practice I joined, so the first few months were slow. This was actually really nice because I got to get the hang of things from the get-go, instead of being plunged into a full schedule. I’m still working on building an external referral base! I would love to hear what others have to say about this.

Rachel Redenius
Location: Cleveland, OH
Completed fellowship: 2017
Practice type: Academics
Practice breakdown: 75% Mohs, 12.5% general dermatology, 12.5% cosmetics

The first year of independent practice can be an exciting and challenging transition. Though you’ll leave fellowship very well-trained, nothing fully prepares you for handling difficult situations on your own. One of the best things you can do early on is to create a network of Mohs surgeons, mentors, and friends who are available to you when you have questions. There is also a private Facebook group for fellowship trained Mohs surgeons that can be a great resource for young surgeons. We all know that complications happen to everyone, but it’s hard not to take it personally when you are first beginning in practice. I would highly recommend reading the books Crucial Conversations and Mindsets. I read these with my fellowship director during my training, and they prepare you to have difficult conversations with patients and colleagues and show you how to view your less-than-perfect outcomes as growth opportunities.

Efficiency is another challenge when you are practicing solo. Even when you can suture quickly, it is stressful to know there are so many other things requiring your time and attention (ex: marking the next patient, reading slides, taking another stage, etc.). Sometimes it is necessary to quickly step out of a case and knock out a couple other tasks to keep your staff busy and keep things moving. We use headsets in our practice so I can always stay up to date with everything that is going on outside of the room. I also find it helpful to have a team huddle with my staff each morning. During this time, we review the schedule and try to anticipate any big cases or challenging patients/situations. It helps us plan ahead and allows us time to come together as a team.

Dominic Ricci
Location: Round Rock, TX
Completed fellowship: 2015
Practice type: Multispecialty group private practice
Practice breakdown: 60% Mohs, 40% general dermatology

I’ve had a slightly atypical route, as I was in private practice for a couple of years before applying into fellowship. This allowed be a bit more flexibility once I matched into fellowship, so I went on a couple of job interviews before starting the fellowship and a couple early into my fellowship year. I was looking for an established multispecialty group practice with multiple dermatologists, good ancillary staff, a solid referral base, and an established number of cases. I also wanted a practice that I knew wouldn’t be consolidated or bought out.

Initially I started slowly, which is what I would recommend for every new fellowship graduate. I started with about two cases per day for the first week or two until I knew how things were going, how my staff was operating, and how the equipment was functioning. I was also given a lot of freedom early on to start my schedule off slowly and allow for a lot of transition time, which was good because we had a brand new histotech. Immediately out of fellowship, I wanted to see every Mohs closure, so I had a lot more follow-ups than I do now. In the near future I see myself slowly transitioning to doing more Mohs and less general dermatology.

Every year I tell the current fellow at my program to try to take initiative, tell the fellowship director that you would like to be the first read on the path, and be the first to design the repair. Then the director can tell you that you are totally wrong, especially for more complex cases. This is far better than having the fellowship director, due to time constraints, draw something and then have you just execute it. The initial decision of what to do can be the most difficult part of transitioning from fellowship to independent practice, so you should practice making those initial decisions. Finally, I tell fellows to talk to a variety of people in different types of employment–solo practice, private practice, and academics–to learn the good and bad of each. Also know what you’re willing to accept in terms of risk and reward before interviewing and signing a contract.

Jonathan Zumwalt
Location: Rancho Cordova, CA
Completed fellowship: 2017
Practice type:  Large multispecialty group
Practice breakdown: 100% Mohs

The most important thing for starting out is creating your own style. You were ingrained in your fellowship about "the way" to do different parts of the surgical day for the patient. You probably saw a variety of surgery styles in your residency, away rotations, interviews and even fellowship. You should be a summation of all your learning during your training. The foundation is there and you are only putting the finishing touches on your own surgical style. The most critical thing to remember is that your surgical style is never finished. It should slowly evolve over your career, learning from both your successes and failures. This includes pushing your comfort zone in creating the best care for your current and future patients, treating them all as if they were family members with skin cancer. We should all be lifelong learners along the road of medicine.

Winter 2017

Staging of Melanoma and SCC in the AJCC 8th Edition Cancer Staging Manual

By Jeffrey F. Scott, MD • 2017-18 FIT Board Observer

As Micrographic Surgery and Dermatologic Oncology fellows-in-training, we are tasked not only with developing our surgical skills, but also with learning to accurately stage skin cancers and staying up-to-date on advances in cutaneous oncology. The Accreditation Council for Graduate Medical Education (ACGME) regards these skills as essential to our training, as they have designated “Mastery of Cutaneous Oncologic Curriculum” as a Milestone for fellows to work towards during their ACGME-accredited procedural dermatology fellowships.

Recently, the American Joint Committee on Cancer (AJCC) published the 8th Edition of their Cancer Staging Manual, which will be implemented on January 1st, 2018. The AJCC cancer staging system has numerous functions, including standardizing nomenclature, advising clinicians in staging, prognosis, and treatment recommendations, determining patient eligibility and stratification for clinical trials, guiding research, and facilitating population-based reporting.

Here, we review key changes to the staging of melanoma and cutaneous squamous cell carcinoma (SCC) found in the AJCC 8th Edition Cancer Staging Manual. This is not meant to be a comprehensive review of the new staging systems, and fellows are encouraged to regularly reference the staging manual as part of their training.1

Two important changes in the 8th Edition staging for melanoma involve the definition of primary tumor (T) classifications. Mitoses have been removed, and the T1a category now includes a 0.8 mm cutoff for Breslow’s thickness. Similar to the 7th Edition, the presence of ulceration upstages the primary tumor from an “a” to “b” classification for each corresponding T stage (i.e. T1b, T2b, etc).2 Thus, the 8th Edition designates melanomas <0.8 mm in thickness without ulceration as T1a tumors, and melanomas <0.8 mm in thickness with ulceration as T1b tumors. The 8th Edition, however, also designates melanomas between 0.8 and 1.0 mm in thickness as T1b tumors, regardless of ulceration status. The thickness cutoffs for T2, T3, and T4 tumors remain the same as in the 7th Edition (>1.0 to 2.0 mm, >2.0 to 4.0 mm, and >4.0 mm, respectively). This is a significant change for thin melanomas, as tumors between 0.8 and 1.0 mm in thickness without ulceration are now classified as T1b tumors and clinically staged as IB in the absence of regional or distant metastases, whereas these same tumors would have previously been classified as T1a tumors and clinically staged as IA in the 7th Edition. Finally, for a given T stage without regional or distant metastases, clinical and pathological staging of IA-IIC disease remains the same as in the 7th Edition.

Regarding regional lymph node (N) status, the 8th Edition removes the terms “microscopic” and “macroscopic” disease, and now refers to disease in lymph nodes as “clinically occult” (i.e. detected by sentinel lymph node biopsy only) and “clinically detected” (i.e. palpable). The 8th Edition also includes new “c” sub-classifications for each N stage (N1c, N2c, N3c), which take into account the presence of in-transit, satellite, and/or microsatellite metastases. As a reminder, in-transit metastases are located >2 cm away from the primary tumor, but before the nearest lymph node, and satellite metastases (macro- and microsatellite metastases) are located within 2 cm of the primary tumor. In contrast, the 7th Edition considered in-transit or satellite metastases without metastastic nodes as N2c disease, and with metastatic nodes as N3 disease. Fellows should consult the staging manual to reference how the extent of regional lymph node and/or lymphatic metastases influences pathological staging (IIIA-IIID).

Finally, regarding distant metastases (M), the 8th Edition designates a new category for distant metastases to the CNS (M1d), which was previously combined with all other visceral sites as M1c disease in the 7th Edition. Moreover, unlike the 7th Edition, an elevated LDH level does not immediately upstage to M1c disease in the 8th Edition. Rather, each M category now includes a separate suffix (1) for an elevated LDH level (M1a(1), M1b(1), etc). All M1 categories result in clinical and pathological stage IV disease.

Cutaneous SCC
A major goal of the 8th Edition staging for cutaneous SCC was to improve risk stratification. The T3 and T4 tumor classifications in the 7th Edition were reserved for rare cases of tumors with bony invasion. As such, the vast majority of high-risk tumors were classified as T2 tumors, limiting the prognostic utility of the staging system. Of note, the 8th Edition staging for cutaneous SCC only applies to head and neck tumors (“Cutaneous Squamous Cell Carcinoma of the Head and Neck”), and cutaneous SCC arising on skin outside the head and neck do not have a dedicated AJCC staging system.1 This is in contrast to the 7th Edition, which included a now-removed chapter encompassing all cutaneous SCCs (“Cutaneous Squamous Cell Carcinoma and Other Cutaneous Carcinomas for All Topographies”).2  Finally, SCC of the eyelid, vulva, penis, perianal skin, and anus all have unique staging systems, and will not be discussed below.1

Similar to the 7th Edition, the 8th Edition designates a clinical size of 2 cm as the cutoff for T1 and T2 tumors. The 7th Edition also identified various high-risk features which upstaged tumors from T1 to T2,  including >2 mm depth of invasion, perineural invasion (PNI), ear or non-hair bearing lip anatomic location, and poorly differentiated or undifferentiated histology. The 8th Edition has modified these high-risk features in a number of important ways, and now only incorporates them into the classification of T3 tumors. T3 tumors are classified as tumors with a clinical size ≥4 cm, or tumors with deep invasion (>6 mm or involvement beyond the subcutaneous fat, rather than the >2 mm cutoff used in the 7th Edition), large-caliber PNI (≥0.1 mm rather than the small-caliber PNI used in the 7th Edition), involvement of named nerves without skull base invasion or transgression, or minor bone erosion. The T4 category is now reserved for tumors with bony invasion, with sub-classifications for gross cortical bone or bone marrow invasion (T4a), and skull base invasion or foramen involvement (T4b). Of note, aggressive histologic features and anatomic site are no longer included in the T classification. Importantly, immunosuppression still does not affect the T classification in the 8th Edition. In summary, T1 and T2 tumors are defined by size alone (<2 cm and between 2 and 4 cm in greatest dimension, respectively), size ≥4 cm and/or high-risk features upstage to T3, and bony involvement upstages to T4.

The regional lymph node (N) status is also significantly modified in the 8th Edition, however a detailed discussion of the revised N staging is beyond the scope of this article. In summary, the 8th Edition considers extracapsular extension, lymph node size (with cutoffs of 3 cm and 6 cm), and laterality (ipsilateral or contralateral lymph node involvement) as critical features of N staging (all of which were not included in the 7th Edition). Finally, all distant metastases are now staged as M1 disease, regardless of the visceral site.

T1, T2, and T3 tumors, without regional or distant metastases, are classified as stage I, II, and III disease, respectively. Stage III disease also includes T1, T2, or T3 tumors with N1 disease, defined as metastasis in a single ipsilateral lymph node, <3 cm in greatest dimension, and without extracapsular extension.  Finally, stage IV disease is reserved for higher burdens of nodal disease (N2-N3), T4 tumors, or any distant metastatic disease (M1).


  1. Amin MB, Edge SB, Greene FL, et al. eds. AJCC Cancer Staging Manual. 8th ed.  New York, NY: Springer; 2017.
  2. Edge SB, Byrd DR, Compton CC, et al. eds.  AJCC Cancer Staging Manual. 7th ed. New York, NY: Springer; 2010.

Summer 2017

Tools and Resources for Continuing Education

By Adele Haimovic, MD • 2016-17 FIT Board Observer

There are many tools available to training fellows and dermatologic surgeons who are looking to continue their education. As the incoming fellows begin their training in Mohs micrographic surgery, I thought this was a perfect time to review helpful educational resources.

  1. ACMS Webinars: On the ACMS website there are recordings of several high-quality anatomy webinars available for fellows-in-training and ACMS members. These useful resources can be purchased here.
  2. ACMS Flaps Workshop: A Hands-on Cutaneous Flap Workshop designed for fellows-in-training will take place the day before the ACMS Annual Meeting in Chicago begins. Many fellows-in-training find this course extremely helpful each year. It fills up quickly, so do not forget to sign up early!
  3. Anatomy Course: Many dermatologic surgeons have found Hugh Greenway’s Annual Superficial Anatomy and Cutaneous Surgery Course very helpful. This week-long course takes place each summer and is known for its helpful workshops and significant amount of hands-on training.
  4. Quest: The American Society for Dermatologic Surgery (ASDS) allows access its Quest digital knowledge network. On Quest, one can test their knowledge with surgical questions, read interesting cases and articles, access Dermatologic Surgery, and participate in a discussion board with their colleagues. This is an excellent resource. 
  5. The National Dermatologic Surgery Journal Club is a great way to discuss new and interesting articles related to dermatologic surgery. This journal club holds monthly webinars where a few chosen articles are presented. Please email kburk@nm.org if you are interested in joining.
  6. Mohs Surgery Career Center: Lastly, a few months into your fellowship, you will begin the job search. This can be an overwhelming process. The online Mohs Surgery Career Center created by the ACMS and ASMH is a useful resource that allows Mohs surgeons to search and apply for open Mohs-related positions.

Spring 2017

Words of Wisdom: Advice from Successful Mohs Surgeons

By Adele Haimovic, MD • 2016-17 FIT Board Observer

As our fellowship year comes to an end, many of us are thinking about future employment opportunities and signing our first contract. As a co-fellow-in-training, I wanted to use this opportunity to share advice from successful practicing Mohs surgeons. I interviewed five Mohs surgeons at different points in their careers and asked them for any tips and words of wisdom they may have.

Thomas E. Rohrer, MD (>20 years in practice)

  1. Was there anything you did during your first few years of practice that you thought was very helpful?
    Starting my career at a University was very beneficial. Having an official title at a large institution afforded me numerous opportunities. I was asked to lecture at national meetings and had the chance to consult for companies at an early stage in my career.
  2. Do you have advice about signing your first contract?
    It is important to find the right fit in the right location. Do not let lawyers get bogged down in the details and destroy a good partnership. I always recommend betting on yourself and going for a higher percentage over base salary and signing bonus.
  3. Is there anything you wish you knew before you started your first job?
    In residency we are taught very little about the business aspect of dermatology. Coding and human resources are crucial to running a successful dermatology practice but we rarely learn these aspects during our training.
  4. What are pitfalls or mistakes people commonly make in the beginning of their career?
    I was very fortunate to have had good mentorship so I do not feel that I stumbled too much. I do think people sometimes feel overwhelmed in the start of their careers and put off their involvement in national dermatologic societies. There is never an easy or good time to become active in these societies. I recommend getting involved early and staying active.
  5. Any other words of wisdom?
    Before joining a group, think about where you would like to set up your life. If you think you know where you want to live, go there. Don’t be afraid of opening your own practice; joining a large established group is not always the best fit.

Eric Parlette, MD (~9 years in practice)

  1. Was there anything you did during your first few years of practice that you thought was very helpful?
    Practice “independently,” meaning after all of your years of training, you now get to make the decisions. Figure out what styles you like and put it all together into your practice. Figure out what you like and not what you are "told" to do. This will lead to more happiness and job satisfaction.
  2. Do you have advice about signing your first contract?
    FAIR. Don't look at the bottom dollar. What do you want? Figure out how many hours a day and days per week you want to work. How much Mohs do you want to do compared to other aspects of dermatology? Is there a chance to grow your practice? Ultimately work for someone or an organization that lets you practice medicine the way you want to practice in a safe and ethical manner and get paid fairly.
  3. Is there anything you wish you knew before you started your first job?
    That there are a lot of people more interested in making a lot of money and are willing to sacrifice quality, ethics, and even legal matters in order to do so. I was pretty naïve. Some people say patient care is always first, but then do not practice in that manner.
  4. What are pitfalls or mistakes people commonly make in the beginning of their career?
    Many people take their first job for one of two reasons, money or prestige. We are wired for success, and after finishing one of the most competitive training programs, you want to continue your path of success. And, in America, success is unfortunately measured often times by fame and fortune, neither of which equal happiness. Figure out what will make you happy, i.e. working certain hours and days and living in a certain place, then that is success! You get what you want then, happiness.
  5. Any other words of wisdom?
    Be Happy. Create a work environment and find a job that allows you to build and grow your professional, personal, and family life. Balance is key.

Todd Cartee, MD (~5 years in practice)

  1. Was there anything you did during your first few years of practice that you thought was very helpful?
    I sought additional training in leg vein treatment. In academics, you need to establish a niche early on so you have an area you are known for, can publish on, and can develop a “road show.” This also provides some degree of security within our ever-changing health care environment. I would advise anyone just starting out to diversify his/her practice to the extent possible.
  2. Do you have advice about signing your first contract?
    My first and biggest piece of advice would be NOT to sweat the small stuff. Contracts are best treated as a shield to protect the things that are REALLY important to you. Trying to predict and incorporate in writing every little detail or eventuality will likely prove unsuccessful and can sour your nascent relationship. Ultimately, there has to be some level of trust between you and your practice/department. That having been said, here are some thoughts:
    1. Read up on current issues concerning physician contracts. As this will likely be the first negotiable contract, it only behooves you to be aware of the current atmosphere. For example, malpractice tail insurance was commonly paid by the practice in the past, but now is commonly paid for by the individual.    
    2. If you are going to consider multiple contracts, timing is everything. Most places will give you 2-3 weeks to review, so having both contracts in hand at the same time can be tricky.  
    3. Don’t be afraid to discuss end-of-employment issues up front. Be sure you and your employer are on the same page so that things can end amicably.  
    4. A contract lawyer who specializes in physician contracts is a great investment.  
    5. If you are in an office with multiple locations, specify which locations you will work at. Therefore, if your employer tries to send you to a location not on the initial list, this is an additional responsibility for which one can and should request extra consideration.  
    6. If you negotiate, give reasons and data whenever possible. Asking for an extra $50,000 per year without any reason is difficult, but if you can demonstrate that the present offer is low compared to MGMA data or better yet to another pending offer you already have, then you are more likely to be successful.
    7. If it is not in a contract, it does not exist!
  3. Is there anything you wish you knew before you started your first job?
    Not leaving soon enough. I have been in the same position since fellowship and I love it. However, that is likely more the exception than the rule. Despite all of your best efforts to get the things that matter to you in writing and doing exhaustive due diligence on the practice and its leadership, ultimately, your first destination post-training is unlikely to prove a perfect fit for any number of reasons. Don’t feel bad about that; your first job is an important and valuable learning experience. Treat it as such and let it guide you in taking your next career steps.

Laura Kruter, MD (~2 years in practice)

  1. Was there anything you did during your first few years of practice that you thought was very helpful?
    Staying in close touch with colleagues and mentors was, and still is, essential. A responsive and trustworthy forum in which to exchange ideas and troubleshoot problems helps diffuse the stress of making so many new decisions on your own.
  2. Do you have advice about signing your first contract?
    Do not be afraid to ask questions. The ease with which you and your potential employer or partner communicate during negotiations is a window into the future. Also, prioritize contract details based on what is important to you. The top of the list is worth asking for, and if not agreed upon, continuing to search for.
  3. Is there anything you wish you knew before you started your first job?
    Learning will continue way past residency and fellowship! It is absolutely normal to feel overwhelmed in the beginning. As with all big changes, time and experience leads to increased confidence. 
  4. What are pitfalls or mistakes people commonly make in the beginning of their career?
    Often people prioritize incorrectly, ignore their gut instincts, and end up in work environments that don't suit their goals. Rather than frame this negatively as a mistake, I'd rather view it as a chance to self-examine and redirect.
  5. Any other words of wisdom?
    Paraphrased from my fellowship director, Dr. Tom Rohrer, start off with good habits, as the habits you keep during the first five years will stay with you throughout your career.

Mary Stevenson, MD (<1 year in practice)

  1. Was there anything you did during your first few years of practice that you thought was very helpful?
    For me, protecting my surgical time was important. I wanted to be able to fully focus on Mohs, reconstruction, and procedures during the time carved out in my schedule for those things. At my practice, this meant scheduling so that my day starts with Mohs surgery and leaves plenty of time before I see follow-ups and consults. I then end the day with standard excisions and larger cosmetic procedures so again this time is purely procedural.
  2. Do you have advice about signing your first contract?
    Be honest with yourself about what you want to do and what will make you feel fulfilled every day. Do not get hung up on the details. Prioritize the major aspects that are important to you and focus your energy there.
  3. Is there anything you wish you knew before you started your first job?
    The best advice anyone ever gave me was that your first job is a new adventure. As well prepared as you are, you still will have no idea what to expect and that’s okay. You have all the tools in your toolbox and need to just remember to build on them. It is impossible to ever feel perfectly prepared, but don’t worry, you are.
  4. What are pitfalls or mistakes people commonly make in the beginning of their career?
    Hard to say—I am only at the beginning
  5. Any other words of wisdom?
    Use your mentors and create a network of colleagues you can talk to about practice. You are entering a new phase and will need help and advice. It is great to have people you trust and respect guide you as you go.

Winter 2016

Did You Know? ACMS Resources Available to Fellows-in-Training

By Adele Haimovic, MD • 2016-17 Board Observer

I was privileged to attend the recent Board of Directors meeting at the ACMS headquarters in Milwaukee, Wis. as your FIT representative, and have prepared this report from my experiences there. As fellows-in-training (FITs) during a challenging time for Mohs surgery, we have multiple charges. First, and foremost, we are developing skills so we can provide our patients with the highest standard of care. In addition, we have to learn about the way medicine works in 2016 and beyond. While many of us put this on the backburner during our schooling, we have to gain a better understanding of the committees the ACMS has established to support our specialty, the requirements physicians must meet, and the changing reimbursement and regulatory climate.

As a co-fellow-in-training, I wanted to use this opportunity to review the important resources and networking and educational tools available to us as FITs of the Mohs College:

Regulations and documentation: Due to the changing reimbursement climate and the numerous documentation requirements imposed on us as physicians, we must make sure to provide our patients with the best treatment, practice in a cost-conscientious manner, and understand the upcoming changes to our system. Many terms such as the RUC (Relative Value Scale Update Committee), MACRA (Medicare Access and CHIP Reauthorization Act), MIPS (Merit-based Incentive Payment System), and APM (Alternative Payment Model) are being referenced by practicing dermatologists. While these terms sound like alphabet soup, it is important to understand what they are and how they function. The RUC is an advisory board to the Centers for Medicare and Medicaid Services (CMS) that determines prices for current procedural terminology (CPT) codes. They essentially review and recommend values for all of our E and M visits and procedures. If selected to participate in a RUC survey, it is critically important to fill those out correctly and seek out help for any questions you may have. Keep in mind all of the time it takes before and after any procedure. MACRA, which is set to start in January 2017, plans to move Medicare payment from a volume paid system to a system that rewards both quality and cost savings. Dermatologists have the choice of participating in the MIPS or the APM model. Although these regulations may seem overwhelming initially, there are many resources available to us to better understand them. The ACMS recently hosted a free webinar explaining MACRA and highlighting the important changes for Mohs surgeons.

Coding and billing: At the ACMS as well as other dermatology organizations’ annual meetings there are sessions geared toward understanding coding and payment structures. The AAD releases a quarterly Derm Coding Consult newsletter and on its website under the Advocacy tab there are numerous articles and a presentation explaining the most up-to-date rulings.

Case logs: The ACMS promotes the highest standard of patient care by requiring its members to have completed a fellowship in Mohs surgery, dermatopathology and reconstructive surgery. As media efforts to promote skin cancer awareness and the effectiveness of Mohs surgery increase, many patients will request a surgeon that is fellowship trained. To join the ACMS, a completed case log with 500 cases must be submitted. Be sure to do this during your fellowship. The ACGME case log should be used to record your cases. At least 50 of the Mohs cases and 50 of the reconstructions submitted must qualify as complex.

Career search: The process of a job search can be overwhelming and frustrating. Earlier this year, the ACMS launched the online Mohs Surgery Career Center at careers.mohscollege.org, and it allows Mohs surgeons to search and apply for open Mohs-related positions. It’s free to search for jobs, set up alerts, and upload your CV for potential employers to search. This online job board is a great resource that young surgeons should take advantage of.

Webinars: On the ACMS website there are two anatomy courses available to fellows-in-training and ACMS members. Both “Navigating Superficial Anatomy of the Face for Mohs Surgeons” and “Upper Limb and Nail Bed Anatomy for Mohs Surgeons” are outstanding educational resources available for purchase at a discounted rate of $75 for fellows-in-training.

Research and presentation opportunities: As part of the ACGME requirements, all Micrographic Surgery and Dermatologic Oncology fellows-in-training must complete an original research project. The ACMS Annual Meeting has two opportunities for FITs to participate in research:

  • Scientific Abstracts: Research that addresses the needs of our patients and the ACMS may be submitted. The fellow-in training will be eligible for the Tromovitch Award Competition. The deadline for submission is Thursday, January 12, 2017.
  • Clinicopathologic Case Competition: Fellows are invited to submit a case that has either rare histopathology or that presents a diagnostic challenge. The deadline for submission is February 15, 2017.
  • Flap Workshop: A hands-on cutaneous flap workshop designed for fellows-in-training will take place the day before the ACMS Annual Meeting begins in San Francisco at the Hilton Union Square. More information will be made available soon.