Practice Tips and Efficacy

Mohs Surgeons Favorites - Part 2

by Mark Russell, MD, FACMS

During their career medical professionals learn from multiple sources based on a variety of exposures including formal and informal training, conferences, independent study, and experience. Education by colleagues represents another learning resource.1 The purpose of this article is to collect favorite practice tips from our experienced colleagues. A survey addressing practice style and practice management was sent to a limited number of Mohs surgeons in private and academic practice. 

I would like to thank those Mohs surgeons who were willing to share their wisdom and respond to the survey. They represent over 500 years of collective practice experience. The conclusion of this two-part report is below.

Lab Tip

John Albertini Expeditor light system
Recut log that documents date/patient/tech/error (e.g. staining, missing epidermis, hole in dermis/fat, floater, etc.)
Annual submission of cases to ACMS Slide Quality Review Program
Elizabeth Billingsley White board with patients name, status, diagnosis, closure
Jeremy Bordeaux Maintain open lines of communication with your tech
Jerry Brewer Open communication
David Brodland Walkie talkie systems to communicate with staff
John Carucci Second histotech
Jonathan Cook Large specimens on large chucks -minimal need to have multiple sections on most cases
Ergonomic interventions in lab
Linear stainer
Glenn Goldman Excellent fume hood
Linear automatic stainer
Large, open space for lab
Will Henghold I think its absolutely critical that the surgeon grosses the tissue (cuts and inks) and makes the map; this should never be delegated to the tech
We communicate via wireless headsets since we have ASC
Nat Jellinek Calling out orientation of double hashes
Accurate surgical mapping  (by size and map template) of surgical defect
Light with magnification in the lab for grossing
Barry Leshin Daily QC on stains
Every 20th case reviewed by pathologist
Immunohistochemistry available on Mohs specimens
Gary Monheit New automatic stainers
Ventilation system above staining apparatus
Andrew Montemarano Ear buds and walkie talkies for all techs and histotechs
Tri Nguyen Histobath CliniFreeze (bath that is minus 80C) - great for flash freezing or fatty specimens; saves time and makes better histology
Transfer cards that can be drawn on, hold tissue on card. Card also serves as quality control, kept as backup to Mohs map inking if there is any discrepancy
Use small centrifuge tubes to hold tissue dyes and embed them in wax container. Prevents drying out of larger bottle and keeps grossing area clean.
Suzanne Olbricht Anything unusual, I walk into the lab and talk to the tech directly
Asymmetric nicks in the specimen so that it can not be rotated
Point system for daily Q/A slides
Michael Ramsey Arrange lab stations according to work sequence, ending in microscope area
Don't skimp on lab space
Convenient access in and out of lab; steps = time
Steven Rotter Debulk the center so lays flat
Tom Stasko Do periodic time studies of the lab process; just doing the study will speed things up
Always have a backup histotech
Reward quality, compliment great slides
Allison Vidimos Linear stainer
Histotech takes completed maps to nurses while staff reads next case
John Zitelli Freezing specimens on glass slides
Use liquid nitrogen to freeze fat
Preach quality slides before speed

Practice Tip

John Albertini Nurses call all patients the day after surgery to check on progress
Expeditor system for nurses, doctors and lab
Waiting area with ambiance, comfortable chairs, recliners, kitchenette, snacks, TV area, quiet area, outdoor patio, bright airy and inviting
Elizabeth Billingsley Post-op phone calls
Snacks in waiting room
Jeremy Bordeaux Sing to my patients! Put them at ease
Jerry Brewer Calling patients when diagnosis needs more surgery
David Brodland Calling Mohs patients at night
1 week follow-up after surgery at no charge
John Carucci Calling post-ops
Phone hub to triage calls
Jonathan Cook Creative scheduling by dedicated staff
Be the best physician you can possibly be - every day, every patient
Communicate with patients before, during and after procedure
Leonard Goldberg Triage of patients by nurse prior to surgery
Glenn Goldman Separate waiting area for Mohs
Family allowed in surgery
MD always sits down with patients face to face before they leave
Will Henghold Absolutely call your patients that evening before surgery; do it every single time; it has been huge for me
I stress to my staff: "Treat our patients as you would want yourself or your family to be treated." I really emphasize that
Keeping a beautiful, clean office
Nat Jellinek Call all patients the day after surgery
Allot one room/surgical patient for duration of case (i.e. no waiting room shuffle)
Allow epinephrine to sit to minimize bleeding/maximize anesthesia
Barry Leshin Establishing practice culture of "patient first"
Carefully hiring staff for interpersonal skills
Comfortable esthetically pleasing waiting area
Gary Monheit Every patient gets a call after surgery
Seeing patients fully dressed with family before and after surgery
Give patient supplies for post-op care
Andrew Montemarano Call patients after surgery
Provide cell phone number for texting patients
Answer calls same day, even when off
Tri Nguyen Motorola wireless headset for best communication
Have pull up bar in lab (exercise, stretch neck and shoulders)
Call 1-2 days before surgery (staff) to confirm appointment and review pre-op instructions; MD calls after surgery to check on recovery
Suzanne Olbricht Tell patient that I brought in the "A Team" just for them
Tell patient that everything is going as expected, having no trouble with surgery
Little bag of bandaging materials to go home with
Michael Ramsey Pre populating EMR note, including photos, reports, prior surgery, etc.
Bold, large reminders at beginning of note regarding antibiotics, NPO status, device hazards, etc.
Keep and update summary of your care to paste into future notes
Steven Rotter Thoroughly explain everything
Call the next day
Tom Stasko Give patients initial dressing supplies
We wait patients in the surgical room;  TV in the room
Detailed pre-op call from staff
Allison Vidimos Calling Mohs patients eve of surgery
Teledermatology for 6 week post Mohs wound check
ACMS Mohs surgery video on our website for pre-op viewing by patient
John Zitelli Calling patients the evening of surgery
The doctor should always be the rate limiting step - never wait
No TV in the waiting room

Hiring/Maintaing Staff

John Albertini Thank staff at end of each day for their efforts; don't take staff for granted
Embrace philosophy that employees want to do a good job and a leader's role is to inspire and set expectations; praise in public and coach/correct in private
Always check personal references and perform background checks and drug testing to prevent mistakes with hiring that are hard to overcome
Elizabeth Billingsley Thank you at the end of every day
Jeremy Bordeaux Take your time and hire the right people!
Make expectations clear and make sure that they are documented
Improvement plan for underperforming employees
Jerry Brewer Choose wisely!
David Brodland Minimum 3 staff interviewing prospective employees
Production incentive
Quality incentives
John Carucci Open communication
Weekly staff meetings
Pay them
Jonathan Cook Treat all with respect
Enjoy your staff
Pay fairly
Leonard Goldberg Pay well
Never lose your temper
Never insult anybody
Glenn Goldman Allow all staff to advance
Give staff as much responsibility as they will accept
Remind them of how important they are regularly
Will Henghold Pay your great people well and let them know you appreciate them on a regular basis
Hire slow and fire fast
Get rid of "pot stirrers" or "mood makers"
Don't get so dependent on an individual who might be great at their job, but disrupt the cohesiveness of the team  - it is not worth it
Nat Jellinek Treat them well
Occasional free lunches/snacks/breakfast
Create a sense of teamwork
Barry Leshin Hire only after extensive vetting and interviewing
Provide competitive benefit package
Expressing thanks and praising work effort
Victor Marks Ask their opinion, teach them, thank them
Gary Monheit Full training with checklist
Do not demand more than an assistant can do
Andrew Montemarano Hire for attitude, not experience
Show staff you value them and treat them with respect
Repeatedly reinforce the mission "caring for patients"
Tri Nguyen Pay them well if they perform
Bonuses incentivize based on individual performance metrics
Be genuinely friendly and interact with drug reps; they often know who the good staff are, or a least, who is looking for jobs
Suzanne Olbricht Greet each team member first thing in the morning
Huddles
Talk up staff at all points of the encounter
Michael Ramsey Do not treat your nurses as if they are your maids
Treat every employee with respect and express your appreciation
Do not call out employees in front of others
Counsel with respect and away from their peers
Steven Rotter Pick someone you want to spend 8 hours a day with
Tom Stasko Always check references before hiring
Involve staff in decisions that affect them
Be aware of what you do and say
Allison Vidimos Engage support staff
John Zitelli Praise when possible and tell them when they make a mistake
Incentive bonuses for what you want to encourage
Let staff participate in decision making - ask their advice

Building/Maintaining a Referral Base

John Albertini Communicate with referring physicians; ask how they want you to address situations like a newly observed tumor or inquiry from a patient
Do great work and treat each patient like a family member and your practice will thrive, methodically, over time. You can't rush patient or referring doctor loyalty and first impressions last so especially important to impress early in career. Quality over quantity will reap long term rewards.
Attend local and state meetings and develop a personal connection
Elizabeth Billingsley Ensure reports are sent on every patient
Occasional phone call asking how we can improve
Jeremy Bordeaux Take excellent care of your patients
Jerry Brewer Treat your colleagues with respect...what goes around comes around
David Brodland Provide follow-up letters
Attend local conferences
John Carucci Provide excellent service
Be available
Communicate
Jonathan Cook Availability
Ability
Affability
Leonard Goldberg Treat your patients well
Don't do what you're not asked to do
Glenn Goldman Provide highest quality care
Communicate very effectively
Be nonjudgmental and accept referrals with grace
Will Henghold Photograph your work and send letters with photos to referring docs, but make sure the photo quality is excellent
Do great work; as an old proverb goes, "The work praises the man."
Nat Jellinek Handwritten letters to referrals
Give everyone your cellphone number
Take their hardest/most challenging patients
Barry Leshin Provide exceptional care
Communicate quickly and make referral process easy and simple
Always be available for calls, work in urgent cases
Victor Marks Call all new referring physicians and established referring docs on occasion for "interesting" things
Gary Monheit Send patient back to referral doctor
Do not suggest another dermatologist or cosmetic procedures on referred Mohs patients letter and/or call to referral doctors
Andrew Montemarano Take great care of patients so they market for you
Communicate frequently and easily
Be available
Tri Nguyen Giving patients and referring physicians your cell phone number so that they know that you are always available (15 years doing this, and no abuses)
Send patients letters with their photos after surgery, as well as calling them after surgery
Send not only referring derm a letter, but also PCP
Suzanne Olbricht Be available: Text, calls, emails, whatever is easiest for referring physician
Talk up referring physician to the patient if at all possible
Be visible at local meetings
Michael Ramsey Promptly send letters/photos/reports to referring physician
Treat referring providers the way you want to be treated
Steven Rotter Be available and give good feedback
Tom Stasko Good communication with referring physicians; send photos
Talk up the referring physician to the patient
Take great care of patients - that will always get back to the referring physican
Allison Vidimos Lectures to local dermatologists and primary care MDs on skin cancer
Advertise and promote multidisciplinary tumor board
Do tissue reads on large tumors that are removed in OR with general anesthesia by plastics, oculoplastics, facial plastics, urology, gynecology or neurosurgery
John Zitelli Be available by phone - NEVER have your nurse call
Send letters with photos post-op
Seek primary care referrals


References

  1. Sargeant J, Mann K, Sinclair D, Ferrier S, Muirhead P, van der Vleuten C, Metsemakers J.  Learning in practice: experiences and perceptions of high-scoring physicians.  Acad Med. 2006 Jul;81(7):655-60.