Winter 2018 e-Newsletter
In This Issue:
- President’s Message
- Viewpoint: Update on Board Certification for Micrographic Dermatologic Surgery
- ACMS Happenings
- Ask Glenn: Answers to Your Mohs Coding & Billing Questions
- Hot Topic: Fire Prevention in Mohs Surgery
- Practice Tips and Efficacy: The Utility of Patient Education Videos Prior to Informed Consent for Mohs Surgery
- Highlights from the Literature: Mohs for Invasive Melanoma/AUC Updates
- Fellow-in-Training Perspectives: Use of Digital Patient Photography for Surgical Site Identification
Dear Colleagues –
With the holidays and a new year approaching, it is an appropriate time review the College’s 2018 milestones: celebrating the College’s 50th Anniversary, achieving subspecialty Board certification in MDS, launching the MohsAIQ registry, establishing the ACMS Foundation, creating our own podcast series, and refreshing our strategic plan.
As you look ahead to the numerous opportunities 2019 will bring, please be aware of the following updates:
Mohs award nominations
Please consider nominating a colleague for the Frederic E. Mohs Award for Career Achievement presented at the Annual Meeting. Use this link to submit your nominations by January 4, 2019.
In-office physician compounding
On November 30, Dr. Allison Vidimos joined representatives of the AAD, ASDS and other specialty groups in a meeting with the United States Pharmacopeial Convention (USP) to discuss revisions to its proposed standards for compounding sterile preparations. The group asked the USP to adopt at least a 12-hour exemption from its safety equipment and process standards to allow us to continue buffering our local anesthetic for patient comfort. Read more here.
Listen, subscribe and rate ACMS podcast
Three episodes of the College’s podcast series, Conversations in Mohs Surgery, are available at www.mohscollege.org/podcast. Host Dr. Thomas Knackstedt takes a closer look at articles published in the micrographic dermatologic surgery literature by speaking with the authors. In the first two episodes, Dr. Jeremy Bordeaux discusses the safety of large skin flap, large skin graft, and interpolation flap surgery and Dr. Jonathan Lopez reviews opioid prescribing for acute postoperative pain. In the latest episode Dr. Sarah Arron discusses her study, Association of Postoperative Antibiotics With Surgical Site Infection in Mohs Micrographic Surgery, published in Dermatologic Surgery in August 2018. In addition to listening on the ACMS website, subscribe to the podcast via iTunes/Apple Podcasts and the Google Play Store. While you’re there, please take a moment to rate and review the podcast.
Board of Directors election opens Jan. 3
The election of three new Board of Directors members and Secretary-Treasurer will open online Jan. 3, 2019. You will soon receive a postcard with a link to election materials. To ensure your ability to vote, please verify your contact information here.
Membership Bulletin e-Newsletter
Please take a moment to read the latest issue of our Membership Bulletin e-newsletter here. I would like to call your attention to several articles of note:
- Dr. Tom Stasko offers an update on the process for Board certification in MDS
- Dr. Mark Russell offers tips to prevent surgical fires
- Dr. Bill Stebbins explores the utility of patient education videos prior to obtaining informed consent
- Dr. Will Henghold examines the recent AUC updates pertaining to the use of Mohs surgery for invasive melanoma
As we end this landmark year, I would like to thank you all again as we endeavor to move the Mohs College from good to great. I look forward to seeing you in Baltimore next May. In the meantime, I would like to extend my warmest wishes to you and your families during the upcoming holiday season.
Barry Leshin, MD, FACMS
ACMS President, 2018-19
Update on Board Certification for Micrographic Dermatologic Surgery
By Thomas Stasko, MD, FACMS
One of the pillar goals of the College’s strategic plan came to fulfillment on October 26, 2018, when the Board of Directors of the American Board of Medical Specialties approved the creation of Micrographic Dermatologic Surgery (MDS) as a subspecialty of Dermatology! Efforts to establish Board certification began over 30 years ago and it is impossible to credit and thank all of the individuals whose work and persistence culminated in this recognition of MSD. Without the steadfast and patient promotion of board certification by the leadership and membership of the College this day would not have arrived. The members’ reasoned, vocal support during the recent process was largely responsible for convincing the American Board of Dermatology and the ABMS that the time for certification had come. We also owe great thanks to the leadership of the ABD for having the continued belief that board certification for MDS was a step forward not only for Mohs surgery, but for all of Dermatology.
The ABD will now implement the certification process. The ABD has stated that candidates for the Micrographic Dermatologic Surgery subspecialty certification must...
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, 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, May 4, 2019 during the Annual Meeting in Baltimore.
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 4, 2019. If you have any questions, contact Mary Riordan at the ACMS office at (414) 347-1103 or firstname.lastname@example.org.
ACMS Meets USP Regarding In-Office Compounding
Physician leaders and legislative advocates from the AAD, ACMS, AMA, ASDS and ASMS met with leaders from the USP, FDA and CDC on Friday, Nov 30 in Maryland to discuss proposed revisions to Chapter 797 on compounded sterile preparations (CSP) that, if finalized and adopted by state pharmacy boards, would create burdensome operational and financial implications for compounding sterile preparations in our practices. The current proposal in Chapter 797 is to discard any unused buffered lidocaine one hour after compounding. Our request is for a 12 hour period of use for buffered lidocaine prepared in aseptic fashion in the office to prevent delays in patient access, while assuring safe patient care. Suzanne Olbricht, MD, AAD president, Seemal Desai, MD, AAD representative to the FDA, Jack Resneck, Jr., MD, Chairman of the AMA Board of Trustees, Murad Alam, MD, President of ASDS, Allison Vidimos, RPh, MD, immediate past president of ACMS and Expert Consultant to the USP compounding committee, and CDR Josephine Nguyen, MD, MHCDS attended the meeting.
The ACMS sent a letter to the USP Compounding Committee during the comment period, and the ACMS joined several other dermatology societies in signing onto a letter created by the AADA discussing our request and the literature in support of a longer use period for compounded buffered lidocaine. Thanks to all ACMS members who submitted comments to the USP, which will be reviewed by the USP Compounding Committee over the next several weeks.
ACMS Foundation Marks Progress, Builds Structure
By Thomas Stasko, MD, FACMS
This has been an incredible year for the Mohs College and Mohs surgery! The College celebrated its 50th anniversary at the Annual Meeting in May. During the meeting, the College announced the establishment of The ACMS Foundation. Honoring the legacy of our founder, Frederic E. Mohs, MD, the Foundation aims to support the next 50 years of growth for our specialty. The ACMS Foundation supports research grants, education and lectureships, travel awards and patient education projects.
Under the guidance of the College’s President, Barry Leshin, the ACMS Foundation Development Task Force (Drs. John Albertini, Scott Fosko, Hugh Greenway, Stan Miller and Allison Vidimos) established a launch goal of $2.5 million in the first five years. ACMS members have already committed $1.36 million, or 54% of the goal, in the first year, and our fundraising efforts continue. The first Foundation-sponsored keynote address will be presented at the 2019 Annual Meeting in Baltimore, made possible by a grateful patient gift to the Foundation for this express purpose.
The ACMS Foundation is classified as a designated fund administered by the Board of Directors of the College. This arrangement provides much greater flexibility for a fund of this size. To develop a structure for accepting donations, a spending policy and the processes for awarding and administering grants and awards, the Board appointed a Governance and Policy Committee. Its members include Drs. Tom Stasko (chair), Marc Brown, Jerry Brewer and Nat Jellinek. One might think that raising and spending money would be very easy. As it turns out there are many considerations to being good stewards.
Send Your Tech to Mohs Technician Quality Assurance Training January 24-25
Do your histotechs need help in reaching a higher level of slide preparation or reinforcing their skills? The American Society for Mohs Histotechnology offers customized, hands-on instruction through its ongoing Mohs Technician Quality Assurance (MTQA) Training Program. Offered exclusively to technicians currently working for ACMS member surgeons, registration is open for the next training session taking place January 24-25, 2019 at the Avantik Academy Mohs Training Campus in Springfield, New Jersey. Topics include mapping and inking, embedding, staining, cryosectioning, CLIA regulations and troubleshooting.
Non-member registration will include ASMH membership through 2019. Upon completion, trainees can claim 12 CEUs through the National Society for Histotechnology and will receive a certificate of completion from the ASMH/ACMS.
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Answers to Your Mohs Coding & Billing Questions
Responses provided by Glenn D. Goldman, MD, FACMS
Many ACMS members have questions about proper coding and billing for Mohs surgery. This reinforces a need for ongoing education to ensure the College meets its goal of integrity and ethics in all aspects of Mohs practice. Dr. Glenn Goldman answers these coding and billing questions submitted to email@example.com. Responses are included in the e-Newsletter for the benefit of all members.
Fire Prevention in Mohs Surgery
By Mark Russell, MD, FACMS
In a recent survey of ACMS members, 11% of those responding reported at least one surgical fire yielding an incidence of 1 fire per 88,620 cases (0.001%).1 While this study was susceptible to recall and voluntary response biases, fires in Mohs surgery appear to be a rare event. However, surgical fires have been found to be more common in a similar specialty, Oculoplastic Surgery, with a reported 32.2-43.5% of Oculoplastic Surgeons experiencing at least one operating room fire.2,3 Therefore, diligence is required to minimize risk of fire and avoid significant adverse outcomes. This article will address causes of surgical fires, methods to minimize risk, and steps to take if a fire occurs.
Three elements are commonly involved with the initiation and maintenance of fire:4,5
- Ignition Source (e.g. electrosurgical unit, thermal cautery, laser)
- Oxidizer (e.g. room air, supplemental oxygen)
- Fuel (e.g. skin, hair, hair spray, alcohol-containing skin preps, aluminum chloride, chlorhexidine, gauze, cotton, drapes, towels, gowns, gloves)
When all three elements are present, especially when supplemental oxygen is in close proximity to the ignition source, the risk of fire is elevated. However, supplemental oxygen is not required and room air can support a fire. In the survey of ACMS members referenced above, none of the fires were associated with the use of supplemental oxygen, and most fires occurred on the scalp followed by the forehead, cheeks, temples, and then the trunk. An example of a patient at elevated risk: a chlorhexidine prep that has not fully dried, a lesion on the head or neck, supplemental oxygen, an occluding surgical drape, and electrofulguration for hemostasis...
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The Utility of Patient Education Videos Prior to Informed Consent for Mohs Surgery
By William Stebbins, MD, FACMS
One of the most important aspects of a successful Mohs surgery experience is effective informed consent and education of our patients before the procedure. Studies have shown that patients recall less than half of what their physicians tell them, so the use of patient education videos before the consultation with the physician can help to improve knowledge retention and decrease patient anxiety about the procedure.1
The ACMS has just released a patient education video about the Mohs surgery process. Dr. Kenny Omlin produced the video, which demonstrates via animation key elements of Mohs surgery. The video is available on the ACMS website and YouTube page, and can be shared with patients via a variety of mechanisms. Members received an email on November 7 detailing the release of this video as well as how to integrate it into one’s practice.
Recently, Newsom et al. at Memorial Sloan Kettering Cancer Center published an excellent study evaluating the utility of a preoperative video consultation for Mohs surgery.2 Their objective was to utilize a preoperative video consult to supplement and modernize the traditional consultation. They evaluated the effect of two different video formats for first-time Mohs patients as well as those who had previously undergone Mohs surgery. Both formats included an overview of NSMC, the Mohs technique, risks of the procedure, and pre/post-op instructions. A traditional video consisted of a PowerPoint presentation with voiceover. The other video was in narrative format that added video footage of the actual surgery, the Mohs lab, and patient testimonials. Both videos were viewed on an iPad immediately before the consult with the surgeon. The study revealed a number of interesting findings...
Mohs for Invasive Melanoma/AUC updates
By William Henghold, MD, FACMS
The Appropriate Use Criteria (AUC) for Mohs micrographic surgery (MMS) will soon be formally updated. When it was first published in 2012 by the Ad Hoc Task Force from four dermatology specialty organizations, including the American College of Mohs Surgery, invasive melanoma (IM) was intentionally excluded from consideration due to the “complexity of the issue” (1). But the AUC for MMS included melanoma in situ (MIS) and deemed it appropriate in ten out of twelve clinical scenarios and uncertain in the remaining two (i.e., non-recurrent lesions on the trunk and extremities, excluding the pretibial surface, hands, feet, nail units and ankles).
The Clinical Practice Guideline (CPG) for the management of primary cutaneous melanoma (CM) has recently been updated (2). Compared to the CPG published in 2011, little has changed with respect to surgical recommendations due to the lack of new randomized controlled trials (3). The updated CPG recognizes the growing body of evidence, primarily in the form of retrospective data, to support the use of MMS for IM, but it provides no specific positive recommendations for its use, other than to clearly state that the current standard of care for CM, whether it be MIS or IM, is surgical excision with histologically clear margins. The updated CPG cautions against the use of < 1 cm surgical margins on the head and neck until more data is available.
The controversy surrounding MMS for CM, and IM in particular, is a curious one...
Use of Digital Patient Photography for Surgical Site Identification
By Thomas S. Bander, MD
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.
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SAVE THE DATE
Mohs Surgery Career Center
Visit careers.mohscollege.org to search, apply for, and post open Mohs-related positions
The ACMS/ASMH Mohs Surgery Career Center is a resource for surgeons, histotechs, physician assistants, dermatopathologists, practice managers, administrative staff and others to search for job openings, post resumes, and connect with employers. The Career Center includes positions in multiple categories, expanded national reach, and the ability to search by position type, work setting, and state.
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