Mohs Surgical Training Around the World: Need for Standardized Database

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Mohs micrographic surgery (MMS) is widely recognized in the United States as the standard of care for the complete margin analysis of skin cancer. However, its global acceptance and implementation show significant variability. Christine P. Lin, MD, resident physician at Stanford University School of Medicine in Stanford, California, led a study presented in a poster at the 2024 American College of Mohs Surgery Annual Meeting, exploring the international landscape of MMS training, practice standards, and the challenges faced by Mohs surgeons worldwide.¹

Study Purpose and Design

The primary aim of this study was to gather comprehensive data on the education, formal training, and practice of MMS globally, with a focus on regions lacking established dermatologic surgical societies. Conducted over five months from August to December 2023, the survey targeted MMS providers outside the United States. The survey included 47 questions covering participants' credentials, certification processes, practice standards, surgical techniques, and barriers to practice expansion.

Survey Participants

A total of 146 participants from 30 countries responded to the survey.The majority of respondents hailed from Brazil (32.9%), the United Kingdom (13.0%), Switzerland (8.2%), and the Netherlands (7.5%). Most respondents (95.2%) had primary training in dermatology, with 67.1% completing their MMS training within their home countries. This training often extended beyond one year (42.5%) and typically required the submission of case logs (60.3%) with a minimum of 100 cases (32.4%) for certification or accreditation.

Practice Patterns and Techniques

On average, 69.2% of the surveyed surgeons performed between 0 to 5 Mohs cases per week, while 20.5% managed 6 to 10 cases weekly. The predominant techniques employed were American standard Mohs (87.9%), slow Mohs (23.5%), and Tübingen-Torte (14.8%). A notable observation was that only 26.4% of surgeons used MMS for treating melanoma. Additionally, 39.0% of respondents either interpreted slides with a pathologist or did not interpret their own slides, and a significant majority (89%) performed their own reconstructions.

Barriers to Practice Expansion

The study identified several barriers impeding the global expansion of MMS. The most frequently reported challenges included limited infrastructure and a lack of public awareness regarding the benefits of MMS, each cited by 41.1% of participants. Other significant barriers included minimal or no reimbursement for MMS procedures (32.2%), as well as other logistical and educational obstacles.

This poster presentation comes on the heels of a call for increased diversity, equity, and inclusion content on dermatology fellowship program websites after Mohs specialty programs had the most prevalent lack of efforts to attract diverse applicants.²

Conclusion

The findings of this study underscore that, while MMS is increasingly recognized as the gold standard for skin cancer treatment worldwide, numerous challenges still hinder its widespread adoption and practice. Limited infrastructure, insufficient public knowledge, and inadequate reimbursement are primary barriers that need to be addressed.

“MMS is gaining worldwide recognition as the gold standard in skin cancer treatment. However, barriers exist worldwide preventing surgeons from practicing at their maximum capacity and offering this treatment to patients,” Lin and her fellow researchers wrote. “A comprehensive catalogue of international MMS is critical to promote the standards of MMS, to ensure competent training, and to facilitate collaborations that strengthen and elevate the practice and recognition of MMS on a global scale.”

Study authors highlighted the need for a comprehensive international database on MMS practices. They believe such a resource would not only promote standardization and competency in MMS training but also facilitate global collaborations aimed at enhancing the practice and recognition of MMS. Efforts to overcome the identified barriers could significantly increase the availability and quality of skin cancer care worldwide, ensuring that more patients benefit from the meticulous margin control that MMS offers.

References

1. Lin C, Voller L, Aasi S. An international perspective on Mohs surgical training. Poster presented at: 2024 American College of Mohs Surgery Annual Meeting; May 2-5, 2024; Phoenix, AZ.
2. Bohler F, Garden A, Taranikanti V. Analyzing diversity, equity, and inclusion content on dermatology fellowship program websites. Med Educ Online. 2024;29(1):2347762. doi:10.1080/10872981.2024.2347762