The making of a specialist

July 1, 2007

There is reason to argue that competence, not necessarily fellowship training, should be a prime consideration in evaluating a dermatologist's credentials. One Mohs surgeon challenges his colleagues to adopt this stance and to unify, rather than divide, the specialty of dermatology.

Key Points

Santa Ana, Calif. - Specialized training in a specific field is invaluable, but it is not the only route to achieving competence. Discrimination based on such credentials fosters a hostile and segregative atmosphere that is detrimental to dermatology as a whole, one surgeon tells Dermatology times.

Dermatologists must unite, stand strong and work together against the sometimes not-so-transparent forces in medicine, medical insurance companies and society that would weaken dermatologists as a group, if allowed, says Matthew M. Goodman, M.D., Mohs surgeon and associate clinical professor, department of dermatology, University of California, Irvine, who has a private practice in Santa Ana, Calif.

"We are too small to be dividing and splintering ourselves too much over narrow fields of interests or specific techniques. We can only benefit from the unifying organizations such as the American Society for Dermatologic Surgery (ASDS) and the American Academy of Dermatology (AAD) that work to strengthen our specialty and encourage continued quality of care," Dr. Goodman says.

According to Dr. Goodman, a good physician must have adequate intelligence and training, as well as experience and ongoing education. He or she also must demonstrate aptitude, caring and integrity.

He says the main factor that defines a good Mohs surgeon is the quality of care for patients.

"In order to uphold a high standard and quality of care, physicians must have several contributing attributes. Thorough knowledge of the field, competent skill, experience, good judgment, caring for well-being of patients, as well as integrity and ethics are all part of the mosaic that defines a good Mohs surgeon," he says.

Mandates for Mohs

Dr. Goodman says that, as a special excisional technique, Mohs surgery requires special mapping with ink, frozen sections, and slide-reading by a surgeon trained in dermatopathology, and can be learned in a dermatology residency program.

According to a 2002 AAD Practice Survey, only 6.9 percent of dermatologists had completed a Mohs fellowship, yet 16.9 percent of dermatologists regularly do the procedure. Where are they gaining this training? Is it necessary to obtain this training through a fellowship? Or is hands-on experience in daily practice a competent teacher?

"Hundreds of residents in dermatology have learned Mohs surgery and perform it competently and successfully in their own practices on 'average' cases. Many practicing dermatologists who are competent in dermatologic surgery and dermatopathology have become competent in Mohs surgery. Experience naturally depends on the willingness of the residency program to provide adequate training and patient experience," Dr. Goodman says.

According to Dr. Goodman, the ASDS offers 12 brochures, but none on Mohs surgery. Brochure topics include botulinum toxin, chemical peeling, dermabrasion, hair restoration, lasers, laser resurfacing, soft tissue fillers, treatments for veins and tumescent liposuction, mastery of none of which requires a fellowship. He says the AAD also offers 12 pamphlets on different subjects, but not a single one on Mohs surgery.

"Many nonfellowship-trained Mohs surgeons are as skilled in Mohs surgery as their fellowship-trained colleagues. (Yet) there is a growing and worrisome trend, where physicians are accusing colleagues as having inferior training without the fellowship," Dr. Goodman says.

He argues that most dermatologists treat children in their private practices without having completed a pediatric dermatology fellowship, or they read their own pathology slides without having done a dermatopathology fellowship. Yet they are competent.

He says dermatologists receive training and gain experience in "average" pediatric cases through their dermatology training programs.

Any pediatric case with which a dermatologist is not comfortable will be referred to a colleague with more experience.

Fellowship fallacy?

In that same vein, other specialties recognize the problem and generally do not require fellowships for competency (i.e., ophthalmology and cataract fellowships, or orthopedics and knee fellowships).