Women Leaders in Mohs Micrographic Surgery: Progress and Pathways Forward

“Fearless” and “courageous” are the first 2 words that come to mind when I think of the women surgeons who helped train me in Mohs. They unabashedly took difficult layers and performed complex reconstruction in ways that toed the line between medicine and art. It was their mentorship that inspired me to surgically take complex tumors head-on for the greater good of the patient. I became a woman leader because I was fortunate enough to learn from other great women. The percentage of women represented in Mohs surgery leadership has gradually increased over the past few years. However, significant gender disparities persist in career advancement, fellowship director positions, metrics of clinical productivity, and invitations to speak at national conferences. Although women do face measurable gaps in reimbursement and recognition, it is inspiring to witness more women entering Mohs fellowship as trainees and pursuing leadership roles within organizations.^1-3

Women Leading in Mohs Surgery Today

Between 1996 and 2023, the number of women Mohs fellowship directors increased from 6% to 25%. This significant change helped increase the visibility of women as experts and knowledgeable teachers of Mohs surgery. Although this is a positive change for the increased representation of women in Mohs, this percentage for fellowship directors still remains below parity despite equal gender distribution among current trainees.² There may also be some differences in how women directors demonstrate leadership patterns. Research shows that women directors are more likely to select women fellows than men. Also, women directors are more likely to achieve directorship positions earlier in their careers (9.1 years after fellowship vs 13.6 years for men).² However, certain measures of academic productivity, such as academic rank and program type, do not show significant differences between men and women directors.² Between 2019 and 2022, women accounted for only 31% to 32% of the Mohs workforce, with this proportion increasing by only 4% between 2013 and 2019.^1,4 Research shows that the youngest cohort of fellowship-trained surgeons (ages 23-29 years) shows more representation of women at 47%, suggesting continuing improvement.⁵

Ever since Frederic E. Mohs developed the Mohs micrographic surgery technique in the 1930s, the field has continued to evolve and incorporate new ideas.^6-8 The field of dermatology has become increasingly dominated by women, now accounting for 62% of dermatology residents. Women also achieved gender parity in Mohs fellowship training in 2021, leading to a transformation in the field’s demographic composition.³ We are living in a time of contemporary women leaders who have built upon the foundation laid by earlier generations who entered a man-dominated surgical subspecialty and persevered despite systemic barriers.

Productivity and Reimbursement Disparities

Despite the strides that women have made in the Mohs, research shows that women surgeons regularly receive fewer cases and receive lower Medicare reimbursement than men, regardless of practice setting.^1,4 In 2018, women performed approximately 123 fewer Mohs cases annually and earned, on average, $73,033 less than men from Medicare.⁴ It is theorized that the financial gap comes from differences in case volume rather than a per-case payment disparity. The payment was equivalent when the data were stratified by productivity level.⁴

Practice setting can also significantly influence gender gaps in payments. Women surgeons in mixed-gender practices experienced the largest gaps in productivity and reimbursement, at 39% below the national male median). However, women in single-surgeon practices showed the smallest gaps (17% productivity, 27% reimbursement).¹ Multisurgeon practices composed entirely of women showed the most improvement over time, with productivity gaps decreasing from 55% to 25% and reimbursement gaps from 47% to 29%.¹

Next, 25% of women Mohs surgeons reported working part time, compared with 19% of men, and 43% of women identified childcare responsibilities as a factor affecting their ability to work full time vs 23% for men.⁹ Furthermore, salaries in large academic centers may be lower than salaries offered to private practice physicians for Mohs. Women surgeons are more likely to practice in academic settings (37% vs 22% of men).⁹

Both women and men in Mohs rate their work content, patient base, and autonomy as top factors for their satisfaction.⁹ Interestingly, 57% of men report being “very satisfied” compared with just 35% of women.⁹ Women surgeons reportedly place a higher value on supervision, feedback, and recognition as contributors to job satisfaction (53% vs 29% for men).⁹

Academic Visibility and Recognition

Historically, women have received fewer speaking opportunities at national dermatologic surgery conferences. At both the American College of Mohs Surgery and American Society for Dermatologic Surgery annual meetings from 2009 to 2017, women had significantly fewer speaking opportunities and less total speaking time. These disparities are most evident in surgical reconstruction topics and least evident in cosmetics presentations.¹⁰ The majority of keynote speakers, top speakers, and repeat speakers were men, although this gap has continued to narrow in recent years.¹⁰ The oral abstract presentations did not show a gender disparity, suggesting equal research productivity among those submitting work.¹⁰

Evidence-Based Strategies to Increase Leadership

Mentorship is essential to career advancement. More importantly, the concept of sponsorship—where senior leaders actively advocate for and create opportunities for mentees—is more instrumental in achieving promotions.¹¹ Women surgeons report a lack of mentoring as an obstacle to professional advancement (40% of women vs 13% of men).¹¹ A 2018 meta-analysis found positive effects from mentoring programs across all studies examining interventions to support women in academic medicine.^11,12

Effective mentorship programs share several characteristics. The American College of Surgeons’ Women in Surgery Committee Mentorship Program demonstrated that mentee-mentor pairs who met 4 or more times annually reported significantly greater benefits in achieving goals, networking opportunities, and professional skill development.¹³ Women surgeons value mentors who are honest, available, and invested in their mentees.¹⁴ Even though studies demonstrate that women prefer gender-concordant mentoring relationships, the scarcity of women mentors in surgical specialties makes this challenging.^11,15

Institutional and Systemic Changes

Addressing organizational structures is essential for sustainable change to create more women leaders.^16,17 The most effective interventions target systemic barriers rather than placing the burden on individual women to adapt. First, critical institutional reforms include increasing salary transparency and pay equity audits to identify and eliminate gender-based compensation gaps.^11,18,19 Second, workplaces can implement flexible work policies that support work-life integration without career penalties.^11,19 Parental leave policies can be amended to provide adequate support for both mothers and fathers. Third, institutions can recognize and provide compensation for service work such as volunteering on committees and mentoring students, which sometimes disproportionately falls to women.^16,17,20

Prioritizing Peer Support and Advocacy

Women surgeons have put forth excellent recommendations for specific actions for both women and men to improve gender equity.²¹ Women should support each other, limit competition, and act as sponsors and mentors for other women surgeons.²¹ Men surgeons should acknowledge any gender bias and actively call out instances of any gender bias when observed.²¹ Creating women’s interest groups and professional networks provides opportunities for peer support and collective advocacy.¹⁷ The finding that women fellowship directors are more likely to select women fellows highlights the importance of diverse leadership in creating inclusive training environments in dermatology.²

Priorities for Increasing Women in Leadership

The continued gradual improvement of women in Mohs leadership positions requires comprehensive intervention. The most effective approach combines individual-level support, such as mentorship and career development, with institutional reforms and cultural transformation.¹¹

As the field continues to evolve with increasing numbers of women trainees achieving gender parity, attention to mentorship and equitable opportunities for academic advancement will be essential for translating trainee diversity into leadership representation. The variation in productivity and reimbursement gaps across practice settings indicates that organizational structure and culture significantly impact women surgeons’ success, suggesting that targeted interventions at the practice level may yield substantial benefits.¹ Women surgeons have shown that they are not afraid to take on the greater challenge, one complex skin cancer and leadership role at a time.

Nicole A. Negbenebor, MD, FAAD, is a Mohs micrographic surgery and cutaneous oncology clinical assistant professor and director of the Skin of Color Clinic in the Department of Dermatology at the University of Iowa in Iowa City.

References

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