Julie Ann Amthor Croley, MD

Mohs micrographic surgery (MMS) has been met with controversy since its inception in the 1930s. Current debate centers on the types of tumors treated with MMS, increasing utilization, third-party payer reimbursement, the Appropriate Use Criteria (AUC), and subspecialty certification.

Controversies in Applications

Controversy surrounding treatment with MMS for certain tumor types is abundant, in large part due to a lack of well-designed studies. Perhaps most notably, the surgical management of melanoma has been hotly contested for decades.¹ An increasing number of Mohs surgeons advocate the use of MMS for treatment of melanoma. Advocates reason that tumor margins may be ill-defined, necessitating histologic examination of the margin for tumor clearance. In a study by Zitelli et al,² 5-year survival and metastatic rates for 535 patients with melanomas treated by MMS with frozen sections were the same or better when compared to historical controls treated with conventional wide local excision. Melanoma-associated antigen recognized by T cells (MART-1) immunostaining may offer improved diagnostic accuracy.³ Others believe that staged excision with permanent sections processed vertically, en face, or horizontally (“slow Mohs”) is more accurate and efficacious for the treatment of melanoma.¹ Advocates of this approach maintain that when compared to MMS with frozen sections, staged excision with permanent sections enables more accurate interpretation of residual melanoma and atypical junctional melanocytic hyperplasia as well as circumvents difficulty in interpreting freeze artifact.⁴

Although Merkel cell carcinoma has traditionally been treated with wide local excision, MMS with or without adjuvant radiotherapy has gained traction as a treatment option. Advocates for treatment by MMS hold that Merkel cell carcinoma is a contiguous tumor with a high rate of residual tumor persistence, making histologic margin control an ideal characteristic of treatment. However, in the absence of large randomized controlled studies comparing MMS to wide local excision, controversy surrounds the most appropriate surgical approach.¹ In a retrospective study of 86 patients by O’Connor et al,⁵ MMS was demonstrated to compare favorably to standard surgical excision. Standard surgical excision was associated with a 31.7% (13/41) local persistence rate and 48.8% (20/41) regional metastasis rate compared to 8.3% (1/12) and 33.3% (4/12) for MMS, respectively.⁵

Controversies in Increasing Utilization

The incidence of skin cancers has increased in recent years. As a result, it is reasonable to expect the rates of MMS to increase. Nonetheless, there is escalating concern among groups of third-party payers, the public, and physicians that MMS is being overused.⁶ Growth of the body of evidence supporting the appropriateness of MMS remains essential. Such studies continue to support reasons for increased MMS usage, demonstrating the stability of the percentage of skin cancers treated with MMS in the setting of increasing skin cancer incidence, the procedure’s superior efficacy for appropriately chosen cases, its expanding application to melanoma and other tumors, and an emphasis of MMS in residency training programs.^6-9

A current hot topic of controversy focuses on the wide variation among Mohs surgeons in the mean number of stages used to resect a tumor. Overuse among outliers has been proposed to stem from lack of technical expertise or from abuse of the current fee-for-service payment model, which bases compensation on the number of stages performed. A study by Krishnan et al¹⁰ determined that the mean number of stages per tumor in the studied population (all physicians [N=2305] receiving Medicare payments for MMS from January 2012 to December 2014) was 1.74, with a range of 1.09 to 4.11. Persistently high outliers were more likely to perform MMS in a solo practice, with an odds ratio of 2.35.¹⁰ In response to the wide variation in mean stages used to resect a skin cancer and its implications on increased financial burden and surgery to individual patients, intervention has been proposed. Notably, it has been demonstrated that mailing out individual reports of practice patterns to high-outlier physicians resulted in a reduction in mean stages per tumor as well as an associated cost savings when compared to outlier physicians who did not receive these reports.¹¹

Controversies in Reimbursement

Mohs micrographic surgery also has been in the spotlight for debate regarding reimbursement. The procedure has been targeted partly in response to its substantial contribution to total Medicare reimbursements paid out. In 2013, primary MMS billing codes constituted nearly 19% of total reimbursements to dermatologists and approximately 0.5% of total reimbursements to all physicians participating in Medicare.¹² Mohs micrographic surgery codes have correspondingly received frequent review by the Relative Value Scale Update Committee and remained on a list of potentially misvalued services according to the Centers for Medicare & Medicaid Services for years.¹³ Due to continued scrutiny and review, especially by the Relative Value Scale Update Committee and Centers for Medicare & Medicaid Services, reimbursement to perform MMS and reconstructive surgery has gone down by more than 20% in the last 15 years.¹⁴ Public perception mirrors third-party payer concerns for overcompensation. An article title in the New York Times theatrically postures “Patients’ Costs Skyrocket, Specialists’ Incomes Soar.” The article recounts an MMS patient’s “outrage at charges” associated with treatment of her “minor medical problem” and the simultaneous “sharp climb” in dermatologist income over the last 2 decades.¹⁵

However, studies continue to demonstrate the cost-effectiveness of MMS. A study by Ravitskiy et al¹⁶ demonstrates the cost-effectiveness of MMS, regardless of place of service or type of tumor. Of 406 tumors studied, MMS was the least expensive surgical procedure evaluated ($805 per tumor) when compared to standard surgical excision with permanent margins ($1026 per tumor), standard surgical excision with frozen margins ($1200 per tumor), and ambulatory surgery center standard surgical excision ($2507 per tumor). Furthermore, adjusted for inflation, the cost of MMS was lower in 2009 vs 1998.¹⁶ Similar results have been consistently demonstrated.¹⁷

Controversies in the AUC

To provide clinicians, policy makers, and insurers guidance for utilization of MMS in the setting of concerns for overutilization, overcompensation, and inappropriate application, the MMS AUC were established in 2012. The guidelines were developed by a process integrating evidence-based medicine, clinical experience, and expert opinion and is applicable to 270 clinical scenarios.¹⁸

A unique set of debate accompanies the guidelines. Namely, controversy has surrounded the classification of most primary superficial basal cell carcinomas as appropriate for treatment by MMS. These tumors have comparable cure rates when treated by MMS or curettage and cryosurgery, are often multifocal and require more Mohs stages than other basal cell carcinoma subtypes, and largely lack data on recurrence and invasion.¹⁹ The guidelines also have been scrutinized for including only studies from the United States.²⁰ Furthermore, the report is largely based on expert opinion rather than evidence.

Some Mohs surgeons have concerns that the guidelines will minimize clinical judgment. Nonetheless, deviations from the AUC practiced by Mohs surgeons have been reported where clinical judgment supplants guideline criteria. The most commonly cited reasons for performing MMS on tumors classified as uncertain or inappropriate, according to one study by Ruiz et al,²¹ included performing multiple MMSs on the same day, tumor location on the lower legs, and incorporation into an adjacent wound. Reported discrepancies in the AUC further emphasize the importance of clinical judgment and call into question the need for future revision of the criteria.²² For example, a primary squamous cell carcinoma in situ greater than or equal to 2 cm located on the trunk and extremities (excluding pretibial surfaces, hands, feet, nail units, and ankles) in a healthy patient is categorized as appropriate, while a recurrent but otherwise identical squamous cell carcinoma in situ is categorized as uncertain. These counterintuitive criteria are unsupported by existing studies.

Controversies in Subspecialty Certification

Recently, debate also has surfaced regarding subspecialty certification. Over the last decade, proponents of subspecialty certification have argued that board certification would bring consistency and decrease divisiveness among dermatologists; help to prevent exclusion of Mohs surgeons from insurance networks and teaching opportunities at the Veterans Administration; and demonstrate competence to patients, the media, and payers. Those in opposition contest that practices may be restricted by insurers using lack of certification to eliminate dermatologists from their networks, economic credentialing may be applied to dermatologists such that those without the subspecialty certification may not be deemed qualified to manage skin cancer, major limitations may be set determining which dermatologists can sit for the certification examination, and subspecialty certification could create disenfranchisement of many dermatologists. A 2017 American Academy of Dermatology member survey demonstrated ambivalence regarding subcertification, with 51% of respondents pro-subcertification and 48% anti-subcertification.²³

Nonetheless, after years of debate the American Board of Dermatology proposed subspecialty certification in Micrographic Dermatologic Surgery, which was approved by the American Board of Medical Specialties on October 26, 2018. The first certification examination will likely take place in 2 years, and a maintenance of certification examination will be required every 10 years.²⁴

Final Thoughts

Further investigation is needed to elucidate and optimize solutions to many of the current controversies associated with MMS.

Mohs micrographic surgery (MMS) has been met with controversy since its inception in the 1930s. Current debate centers on the types of tumors treated with MMS, increasing utilization, third-party payer reimbursement, the Appropriate Use Criteria (AUC), and subspecialty certification.

Controversies in Applications

Controversy surrounding treatment with MMS for certain tumor types is abundant, in large part due to a lack of well-designed studies. Perhaps most notably, the surgical management of melanoma has been hotly contested for decades.¹ An increasing number of Mohs surgeons advocate the use of MMS for treatment of melanoma. Advocates reason that tumor margins may be ill-defined, necessitating histologic examination of the margin for tumor clearance. In a study by Zitelli et al,² 5-year survival and metastatic rates for 535 patients with melanomas treated by MMS with frozen sections were the same or better when compared to historical controls treated with conventional wide local excision. Melanoma-associated antigen recognized by T cells (MART-1) immunostaining may offer improved diagnostic accuracy.³ Others believe that staged excision with permanent sections processed vertically, en face, or horizontally (“slow Mohs”) is more accurate and efficacious for the treatment of melanoma.¹ Advocates of this approach maintain that when compared to MMS with frozen sections, staged excision with permanent sections enables more accurate interpretation of residual melanoma and atypical junctional melanocytic hyperplasia as well as circumvents difficulty in interpreting freeze artifact.⁴

Although Merkel cell carcinoma has traditionally been treated with wide local excision, MMS with or without adjuvant radiotherapy has gained traction as a treatment option. Advocates for treatment by MMS hold that Merkel cell carcinoma is a contiguous tumor with a high rate of residual tumor persistence, making histologic margin control an ideal characteristic of treatment. However, in the absence of large randomized controlled studies comparing MMS to wide local excision, controversy surrounds the most appropriate surgical approach.¹ In a retrospective study of 86 patients by O’Connor et al,⁵ MMS was demonstrated to compare favorably to standard surgical excision. Standard surgical excision was associated with a 31.7% (13/41) local persistence rate and 48.8% (20/41) regional metastasis rate compared to 8.3% (1/12) and 33.3% (4/12) for MMS, respectively.⁵

Controversies in Increasing Utilization

The incidence of skin cancers has increased in recent years. As a result, it is reasonable to expect the rates of MMS to increase. Nonetheless, there is escalating concern among groups of third-party payers, the public, and physicians that MMS is being overused.⁶ Growth of the body of evidence supporting the appropriateness of MMS remains essential. Such studies continue to support reasons for increased MMS usage, demonstrating the stability of the percentage of skin cancers treated with MMS in the setting of increasing skin cancer incidence, the procedure’s superior efficacy for appropriately chosen cases, its expanding application to melanoma and other tumors, and an emphasis of MMS in residency training programs.^6-9

A current hot topic of controversy focuses on the wide variation among Mohs surgeons in the mean number of stages used to resect a tumor. Overuse among outliers has been proposed to stem from lack of technical expertise or from abuse of the current fee-for-service payment model, which bases compensation on the number of stages performed. A study by Krishnan et al¹⁰ determined that the mean number of stages per tumor in the studied population (all physicians [N=2305] receiving Medicare payments for MMS from January 2012 to December 2014) was 1.74, with a range of 1.09 to 4.11. Persistently high outliers were more likely to perform MMS in a solo practice, with an odds ratio of 2.35.¹⁰ In response to the wide variation in mean stages used to resect a skin cancer and its implications on increased financial burden and surgery to individual patients, intervention has been proposed. Notably, it has been demonstrated that mailing out individual reports of practice patterns to high-outlier physicians resulted in a reduction in mean stages per tumor as well as an associated cost savings when compared to outlier physicians who did not receive these reports.¹¹

Controversies in Reimbursement

Mohs micrographic surgery also has been in the spotlight for debate regarding reimbursement. The procedure has been targeted partly in response to its substantial contribution to total Medicare reimbursements paid out. In 2013, primary MMS billing codes constituted nearly 19% of total reimbursements to dermatologists and approximately 0.5% of total reimbursements to all physicians participating in Medicare.¹² Mohs micrographic surgery codes have correspondingly received frequent review by the Relative Value Scale Update Committee and remained on a list of potentially misvalued services according to the Centers for Medicare & Medicaid Services for years.¹³ Due to continued scrutiny and review, especially by the Relative Value Scale Update Committee and Centers for Medicare & Medicaid Services, reimbursement to perform MMS and reconstructive surgery has gone down by more than 20% in the last 15 years.¹⁴ Public perception mirrors third-party payer concerns for overcompensation. An article title in the New York Times theatrically postures “Patients’ Costs Skyrocket, Specialists’ Incomes Soar.” The article recounts an MMS patient’s “outrage at charges” associated with treatment of her “minor medical problem” and the simultaneous “sharp climb” in dermatologist income over the last 2 decades.¹⁵

However, studies continue to demonstrate the cost-effectiveness of MMS. A study by Ravitskiy et al¹⁶ demonstrates the cost-effectiveness of MMS, regardless of place of service or type of tumor. Of 406 tumors studied, MMS was the least expensive surgical procedure evaluated ($805 per tumor) when compared to standard surgical excision with permanent margins ($1026 per tumor), standard surgical excision with frozen margins ($1200 per tumor), and ambulatory surgery center standard surgical excision ($2507 per tumor). Furthermore, adjusted for inflation, the cost of MMS was lower in 2009 vs 1998.¹⁶ Similar results have been consistently demonstrated.¹⁷

Controversies in the AUC

To provide clinicians, policy makers, and insurers guidance for utilization of MMS in the setting of concerns for overutilization, overcompensation, and inappropriate application, the MMS AUC were established in 2012. The guidelines were developed by a process integrating evidence-based medicine, clinical experience, and expert opinion and is applicable to 270 clinical scenarios.¹⁸

A unique set of debate accompanies the guidelines. Namely, controversy has surrounded the classification of most primary superficial basal cell carcinomas as appropriate for treatment by MMS. These tumors have comparable cure rates when treated by MMS or curettage and cryosurgery, are often multifocal and require more Mohs stages than other basal cell carcinoma subtypes, and largely lack data on recurrence and invasion.¹⁹ The guidelines also have been scrutinized for including only studies from the United States.²⁰ Furthermore, the report is largely based on expert opinion rather than evidence.

Some Mohs surgeons have concerns that the guidelines will minimize clinical judgment. Nonetheless, deviations from the AUC practiced by Mohs surgeons have been reported where clinical judgment supplants guideline criteria. The most commonly cited reasons for performing MMS on tumors classified as uncertain or inappropriate, according to one study by Ruiz et al,²¹ included performing multiple MMSs on the same day, tumor location on the lower legs, and incorporation into an adjacent wound. Reported discrepancies in the AUC further emphasize the importance of clinical judgment and call into question the need for future revision of the criteria.²² For example, a primary squamous cell carcinoma in situ greater than or equal to 2 cm located on the trunk and extremities (excluding pretibial surfaces, hands, feet, nail units, and ankles) in a healthy patient is categorized as appropriate, while a recurrent but otherwise identical squamous cell carcinoma in situ is categorized as uncertain. These counterintuitive criteria are unsupported by existing studies.

Controversies in Subspecialty Certification

Recently, debate also has surfaced regarding subspecialty certification. Over the last decade, proponents of subspecialty certification have argued that board certification would bring consistency and decrease divisiveness among dermatologists; help to prevent exclusion of Mohs surgeons from insurance networks and teaching opportunities at the Veterans Administration; and demonstrate competence to patients, the media, and payers. Those in opposition contest that practices may be restricted by insurers using lack of certification to eliminate dermatologists from their networks, economic credentialing may be applied to dermatologists such that those without the subspecialty certification may not be deemed qualified to manage skin cancer, major limitations may be set determining which dermatologists can sit for the certification examination, and subspecialty certification could create disenfranchisement of many dermatologists. A 2017 American Academy of Dermatology member survey demonstrated ambivalence regarding subcertification, with 51% of respondents pro-subcertification and 48% anti-subcertification.²³

Nonetheless, after years of debate the American Board of Dermatology proposed subspecialty certification in Micrographic Dermatologic Surgery, which was approved by the American Board of Medical Specialties on October 26, 2018. The first certification examination will likely take place in 2 years, and a maintenance of certification examination will be required every 10 years.²⁴

Final Thoughts

Further investigation is needed to elucidate and optimize solutions to many of the current controversies associated with MMS.

Mohs micrographic surgery (MMS) has been met with controversy since its inception in the 1930s. Current debate centers on the types of tumors treated with MMS, increasing utilization, third-party payer reimbursement, the Appropriate Use Criteria (AUC), and subspecialty certification.

Controversies in Applications

Controversy surrounding treatment with MMS for certain tumor types is abundant, in large part due to a lack of well-designed studies. Perhaps most notably, the surgical management of melanoma has been hotly contested for decades.¹ An increasing number of Mohs surgeons advocate the use of MMS for treatment of melanoma. Advocates reason that tumor margins may be ill-defined, necessitating histologic examination of the margin for tumor clearance. In a study by Zitelli et al,² 5-year survival and metastatic rates for 535 patients with melanomas treated by MMS with frozen sections were the same or better when compared to historical controls treated with conventional wide local excision. Melanoma-associated antigen recognized by T cells (MART-1) immunostaining may offer improved diagnostic accuracy.³ Others believe that staged excision with permanent sections processed vertically, en face, or horizontally (“slow Mohs”) is more accurate and efficacious for the treatment of melanoma.¹ Advocates of this approach maintain that when compared to MMS with frozen sections, staged excision with permanent sections enables more accurate interpretation of residual melanoma and atypical junctional melanocytic hyperplasia as well as circumvents difficulty in interpreting freeze artifact.⁴

Although Merkel cell carcinoma has traditionally been treated with wide local excision, MMS with or without adjuvant radiotherapy has gained traction as a treatment option. Advocates for treatment by MMS hold that Merkel cell carcinoma is a contiguous tumor with a high rate of residual tumor persistence, making histologic margin control an ideal characteristic of treatment. However, in the absence of large randomized controlled studies comparing MMS to wide local excision, controversy surrounds the most appropriate surgical approach.¹ In a retrospective study of 86 patients by O’Connor et al,⁵ MMS was demonstrated to compare favorably to standard surgical excision. Standard surgical excision was associated with a 31.7% (13/41) local persistence rate and 48.8% (20/41) regional metastasis rate compared to 8.3% (1/12) and 33.3% (4/12) for MMS, respectively.⁵

Controversies in Increasing Utilization

The incidence of skin cancers has increased in recent years. As a result, it is reasonable to expect the rates of MMS to increase. Nonetheless, there is escalating concern among groups of third-party payers, the public, and physicians that MMS is being overused.⁶ Growth of the body of evidence supporting the appropriateness of MMS remains essential. Such studies continue to support reasons for increased MMS usage, demonstrating the stability of the percentage of skin cancers treated with MMS in the setting of increasing skin cancer incidence, the procedure’s superior efficacy for appropriately chosen cases, its expanding application to melanoma and other tumors, and an emphasis of MMS in residency training programs.^6-9

A current hot topic of controversy focuses on the wide variation among Mohs surgeons in the mean number of stages used to resect a tumor. Overuse among outliers has been proposed to stem from lack of technical expertise or from abuse of the current fee-for-service payment model, which bases compensation on the number of stages performed. A study by Krishnan et al¹⁰ determined that the mean number of stages per tumor in the studied population (all physicians [N=2305] receiving Medicare payments for MMS from January 2012 to December 2014) was 1.74, with a range of 1.09 to 4.11. Persistently high outliers were more likely to perform MMS in a solo practice, with an odds ratio of 2.35.¹⁰ In response to the wide variation in mean stages used to resect a skin cancer and its implications on increased financial burden and surgery to individual patients, intervention has been proposed. Notably, it has been demonstrated that mailing out individual reports of practice patterns to high-outlier physicians resulted in a reduction in mean stages per tumor as well as an associated cost savings when compared to outlier physicians who did not receive these reports.¹¹

Controversies in Reimbursement

Mohs micrographic surgery also has been in the spotlight for debate regarding reimbursement. The procedure has been targeted partly in response to its substantial contribution to total Medicare reimbursements paid out. In 2013, primary MMS billing codes constituted nearly 19% of total reimbursements to dermatologists and approximately 0.5% of total reimbursements to all physicians participating in Medicare.¹² Mohs micrographic surgery codes have correspondingly received frequent review by the Relative Value Scale Update Committee and remained on a list of potentially misvalued services according to the Centers for Medicare & Medicaid Services for years.¹³ Due to continued scrutiny and review, especially by the Relative Value Scale Update Committee and Centers for Medicare & Medicaid Services, reimbursement to perform MMS and reconstructive surgery has gone down by more than 20% in the last 15 years.¹⁴ Public perception mirrors third-party payer concerns for overcompensation. An article title in the New York Times theatrically postures “Patients’ Costs Skyrocket, Specialists’ Incomes Soar.” The article recounts an MMS patient’s “outrage at charges” associated with treatment of her “minor medical problem” and the simultaneous “sharp climb” in dermatologist income over the last 2 decades.¹⁵

However, studies continue to demonstrate the cost-effectiveness of MMS. A study by Ravitskiy et al¹⁶ demonstrates the cost-effectiveness of MMS, regardless of place of service or type of tumor. Of 406 tumors studied, MMS was the least expensive surgical procedure evaluated ($805 per tumor) when compared to standard surgical excision with permanent margins ($1026 per tumor), standard surgical excision with frozen margins ($1200 per tumor), and ambulatory surgery center standard surgical excision ($2507 per tumor). Furthermore, adjusted for inflation, the cost of MMS was lower in 2009 vs 1998.¹⁶ Similar results have been consistently demonstrated.¹⁷

Controversies in the AUC

To provide clinicians, policy makers, and insurers guidance for utilization of MMS in the setting of concerns for overutilization, overcompensation, and inappropriate application, the MMS AUC were established in 2012. The guidelines were developed by a process integrating evidence-based medicine, clinical experience, and expert opinion and is applicable to 270 clinical scenarios.¹⁸

A unique set of debate accompanies the guidelines. Namely, controversy has surrounded the classification of most primary superficial basal cell carcinomas as appropriate for treatment by MMS. These tumors have comparable cure rates when treated by MMS or curettage and cryosurgery, are often multifocal and require more Mohs stages than other basal cell carcinoma subtypes, and largely lack data on recurrence and invasion.¹⁹ The guidelines also have been scrutinized for including only studies from the United States.²⁰ Furthermore, the report is largely based on expert opinion rather than evidence.

Some Mohs surgeons have concerns that the guidelines will minimize clinical judgment. Nonetheless, deviations from the AUC practiced by Mohs surgeons have been reported where clinical judgment supplants guideline criteria. The most commonly cited reasons for performing MMS on tumors classified as uncertain or inappropriate, according to one study by Ruiz et al,²¹ included performing multiple MMSs on the same day, tumor location on the lower legs, and incorporation into an adjacent wound. Reported discrepancies in the AUC further emphasize the importance of clinical judgment and call into question the need for future revision of the criteria.²² For example, a primary squamous cell carcinoma in situ greater than or equal to 2 cm located on the trunk and extremities (excluding pretibial surfaces, hands, feet, nail units, and ankles) in a healthy patient is categorized as appropriate, while a recurrent but otherwise identical squamous cell carcinoma in situ is categorized as uncertain. These counterintuitive criteria are unsupported by existing studies.

Controversies in Subspecialty Certification

Recently, debate also has surfaced regarding subspecialty certification. Over the last decade, proponents of subspecialty certification have argued that board certification would bring consistency and decrease divisiveness among dermatologists; help to prevent exclusion of Mohs surgeons from insurance networks and teaching opportunities at the Veterans Administration; and demonstrate competence to patients, the media, and payers. Those in opposition contest that practices may be restricted by insurers using lack of certification to eliminate dermatologists from their networks, economic credentialing may be applied to dermatologists such that those without the subspecialty certification may not be deemed qualified to manage skin cancer, major limitations may be set determining which dermatologists can sit for the certification examination, and subspecialty certification could create disenfranchisement of many dermatologists. A 2017 American Academy of Dermatology member survey demonstrated ambivalence regarding subcertification, with 51% of respondents pro-subcertification and 48% anti-subcertification.²³

Nonetheless, after years of debate the American Board of Dermatology proposed subspecialty certification in Micrographic Dermatologic Surgery, which was approved by the American Board of Medical Specialties on October 26, 2018. The first certification examination will likely take place in 2 years, and a maintenance of certification examination will be required every 10 years.²⁴

Final Thoughts

Further investigation is needed to elucidate and optimize solutions to many of the current controversies associated with MMS.

Dermatologist Dr. Jeffrey Benabio quipped, “The phrase ‘dermatologist burnout’ may seem as oxymoronic as jumbo shrimp, yet both are real.”¹ Indeed, dermatologists often self-report as among the happiest specialists both at work and home, according to the annual Medscape Physician Lifestyle and Happiness Report.² Similarly, others in the medical field may perceive dermatologists as low-stress providers—well-groomed, well-rested rays of sunshine, getting out of work every day at 5:00 pm to catch happy hour and live the #dermlife. However, the reality is that the syndrome of burnout does not spare our specialty. In fact, the low-stress perception of dermatologists may instead make recognizing burnout within others and ourselves challenging. Awareness of the notable prevalence of burnout within dermatology may facilitate identification and modification of associated predictors.

Burnout in Dermatology Residents

Burnout is a syndrome of emotional exhaustion, depersonalization, and a sense of reduced personal accomplishment that affects residents of all specialties³; however, there is a paucity of literature on burnout as it relates to dermatology. Although long work hours and schedule volatility have captured the focus of resident burnout conversations, a less discussed set of factors may contribute to dermatology resident burnout, such as increasing patient load, intensifying regulations, and an unrelenting pace of clinic. A recent survey study by Shoimer et al³ found that 61% of 116 participating Canadian dermatology residents cited examinations (including the board certifying examination) as their top stressor, followed by work (27%). Other stressors included family, relationships, finances, pressure from staff, research, and moving. More than 50% of dermatology residents surveyed experienced high levels of emotional exhaustion and depersonalization, while 40% demonstrated a low sense of personal accomplishment, all of which are determinants of the burnout syndrome.³

Comparison to Residents in Other Specialties

Although dermatology residents experience lower burnout rates than colleagues in other specialties, the absolute prevalence warrants attention. A recent study published in the Journal of the American Medical Association of 3588 second-year medical residents in the United States found that rates of burnout symptoms across clinical specialties ranged from 29.6% to 63.8%. The highest rates of burnout were found in urology (63.8%), neurology (61.6%), and ophthalmology (55.8%), but the lowest reported rate of burnout was demonstrated in dermatology (29.6%).⁴ Although dermatology ranked the lowest, that is still nearly a whopping 1 in 3 dermatology residents with burnout symptoms. The absolute prevalence should not be obscured by the ranking among other specialties.

Preventing Burnout

Several burnout prevention and coping strategies across specialties have been suggested.

Mindfulness and Self-awareness
A study by Chaukos et al⁵ found that mindfulness and self-awareness are resilience factors associated with resident burnout. Counseling is one strategy demonstrated to increase self-awareness. Mindfulness may be practiced through meditation or yoga. Regular meditation has been shown to improve mood and emotional stress.⁶ Similarly, yoga has been shown to yield physical, emotional, and psychological benefits to resdients.⁷

Work Factors
A supportive clinical faculty and receiving constructive monthly performance feedback have been negatively correlated with dermatology resident burnout.³ Other workplace interventions demonstrating utility in decreasing resident burnout include increasing staff awareness about burnout, increasing support for health professionals treating challenging populations, and ensuring a reasonable workload.⁶

Sleep
It has been demonstrated that sleeping less than 7 hours per night also is associated with resident burnout,⁷ yet it has been reported that 72% of dermatology residents fall into this category.³ Poor sleep quality has been shown to be a predictor of lower academic performance. It has been proposed that to minimize sleep deprivation and poor sleep quality, institutions should focus on programs that promote regular exercise, sleep hygiene, mindfulness, and time-out activities such as meditation.⁷

Social Support
Focusing on peers may foster the inner strength to endure suffering.¹ Venting, laughing, and discussing care with colleagues has been demonstrated to decrease anxiety.⁶ Work-related social networks may be strengthened through attendance at conferences, lectures, and professional organizations.⁷ Additionally, social supports and spending quality time with family have been demonstrated as negative predictors of dermatology resident burnout.³

Physical Exercise
Exercise has been demonstrated to improve mood, anxiety, and depression, thereby decreasing resident burnout.⁶

Final Thoughts

Burnout among dermatology residents warrants awareness, as it does in other medical specialties. Awareness may facilitate identification and prevention, the latter of which is perhaps best summarized by the words of psychologist Dr. Christina Maslach: “If all of the knowledge and advice about how to beat burnout could be summed up in 1 word, that word would be balance—balance between giving and getting, balance between stress and calm, balance between work and home.”⁸

Dermatologist Dr. Jeffrey Benabio quipped, “The phrase ‘dermatologist burnout’ may seem as oxymoronic as jumbo shrimp, yet both are real.”¹ Indeed, dermatologists often self-report as among the happiest specialists both at work and home, according to the annual Medscape Physician Lifestyle and Happiness Report.² Similarly, others in the medical field may perceive dermatologists as low-stress providers—well-groomed, well-rested rays of sunshine, getting out of work every day at 5:00 pm to catch happy hour and live the #dermlife. However, the reality is that the syndrome of burnout does not spare our specialty. In fact, the low-stress perception of dermatologists may instead make recognizing burnout within others and ourselves challenging. Awareness of the notable prevalence of burnout within dermatology may facilitate identification and modification of associated predictors.

Burnout in Dermatology Residents

Burnout is a syndrome of emotional exhaustion, depersonalization, and a sense of reduced personal accomplishment that affects residents of all specialties³; however, there is a paucity of literature on burnout as it relates to dermatology. Although long work hours and schedule volatility have captured the focus of resident burnout conversations, a less discussed set of factors may contribute to dermatology resident burnout, such as increasing patient load, intensifying regulations, and an unrelenting pace of clinic. A recent survey study by Shoimer et al³ found that 61% of 116 participating Canadian dermatology residents cited examinations (including the board certifying examination) as their top stressor, followed by work (27%). Other stressors included family, relationships, finances, pressure from staff, research, and moving. More than 50% of dermatology residents surveyed experienced high levels of emotional exhaustion and depersonalization, while 40% demonstrated a low sense of personal accomplishment, all of which are determinants of the burnout syndrome.³

Comparison to Residents in Other Specialties

Although dermatology residents experience lower burnout rates than colleagues in other specialties, the absolute prevalence warrants attention. A recent study published in the Journal of the American Medical Association of 3588 second-year medical residents in the United States found that rates of burnout symptoms across clinical specialties ranged from 29.6% to 63.8%. The highest rates of burnout were found in urology (63.8%), neurology (61.6%), and ophthalmology (55.8%), but the lowest reported rate of burnout was demonstrated in dermatology (29.6%).⁴ Although dermatology ranked the lowest, that is still nearly a whopping 1 in 3 dermatology residents with burnout symptoms. The absolute prevalence should not be obscured by the ranking among other specialties.

Preventing Burnout

Several burnout prevention and coping strategies across specialties have been suggested.

Mindfulness and Self-awareness
A study by Chaukos et al⁵ found that mindfulness and self-awareness are resilience factors associated with resident burnout. Counseling is one strategy demonstrated to increase self-awareness. Mindfulness may be practiced through meditation or yoga. Regular meditation has been shown to improve mood and emotional stress.⁶ Similarly, yoga has been shown to yield physical, emotional, and psychological benefits to resdients.⁷

Work Factors
A supportive clinical faculty and receiving constructive monthly performance feedback have been negatively correlated with dermatology resident burnout.³ Other workplace interventions demonstrating utility in decreasing resident burnout include increasing staff awareness about burnout, increasing support for health professionals treating challenging populations, and ensuring a reasonable workload.⁶

Sleep
It has been demonstrated that sleeping less than 7 hours per night also is associated with resident burnout,⁷ yet it has been reported that 72% of dermatology residents fall into this category.³ Poor sleep quality has been shown to be a predictor of lower academic performance. It has been proposed that to minimize sleep deprivation and poor sleep quality, institutions should focus on programs that promote regular exercise, sleep hygiene, mindfulness, and time-out activities such as meditation.⁷

Social Support
Focusing on peers may foster the inner strength to endure suffering.¹ Venting, laughing, and discussing care with colleagues has been demonstrated to decrease anxiety.⁶ Work-related social networks may be strengthened through attendance at conferences, lectures, and professional organizations.⁷ Additionally, social supports and spending quality time with family have been demonstrated as negative predictors of dermatology resident burnout.³

Physical Exercise
Exercise has been demonstrated to improve mood, anxiety, and depression, thereby decreasing resident burnout.⁶

Final Thoughts

Burnout among dermatology residents warrants awareness, as it does in other medical specialties. Awareness may facilitate identification and prevention, the latter of which is perhaps best summarized by the words of psychologist Dr. Christina Maslach: “If all of the knowledge and advice about how to beat burnout could be summed up in 1 word, that word would be balance—balance between giving and getting, balance between stress and calm, balance between work and home.”⁸

Dermatologist Dr. Jeffrey Benabio quipped, “The phrase ‘dermatologist burnout’ may seem as oxymoronic as jumbo shrimp, yet both are real.”¹ Indeed, dermatologists often self-report as among the happiest specialists both at work and home, according to the annual Medscape Physician Lifestyle and Happiness Report.² Similarly, others in the medical field may perceive dermatologists as low-stress providers—well-groomed, well-rested rays of sunshine, getting out of work every day at 5:00 pm to catch happy hour and live the #dermlife. However, the reality is that the syndrome of burnout does not spare our specialty. In fact, the low-stress perception of dermatologists may instead make recognizing burnout within others and ourselves challenging. Awareness of the notable prevalence of burnout within dermatology may facilitate identification and modification of associated predictors.

Burnout in Dermatology Residents

Burnout is a syndrome of emotional exhaustion, depersonalization, and a sense of reduced personal accomplishment that affects residents of all specialties³; however, there is a paucity of literature on burnout as it relates to dermatology. Although long work hours and schedule volatility have captured the focus of resident burnout conversations, a less discussed set of factors may contribute to dermatology resident burnout, such as increasing patient load, intensifying regulations, and an unrelenting pace of clinic. A recent survey study by Shoimer et al³ found that 61% of 116 participating Canadian dermatology residents cited examinations (including the board certifying examination) as their top stressor, followed by work (27%). Other stressors included family, relationships, finances, pressure from staff, research, and moving. More than 50% of dermatology residents surveyed experienced high levels of emotional exhaustion and depersonalization, while 40% demonstrated a low sense of personal accomplishment, all of which are determinants of the burnout syndrome.³

Comparison to Residents in Other Specialties

Although dermatology residents experience lower burnout rates than colleagues in other specialties, the absolute prevalence warrants attention. A recent study published in the Journal of the American Medical Association of 3588 second-year medical residents in the United States found that rates of burnout symptoms across clinical specialties ranged from 29.6% to 63.8%. The highest rates of burnout were found in urology (63.8%), neurology (61.6%), and ophthalmology (55.8%), but the lowest reported rate of burnout was demonstrated in dermatology (29.6%).⁴ Although dermatology ranked the lowest, that is still nearly a whopping 1 in 3 dermatology residents with burnout symptoms. The absolute prevalence should not be obscured by the ranking among other specialties.

Preventing Burnout

Several burnout prevention and coping strategies across specialties have been suggested.

Mindfulness and Self-awareness
A study by Chaukos et al⁵ found that mindfulness and self-awareness are resilience factors associated with resident burnout. Counseling is one strategy demonstrated to increase self-awareness. Mindfulness may be practiced through meditation or yoga. Regular meditation has been shown to improve mood and emotional stress.⁶ Similarly, yoga has been shown to yield physical, emotional, and psychological benefits to resdients.⁷

Work Factors
A supportive clinical faculty and receiving constructive monthly performance feedback have been negatively correlated with dermatology resident burnout.³ Other workplace interventions demonstrating utility in decreasing resident burnout include increasing staff awareness about burnout, increasing support for health professionals treating challenging populations, and ensuring a reasonable workload.⁶

Sleep
It has been demonstrated that sleeping less than 7 hours per night also is associated with resident burnout,⁷ yet it has been reported that 72% of dermatology residents fall into this category.³ Poor sleep quality has been shown to be a predictor of lower academic performance. It has been proposed that to minimize sleep deprivation and poor sleep quality, institutions should focus on programs that promote regular exercise, sleep hygiene, mindfulness, and time-out activities such as meditation.⁷

Social Support
Focusing on peers may foster the inner strength to endure suffering.¹ Venting, laughing, and discussing care with colleagues has been demonstrated to decrease anxiety.⁶ Work-related social networks may be strengthened through attendance at conferences, lectures, and professional organizations.⁷ Additionally, social supports and spending quality time with family have been demonstrated as negative predictors of dermatology resident burnout.³

Physical Exercise
Exercise has been demonstrated to improve mood, anxiety, and depression, thereby decreasing resident burnout.⁶

Final Thoughts

Burnout among dermatology residents warrants awareness, as it does in other medical specialties. Awareness may facilitate identification and prevention, the latter of which is perhaps best summarized by the words of psychologist Dr. Christina Maslach: “If all of the knowledge and advice about how to beat burnout could be summed up in 1 word, that word would be balance—balance between giving and getting, balance between stress and calm, balance between work and home.”⁸

Practice Gap

Common donor sites for split-thickness skin grafts (STSGs) include the abdomen, buttocks, inner upper arms and forearms, and thighs. Challenges associated with donor site wounds in these areas include slow healing times and poor scar cosmesis. Although the scalp is not commonly considered when selecting a STSG donor site, harvesting from this area yields optimal results to improve these shortcomings.

Tools

A Weck knife facilitates STSG harvesting in an operationally timely, convenient fashion from larger donor sites up to 5.5 cm in width, such as the scalp, using adjustable thickness control guards.

The Technique

The donor site is lubricated with a sterile mineral oil. An assistant provides tension, leading the trajectory of the Weck knife with a guard. Small, gentle, back-and-forth strokes are made with the Weck knife to harvest the graft, which is then meshed with a No. 15 blade by placing the belly of the blade on the tissue and rolling it to-and-fro. The recipient site cartilage is fenestrated with a 2-mm punch biopsy.

A 48-year-old man underwent Mohs micrographic surgery for treatment of a primary basal cell carcinoma of the left helix, resulting in a 2.5×1.3-cm defect after 2 stages. A Weck knife with a 0.012-in guard was used to harvest an STSG from the postauricular scalp (Figure, A), and the graft was inset to the recipient wound bed. Hemostasis at the scalp donor site was achieved through application of pressure and sterile gauze that was saturated with local 1% lidocaine anesthesia containing 1:400,000 epinephrine. Both recipient and donor sites were dressed with tie-over bolsters that were sutured into place. At 2-week follow-up, the donor site was fully reepithelialized and hair regrowth obscured the defect (Figure, B).

Practice Implications

Our case demonstrates the advantages of the scalp as an STSG donor site with prompt healing time and excellent cosmesis. Because grafts are harvested at a depth superficial to the hair follicle, the hair regrows to conceal the donor site scar. Additionally, the robust blood supply of the scalp and hair follicle density optimize healing time. The location of the donor site at the postauricular scalp facilitates accessibility for wound care by the patient. Electrocautery or chemical styptics used for hemostasis may traumatize the hair follicles and risk causing alopecia; therefore, as demonstrated in our case, the preferred method to achieve hemostasis is the use of pressure or application of sterile gauze that has been saturated with local 1% lidocaine anesthesia containing 1:400,000 epinephrine, followed by a pressure dressing provided by a sutured bolster.

Our case also demonstrates the utility of the Weck knife, which was introduced in 1968 as a modification of existing instruments to improve the ease of harvesting STSGs by appending a fixed handle and interchangeable depth gauges to a straight razor.^1,2 The Weck knife can obtain grafts up to 5.5 cm in width (length may be as long as anatomically available), often circumventing the need to overlap grafts of smaller widths for repair of larger defects. Furthermore, grafts are harvested at a depth superficial to the hair follicle, averting donor site alopecia. These characteristics make the technique an ideal option for harvesting grafts from the scalp and other large donor sites.

Limitations of the Weck knife technique include the inability to harvest grafts from small donor sites in difficult-to-access anatomic regions or from areas with notable 3-dimensional structure. For harvesting such grafts, we prefer the DermaBlade (AccuTec Blades). Furthermore, assistance for providing tension along the trajectory of the Weck blade with a guard is optimal when performing the procedure. For practices not already utilizing a Weck knife, the technique necessitates additional training and cost. Nonetheless, for STSGs in which large donor site surface area, adjustable thickness, and convenient and timely operational technique are desired, the Weck knife should be considered as part of the dermatologic surgeon’s armamentarium.

Practice Gap

Common donor sites for split-thickness skin grafts (STSGs) include the abdomen, buttocks, inner upper arms and forearms, and thighs. Challenges associated with donor site wounds in these areas include slow healing times and poor scar cosmesis. Although the scalp is not commonly considered when selecting a STSG donor site, harvesting from this area yields optimal results to improve these shortcomings.

Tools

A Weck knife facilitates STSG harvesting in an operationally timely, convenient fashion from larger donor sites up to 5.5 cm in width, such as the scalp, using adjustable thickness control guards.

The Technique

The donor site is lubricated with a sterile mineral oil. An assistant provides tension, leading the trajectory of the Weck knife with a guard. Small, gentle, back-and-forth strokes are made with the Weck knife to harvest the graft, which is then meshed with a No. 15 blade by placing the belly of the blade on the tissue and rolling it to-and-fro. The recipient site cartilage is fenestrated with a 2-mm punch biopsy.

A 48-year-old man underwent Mohs micrographic surgery for treatment of a primary basal cell carcinoma of the left helix, resulting in a 2.5×1.3-cm defect after 2 stages. A Weck knife with a 0.012-in guard was used to harvest an STSG from the postauricular scalp (Figure, A), and the graft was inset to the recipient wound bed. Hemostasis at the scalp donor site was achieved through application of pressure and sterile gauze that was saturated with local 1% lidocaine anesthesia containing 1:400,000 epinephrine. Both recipient and donor sites were dressed with tie-over bolsters that were sutured into place. At 2-week follow-up, the donor site was fully reepithelialized and hair regrowth obscured the defect (Figure, B).

Practice Implications

Our case demonstrates the advantages of the scalp as an STSG donor site with prompt healing time and excellent cosmesis. Because grafts are harvested at a depth superficial to the hair follicle, the hair regrows to conceal the donor site scar. Additionally, the robust blood supply of the scalp and hair follicle density optimize healing time. The location of the donor site at the postauricular scalp facilitates accessibility for wound care by the patient. Electrocautery or chemical styptics used for hemostasis may traumatize the hair follicles and risk causing alopecia; therefore, as demonstrated in our case, the preferred method to achieve hemostasis is the use of pressure or application of sterile gauze that has been saturated with local 1% lidocaine anesthesia containing 1:400,000 epinephrine, followed by a pressure dressing provided by a sutured bolster.

Our case also demonstrates the utility of the Weck knife, which was introduced in 1968 as a modification of existing instruments to improve the ease of harvesting STSGs by appending a fixed handle and interchangeable depth gauges to a straight razor.^1,2 The Weck knife can obtain grafts up to 5.5 cm in width (length may be as long as anatomically available), often circumventing the need to overlap grafts of smaller widths for repair of larger defects. Furthermore, grafts are harvested at a depth superficial to the hair follicle, averting donor site alopecia. These characteristics make the technique an ideal option for harvesting grafts from the scalp and other large donor sites.

Limitations of the Weck knife technique include the inability to harvest grafts from small donor sites in difficult-to-access anatomic regions or from areas with notable 3-dimensional structure. For harvesting such grafts, we prefer the DermaBlade (AccuTec Blades). Furthermore, assistance for providing tension along the trajectory of the Weck blade with a guard is optimal when performing the procedure. For practices not already utilizing a Weck knife, the technique necessitates additional training and cost. Nonetheless, for STSGs in which large donor site surface area, adjustable thickness, and convenient and timely operational technique are desired, the Weck knife should be considered as part of the dermatologic surgeon’s armamentarium.

Practice Gap

Common donor sites for split-thickness skin grafts (STSGs) include the abdomen, buttocks, inner upper arms and forearms, and thighs. Challenges associated with donor site wounds in these areas include slow healing times and poor scar cosmesis. Although the scalp is not commonly considered when selecting a STSG donor site, harvesting from this area yields optimal results to improve these shortcomings.

Tools

A Weck knife facilitates STSG harvesting in an operationally timely, convenient fashion from larger donor sites up to 5.5 cm in width, such as the scalp, using adjustable thickness control guards.

The Technique

The donor site is lubricated with a sterile mineral oil. An assistant provides tension, leading the trajectory of the Weck knife with a guard. Small, gentle, back-and-forth strokes are made with the Weck knife to harvest the graft, which is then meshed with a No. 15 blade by placing the belly of the blade on the tissue and rolling it to-and-fro. The recipient site cartilage is fenestrated with a 2-mm punch biopsy.

A 48-year-old man underwent Mohs micrographic surgery for treatment of a primary basal cell carcinoma of the left helix, resulting in a 2.5×1.3-cm defect after 2 stages. A Weck knife with a 0.012-in guard was used to harvest an STSG from the postauricular scalp (Figure, A), and the graft was inset to the recipient wound bed. Hemostasis at the scalp donor site was achieved through application of pressure and sterile gauze that was saturated with local 1% lidocaine anesthesia containing 1:400,000 epinephrine. Both recipient and donor sites were dressed with tie-over bolsters that were sutured into place. At 2-week follow-up, the donor site was fully reepithelialized and hair regrowth obscured the defect (Figure, B).

Practice Implications

Our case demonstrates the advantages of the scalp as an STSG donor site with prompt healing time and excellent cosmesis. Because grafts are harvested at a depth superficial to the hair follicle, the hair regrows to conceal the donor site scar. Additionally, the robust blood supply of the scalp and hair follicle density optimize healing time. The location of the donor site at the postauricular scalp facilitates accessibility for wound care by the patient. Electrocautery or chemical styptics used for hemostasis may traumatize the hair follicles and risk causing alopecia; therefore, as demonstrated in our case, the preferred method to achieve hemostasis is the use of pressure or application of sterile gauze that has been saturated with local 1% lidocaine anesthesia containing 1:400,000 epinephrine, followed by a pressure dressing provided by a sutured bolster.

Our case also demonstrates the utility of the Weck knife, which was introduced in 1968 as a modification of existing instruments to improve the ease of harvesting STSGs by appending a fixed handle and interchangeable depth gauges to a straight razor.^1,2 The Weck knife can obtain grafts up to 5.5 cm in width (length may be as long as anatomically available), often circumventing the need to overlap grafts of smaller widths for repair of larger defects. Furthermore, grafts are harvested at a depth superficial to the hair follicle, averting donor site alopecia. These characteristics make the technique an ideal option for harvesting grafts from the scalp and other large donor sites.

Limitations of the Weck knife technique include the inability to harvest grafts from small donor sites in difficult-to-access anatomic regions or from areas with notable 3-dimensional structure. For harvesting such grafts, we prefer the DermaBlade (AccuTec Blades). Furthermore, assistance for providing tension along the trajectory of the Weck blade with a guard is optimal when performing the procedure. For practices not already utilizing a Weck knife, the technique necessitates additional training and cost. Nonetheless, for STSGs in which large donor site surface area, adjustable thickness, and convenient and timely operational technique are desired, the Weck knife should be considered as part of the dermatologic surgeon’s armamentarium.

Originating in 1968, the dermatologic surgery fellowship is as young as many dermatologists in practice today. Not surprisingly, the blossoming fellowship has undergone its fair share of both growth and growing pains over the last 5 decades. 

A Brief History

The first dermatologic surgery fellowship was born in 1968 when Dr. Perry Robins established a program at the New York University Medical Center for training in chemosurgery.¹ The fellowship quickly underwent notable change with the rising popularity of the fresh tissue technique, which was first performed by Dr. Fred Mohs in 1953 and made popular following publication of a series of landmark articles on the technique by Drs. Sam Stegman and Theodore Tromovitch in the late 1960s and early 1970s. The fellowship correspondingly saw a rise in fresh tissue technique training, accompanied by a decline in chemosurgery training. In 1974, Dr. Daniel Jones coined the term micrographic surgery to describe the favored technique, and at the 1985 annual meeting of the American College of Chemosurgery, the name of the technique was changed to Mohs micrographic surgery.¹

By 1995, the fellowship was officially named Procedural Dermatology, and programs were exclusively accredited by the American College of Mohs Surgery (ACMS). A 1-year Procedural Dermatology fellowship gained accreditation by the Accreditation Council for Graduate Medical Education (ACGME) in 2003.² Beginning in July 2013, all fellowship programs in the United States fell under the governance of the ACGME; however, the ACMS has remained the sponsor of the matching process.³ In 2014, the ACGME changed the name of the fellowship to Micrographic Surgery and Dermatologic Oncology (MSDO).² Fellowship training today is centered on the core elements of cutaneous oncologic surgery, cutaneous reconstructive surgery, and dermatologic oncology; however, the scope of training in technologies and techniques offered has continued to broaden.⁴ Many programs now offer additional training in cosmetic and other procedural dermatology. To date, there are 76 accredited MSDO fellowship training programs in the United States and more than 1500 fellowship-trained micrographic surgeons.^2,4

Trends in Program and Match Statistics

As the role of dermatologic surgery within the field of dermatology continues to expand, the MSDO fellowship has become increasingly popular over the last decade. From 2005 to 2018, applicants participating in the fellowship match increased by 34%.³ Despite the fellowship’s growing popularity, programs participating in the match have remained largely stable from 2005 to 2018, with 50 positions offered in 2005 and 58 in 2018. The match rate has correspondingly decreased from 66.2% in 2005 to 61.1% in 2018.³ 

Changes in the Match Process

The fellowship match is processed by the SF Match and sponsored by the ACMS. Over the last decade, programs have increasingly opted for exemptions from participation in the SF Match. In 2005, there were 8 match exemptions. In 2018, there were 20.⁴ Despite the increasing popularity of match exemptions, in October 2018 the ACMS Board of Directors approved a new policy that eliminated match exemptions, with the exception of applicants on active military duty and international (non-Canadian) applicants. All other applicants applying for a fellowship position for the 2020-2021 academic year must participate in the match.⁴ This new policy attempts to ensure a fair match process, especially for applicants who have trained at a program without an affiliated MSDO fellowship. 

The Road to Board Certification

Further growth during the fellowship’s mid-adult years centered on the long-contested debate on subspecialty board certification. In 2009, an American Society for Dermatologic Surgery membership survey demonstrated an overwhelming majority in opposition. In 2014, the debate resurfaced. At the 2016 American Society for Dermatologic Surgery annual meeting, former American Academy of Dermatology presidents Brett Coldiron, MD, and Darrell S. Rigel, MD, MS, conveyed opposing positions, after which an audience survey demonstrated a 69% opposition rate. Proponents continued to argue that board certification would decrease divisiveness in the specialty, create a better brand, help to obtain a Medicare specialty designation that could help prevent exclusion of Mohs surgeons from insurance networks, give allopathic dermatologists the same opportunity for certification as osteopathic counterparts, and demonstrate competence to the public. Those in opposition argued that the term dermatologic oncology erroneously suggests general dermatologists are not experts in the treatment of skin cancers, practices may be restricted by carriers misusing the new credential, and subspecialty certification would actually create division among practicing dermatologists.⁵

Following years of debate, the American Board of Dermatology’s proposal to offer subspecialty certification in Micrographic Dermatologic Surgery was submitted to the American Board of Medical Specialties and approved on October 26, 2018. The name of the new subspecialty (Micrographic Dermatologic Surgery) is different than that of the fellowship (Micrographic Surgery and Dermatologic Oncology), a decision reached in response to diplomats indicating discomfort with the term oncology potentially misleading the public that general dermatologists do not treat skin cancer. Per the American Board of Dermatology official website, the first certification examination likely will take place in about 2 years. A maintenance of certification examination for the subspecialty will be required every 10 years.⁶

Final Thoughts 

During its short history, the MSDO fellowship has undergone a notable evolution in recognition, popularity among residents, match process, and board certification, which attests to its adaptability over time and growing prominence.

Originating in 1968, the dermatologic surgery fellowship is as young as many dermatologists in practice today. Not surprisingly, the blossoming fellowship has undergone its fair share of both growth and growing pains over the last 5 decades. 

A Brief History

The first dermatologic surgery fellowship was born in 1968 when Dr. Perry Robins established a program at the New York University Medical Center for training in chemosurgery.¹ The fellowship quickly underwent notable change with the rising popularity of the fresh tissue technique, which was first performed by Dr. Fred Mohs in 1953 and made popular following publication of a series of landmark articles on the technique by Drs. Sam Stegman and Theodore Tromovitch in the late 1960s and early 1970s. The fellowship correspondingly saw a rise in fresh tissue technique training, accompanied by a decline in chemosurgery training. In 1974, Dr. Daniel Jones coined the term micrographic surgery to describe the favored technique, and at the 1985 annual meeting of the American College of Chemosurgery, the name of the technique was changed to Mohs micrographic surgery.¹

By 1995, the fellowship was officially named Procedural Dermatology, and programs were exclusively accredited by the American College of Mohs Surgery (ACMS). A 1-year Procedural Dermatology fellowship gained accreditation by the Accreditation Council for Graduate Medical Education (ACGME) in 2003.² Beginning in July 2013, all fellowship programs in the United States fell under the governance of the ACGME; however, the ACMS has remained the sponsor of the matching process.³ In 2014, the ACGME changed the name of the fellowship to Micrographic Surgery and Dermatologic Oncology (MSDO).² Fellowship training today is centered on the core elements of cutaneous oncologic surgery, cutaneous reconstructive surgery, and dermatologic oncology; however, the scope of training in technologies and techniques offered has continued to broaden.⁴ Many programs now offer additional training in cosmetic and other procedural dermatology. To date, there are 76 accredited MSDO fellowship training programs in the United States and more than 1500 fellowship-trained micrographic surgeons.^2,4

Trends in Program and Match Statistics

As the role of dermatologic surgery within the field of dermatology continues to expand, the MSDO fellowship has become increasingly popular over the last decade. From 2005 to 2018, applicants participating in the fellowship match increased by 34%.³ Despite the fellowship’s growing popularity, programs participating in the match have remained largely stable from 2005 to 2018, with 50 positions offered in 2005 and 58 in 2018. The match rate has correspondingly decreased from 66.2% in 2005 to 61.1% in 2018.³ 

Changes in the Match Process

The fellowship match is processed by the SF Match and sponsored by the ACMS. Over the last decade, programs have increasingly opted for exemptions from participation in the SF Match. In 2005, there were 8 match exemptions. In 2018, there were 20.⁴ Despite the increasing popularity of match exemptions, in October 2018 the ACMS Board of Directors approved a new policy that eliminated match exemptions, with the exception of applicants on active military duty and international (non-Canadian) applicants. All other applicants applying for a fellowship position for the 2020-2021 academic year must participate in the match.⁴ This new policy attempts to ensure a fair match process, especially for applicants who have trained at a program without an affiliated MSDO fellowship. 

The Road to Board Certification

Further growth during the fellowship’s mid-adult years centered on the long-contested debate on subspecialty board certification. In 2009, an American Society for Dermatologic Surgery membership survey demonstrated an overwhelming majority in opposition. In 2014, the debate resurfaced. At the 2016 American Society for Dermatologic Surgery annual meeting, former American Academy of Dermatology presidents Brett Coldiron, MD, and Darrell S. Rigel, MD, MS, conveyed opposing positions, after which an audience survey demonstrated a 69% opposition rate. Proponents continued to argue that board certification would decrease divisiveness in the specialty, create a better brand, help to obtain a Medicare specialty designation that could help prevent exclusion of Mohs surgeons from insurance networks, give allopathic dermatologists the same opportunity for certification as osteopathic counterparts, and demonstrate competence to the public. Those in opposition argued that the term dermatologic oncology erroneously suggests general dermatologists are not experts in the treatment of skin cancers, practices may be restricted by carriers misusing the new credential, and subspecialty certification would actually create division among practicing dermatologists.⁵

Following years of debate, the American Board of Dermatology’s proposal to offer subspecialty certification in Micrographic Dermatologic Surgery was submitted to the American Board of Medical Specialties and approved on October 26, 2018. The name of the new subspecialty (Micrographic Dermatologic Surgery) is different than that of the fellowship (Micrographic Surgery and Dermatologic Oncology), a decision reached in response to diplomats indicating discomfort with the term oncology potentially misleading the public that general dermatologists do not treat skin cancer. Per the American Board of Dermatology official website, the first certification examination likely will take place in about 2 years. A maintenance of certification examination for the subspecialty will be required every 10 years.⁶

Final Thoughts 

During its short history, the MSDO fellowship has undergone a notable evolution in recognition, popularity among residents, match process, and board certification, which attests to its adaptability over time and growing prominence.

Originating in 1968, the dermatologic surgery fellowship is as young as many dermatologists in practice today. Not surprisingly, the blossoming fellowship has undergone its fair share of both growth and growing pains over the last 5 decades. 

A Brief History

The first dermatologic surgery fellowship was born in 1968 when Dr. Perry Robins established a program at the New York University Medical Center for training in chemosurgery.¹ The fellowship quickly underwent notable change with the rising popularity of the fresh tissue technique, which was first performed by Dr. Fred Mohs in 1953 and made popular following publication of a series of landmark articles on the technique by Drs. Sam Stegman and Theodore Tromovitch in the late 1960s and early 1970s. The fellowship correspondingly saw a rise in fresh tissue technique training, accompanied by a decline in chemosurgery training. In 1974, Dr. Daniel Jones coined the term micrographic surgery to describe the favored technique, and at the 1985 annual meeting of the American College of Chemosurgery, the name of the technique was changed to Mohs micrographic surgery.¹

By 1995, the fellowship was officially named Procedural Dermatology, and programs were exclusively accredited by the American College of Mohs Surgery (ACMS). A 1-year Procedural Dermatology fellowship gained accreditation by the Accreditation Council for Graduate Medical Education (ACGME) in 2003.² Beginning in July 2013, all fellowship programs in the United States fell under the governance of the ACGME; however, the ACMS has remained the sponsor of the matching process.³ In 2014, the ACGME changed the name of the fellowship to Micrographic Surgery and Dermatologic Oncology (MSDO).² Fellowship training today is centered on the core elements of cutaneous oncologic surgery, cutaneous reconstructive surgery, and dermatologic oncology; however, the scope of training in technologies and techniques offered has continued to broaden.⁴ Many programs now offer additional training in cosmetic and other procedural dermatology. To date, there are 76 accredited MSDO fellowship training programs in the United States and more than 1500 fellowship-trained micrographic surgeons.^2,4

Trends in Program and Match Statistics

As the role of dermatologic surgery within the field of dermatology continues to expand, the MSDO fellowship has become increasingly popular over the last decade. From 2005 to 2018, applicants participating in the fellowship match increased by 34%.³ Despite the fellowship’s growing popularity, programs participating in the match have remained largely stable from 2005 to 2018, with 50 positions offered in 2005 and 58 in 2018. The match rate has correspondingly decreased from 66.2% in 2005 to 61.1% in 2018.³ 

Changes in the Match Process

The fellowship match is processed by the SF Match and sponsored by the ACMS. Over the last decade, programs have increasingly opted for exemptions from participation in the SF Match. In 2005, there were 8 match exemptions. In 2018, there were 20.⁴ Despite the increasing popularity of match exemptions, in October 2018 the ACMS Board of Directors approved a new policy that eliminated match exemptions, with the exception of applicants on active military duty and international (non-Canadian) applicants. All other applicants applying for a fellowship position for the 2020-2021 academic year must participate in the match.⁴ This new policy attempts to ensure a fair match process, especially for applicants who have trained at a program without an affiliated MSDO fellowship. 

The Road to Board Certification

Further growth during the fellowship’s mid-adult years centered on the long-contested debate on subspecialty board certification. In 2009, an American Society for Dermatologic Surgery membership survey demonstrated an overwhelming majority in opposition. In 2014, the debate resurfaced. At the 2016 American Society for Dermatologic Surgery annual meeting, former American Academy of Dermatology presidents Brett Coldiron, MD, and Darrell S. Rigel, MD, MS, conveyed opposing positions, after which an audience survey demonstrated a 69% opposition rate. Proponents continued to argue that board certification would decrease divisiveness in the specialty, create a better brand, help to obtain a Medicare specialty designation that could help prevent exclusion of Mohs surgeons from insurance networks, give allopathic dermatologists the same opportunity for certification as osteopathic counterparts, and demonstrate competence to the public. Those in opposition argued that the term dermatologic oncology erroneously suggests general dermatologists are not experts in the treatment of skin cancers, practices may be restricted by carriers misusing the new credential, and subspecialty certification would actually create division among practicing dermatologists.⁵

Following years of debate, the American Board of Dermatology’s proposal to offer subspecialty certification in Micrographic Dermatologic Surgery was submitted to the American Board of Medical Specialties and approved on October 26, 2018. The name of the new subspecialty (Micrographic Dermatologic Surgery) is different than that of the fellowship (Micrographic Surgery and Dermatologic Oncology), a decision reached in response to diplomats indicating discomfort with the term oncology potentially misleading the public that general dermatologists do not treat skin cancer. Per the American Board of Dermatology official website, the first certification examination likely will take place in about 2 years. A maintenance of certification examination for the subspecialty will be required every 10 years.⁶

Final Thoughts 

During its short history, the MSDO fellowship has undergone a notable evolution in recognition, popularity among residents, match process, and board certification, which attests to its adaptability over time and growing prominence.

As the residents on the podium ran through case presentations at the Texas Dermatological Society meeting this past fall (September 21-22, 2018; Galveston, Texas), I discretely surveyed the room. To no surprise, perhaps half of the attendees at some point during the hour-long presentation glanced down at their smartphones, and 2018 statistics suggest that approximately 74% of these Internet glances were made by engagers of social media sites.¹ My FOMO (fear of missing out) kicked in. What was everyone looking at? I opened Instagram on my smartphone and plastered at the top of my home page were Texas Dermatological Society–related “stories” posted by other dermatology residents from across the state, one story featuring the very presentation I was attending. I peeked 2 rows ahead to find the social media “influencer” I have been following on Instagram for months in real life for the first time.

It is not just the younger population glued to their social media accounts. In fact, Facebook boasted a more than 80% increase in users 55 years and older between 2011 and 2014 and a 41% increase in users aged 35 to 54 years.² In total, there were 3.2 billion social media users globally in 2018.³ With such a large portion of the population engaged in social media, it is no wonder that it has become a rapidly emerging presence within the field of dermatology.

#Ad

Social media has become a powerful marketing tool for the practicing dermatologist. In a recent survey, 41% of social media users reported that social media influenced their choice of a particular physician, facility, or medical practice.⁴ Corresponding to this behavior, dermatology practices also have used social media to educate patients on services offered, acquire new patients, engage existing patients, create brand loyalty, become a trusted source of medical information in a sea of digital misinformation, and facilitate positive word-of-mouth opportunities.⁵ In fact, 53% of physician practices in the United States operate a Facebook page.⁶ For these physicians, marketing through social media carries the advantages of low cost and rapid transmission of information to a wide audience.⁷ Furthermore, the development of business insights and statistics by some social media platforms, such as those available to users on business profiles on Instagram, enables practices and marketers to target their audiences and optimize reach.

#DermLife

The role of social media in dermatology extends far beyond marketing. Lifestyle blogs centered on daily life as a medical provider, even within the field of dermatology, are gaining popularity. Dermatology-centered lifestyle blogs often incorporate the root derm in their handle, enabling other users to identify the account holder and interact in meaningful ways. According to a post from one popular Instagram influencer Dr. Audrey Sue Cruz (@dr.audreyxsue), such profiles may serve to prevent burnout, provide a creative outlet, share life as a resident, develop a supportive community, provide mentorship, and spread inspiration.

#Hashtag

Another interesting utility of social media is the use of standardized hashtags to facilitate scientific and clinical dialogue among medical professionals. Standardization of hashtag ontology on Twitter and Instagram has been adopted by the urology and gastroenterology fields to filter out “noise” by individuals not intending to join academic discussion.⁸ In dermatology, standardized hashtags have not been adopted, to my knowledge; however, a search for esoteric dermatologic terms such as #dermatopathology or #mohssurgery directs users to specialty-specific discussions.

#DontFryDay

Another role of social media in dermatology is dissemination of information. One notable example is the reach on Twitter of the “Don’t Fry Day” campaign, an annual campaign by the National Council on Skin Cancer Prevention to promote sun safety awareness and sun protection behaviors. In a recent study by Nguyen et al,⁹ the hashtag #DontFryDay was tracked on Twitter to assess the reach of the campaign. They found that this campaign had an impressive reach of approximately 1200 contributors, resulting in more than 16.5 million impressions; 18 celebrities and verified individuals accounted for 8,735,549 impressions.⁹

Despite the large potential for dissemination of information on social media, in 2014 none of the top 10 dermatologic journals or professional dermatologic organizations maintained an Instagram account. Only one of the top 10 patient advocate groups related to dermatology conditions—the Melanoma Research Foundation—was found on Instagram as of 2014.¹⁰ Furthermore, none of the top 10 most popular dermatology journals, professional dermatology organizations, or dermatology-related patient advocate groups could be found on Tumblr as of 2014.¹¹ Although some of the aforementioned organizations have since adopted social media accounts, such as Cutis and Dermatology News (@mdedgederm) on Instagram in 2018, these social media platforms remain largely untapped outlets for dissemination of information to the public by reputable sources.

#VerifyHealthcare

Although social media has offered many advantages to the field of dermatology, it also has brought about unique challenges such as blind authorship, lack of source citation, and presentation of opinion as fact.⁷ To compound the challenge, 90% of millennials aged 18 to 24 years reportedly trust health care information shared by others on social media.¹² Do we, as dermatologists, have a duty to take to social media to provide reputable health information? In an effort to address this emerging problem, popular Instagram influencer Dr. Austin Chiang (@austinchiangmd) initiated the #VerifyHealthcare movement, which called for physicians active on social media to practice transparency by providing users with their credentials.¹³ The goal of the movement is to help users differentiate medical information disseminated by trained medical professionals from misinformation by disreputable sources.

Final Thoughts

Despite its shortcomings, the emerging roles of social media in dermatology have proven to be a prominent force here to stay, providing new and innovative opportunities to dermatologists for social networking, dissemination of health information, motivation and inspiration, and marketing.

As the residents on the podium ran through case presentations at the Texas Dermatological Society meeting this past fall (September 21-22, 2018; Galveston, Texas), I discretely surveyed the room. To no surprise, perhaps half of the attendees at some point during the hour-long presentation glanced down at their smartphones, and 2018 statistics suggest that approximately 74% of these Internet glances were made by engagers of social media sites.¹ My FOMO (fear of missing out) kicked in. What was everyone looking at? I opened Instagram on my smartphone and plastered at the top of my home page were Texas Dermatological Society–related “stories” posted by other dermatology residents from across the state, one story featuring the very presentation I was attending. I peeked 2 rows ahead to find the social media “influencer” I have been following on Instagram for months in real life for the first time.

It is not just the younger population glued to their social media accounts. In fact, Facebook boasted a more than 80% increase in users 55 years and older between 2011 and 2014 and a 41% increase in users aged 35 to 54 years.² In total, there were 3.2 billion social media users globally in 2018.³ With such a large portion of the population engaged in social media, it is no wonder that it has become a rapidly emerging presence within the field of dermatology.

#Ad

Social media has become a powerful marketing tool for the practicing dermatologist. In a recent survey, 41% of social media users reported that social media influenced their choice of a particular physician, facility, or medical practice.⁴ Corresponding to this behavior, dermatology practices also have used social media to educate patients on services offered, acquire new patients, engage existing patients, create brand loyalty, become a trusted source of medical information in a sea of digital misinformation, and facilitate positive word-of-mouth opportunities.⁵ In fact, 53% of physician practices in the United States operate a Facebook page.⁶ For these physicians, marketing through social media carries the advantages of low cost and rapid transmission of information to a wide audience.⁷ Furthermore, the development of business insights and statistics by some social media platforms, such as those available to users on business profiles on Instagram, enables practices and marketers to target their audiences and optimize reach.

#DermLife

The role of social media in dermatology extends far beyond marketing. Lifestyle blogs centered on daily life as a medical provider, even within the field of dermatology, are gaining popularity. Dermatology-centered lifestyle blogs often incorporate the root derm in their handle, enabling other users to identify the account holder and interact in meaningful ways. According to a post from one popular Instagram influencer Dr. Audrey Sue Cruz (@dr.audreyxsue), such profiles may serve to prevent burnout, provide a creative outlet, share life as a resident, develop a supportive community, provide mentorship, and spread inspiration.

#Hashtag

Another interesting utility of social media is the use of standardized hashtags to facilitate scientific and clinical dialogue among medical professionals. Standardization of hashtag ontology on Twitter and Instagram has been adopted by the urology and gastroenterology fields to filter out “noise” by individuals not intending to join academic discussion.⁸ In dermatology, standardized hashtags have not been adopted, to my knowledge; however, a search for esoteric dermatologic terms such as #dermatopathology or #mohssurgery directs users to specialty-specific discussions.

#DontFryDay

Another role of social media in dermatology is dissemination of information. One notable example is the reach on Twitter of the “Don’t Fry Day” campaign, an annual campaign by the National Council on Skin Cancer Prevention to promote sun safety awareness and sun protection behaviors. In a recent study by Nguyen et al,⁹ the hashtag #DontFryDay was tracked on Twitter to assess the reach of the campaign. They found that this campaign had an impressive reach of approximately 1200 contributors, resulting in more than 16.5 million impressions; 18 celebrities and verified individuals accounted for 8,735,549 impressions.⁹

Despite the large potential for dissemination of information on social media, in 2014 none of the top 10 dermatologic journals or professional dermatologic organizations maintained an Instagram account. Only one of the top 10 patient advocate groups related to dermatology conditions—the Melanoma Research Foundation—was found on Instagram as of 2014.¹⁰ Furthermore, none of the top 10 most popular dermatology journals, professional dermatology organizations, or dermatology-related patient advocate groups could be found on Tumblr as of 2014.¹¹ Although some of the aforementioned organizations have since adopted social media accounts, such as Cutis and Dermatology News (@mdedgederm) on Instagram in 2018, these social media platforms remain largely untapped outlets for dissemination of information to the public by reputable sources.

#VerifyHealthcare

Although social media has offered many advantages to the field of dermatology, it also has brought about unique challenges such as blind authorship, lack of source citation, and presentation of opinion as fact.⁷ To compound the challenge, 90% of millennials aged 18 to 24 years reportedly trust health care information shared by others on social media.¹² Do we, as dermatologists, have a duty to take to social media to provide reputable health information? In an effort to address this emerging problem, popular Instagram influencer Dr. Austin Chiang (@austinchiangmd) initiated the #VerifyHealthcare movement, which called for physicians active on social media to practice transparency by providing users with their credentials.¹³ The goal of the movement is to help users differentiate medical information disseminated by trained medical professionals from misinformation by disreputable sources.

Final Thoughts

Despite its shortcomings, the emerging roles of social media in dermatology have proven to be a prominent force here to stay, providing new and innovative opportunities to dermatologists for social networking, dissemination of health information, motivation and inspiration, and marketing.

As the residents on the podium ran through case presentations at the Texas Dermatological Society meeting this past fall (September 21-22, 2018; Galveston, Texas), I discretely surveyed the room. To no surprise, perhaps half of the attendees at some point during the hour-long presentation glanced down at their smartphones, and 2018 statistics suggest that approximately 74% of these Internet glances were made by engagers of social media sites.¹ My FOMO (fear of missing out) kicked in. What was everyone looking at? I opened Instagram on my smartphone and plastered at the top of my home page were Texas Dermatological Society–related “stories” posted by other dermatology residents from across the state, one story featuring the very presentation I was attending. I peeked 2 rows ahead to find the social media “influencer” I have been following on Instagram for months in real life for the first time.

It is not just the younger population glued to their social media accounts. In fact, Facebook boasted a more than 80% increase in users 55 years and older between 2011 and 2014 and a 41% increase in users aged 35 to 54 years.² In total, there were 3.2 billion social media users globally in 2018.³ With such a large portion of the population engaged in social media, it is no wonder that it has become a rapidly emerging presence within the field of dermatology.

#Ad

Social media has become a powerful marketing tool for the practicing dermatologist. In a recent survey, 41% of social media users reported that social media influenced their choice of a particular physician, facility, or medical practice.⁴ Corresponding to this behavior, dermatology practices also have used social media to educate patients on services offered, acquire new patients, engage existing patients, create brand loyalty, become a trusted source of medical information in a sea of digital misinformation, and facilitate positive word-of-mouth opportunities.⁵ In fact, 53% of physician practices in the United States operate a Facebook page.⁶ For these physicians, marketing through social media carries the advantages of low cost and rapid transmission of information to a wide audience.⁷ Furthermore, the development of business insights and statistics by some social media platforms, such as those available to users on business profiles on Instagram, enables practices and marketers to target their audiences and optimize reach.

#DermLife

The role of social media in dermatology extends far beyond marketing. Lifestyle blogs centered on daily life as a medical provider, even within the field of dermatology, are gaining popularity. Dermatology-centered lifestyle blogs often incorporate the root derm in their handle, enabling other users to identify the account holder and interact in meaningful ways. According to a post from one popular Instagram influencer Dr. Audrey Sue Cruz (@dr.audreyxsue), such profiles may serve to prevent burnout, provide a creative outlet, share life as a resident, develop a supportive community, provide mentorship, and spread inspiration.

#Hashtag

Another interesting utility of social media is the use of standardized hashtags to facilitate scientific and clinical dialogue among medical professionals. Standardization of hashtag ontology on Twitter and Instagram has been adopted by the urology and gastroenterology fields to filter out “noise” by individuals not intending to join academic discussion.⁸ In dermatology, standardized hashtags have not been adopted, to my knowledge; however, a search for esoteric dermatologic terms such as #dermatopathology or #mohssurgery directs users to specialty-specific discussions.

#DontFryDay

Another role of social media in dermatology is dissemination of information. One notable example is the reach on Twitter of the “Don’t Fry Day” campaign, an annual campaign by the National Council on Skin Cancer Prevention to promote sun safety awareness and sun protection behaviors. In a recent study by Nguyen et al,⁹ the hashtag #DontFryDay was tracked on Twitter to assess the reach of the campaign. They found that this campaign had an impressive reach of approximately 1200 contributors, resulting in more than 16.5 million impressions; 18 celebrities and verified individuals accounted for 8,735,549 impressions.⁹

Despite the large potential for dissemination of information on social media, in 2014 none of the top 10 dermatologic journals or professional dermatologic organizations maintained an Instagram account. Only one of the top 10 patient advocate groups related to dermatology conditions—the Melanoma Research Foundation—was found on Instagram as of 2014.¹⁰ Furthermore, none of the top 10 most popular dermatology journals, professional dermatology organizations, or dermatology-related patient advocate groups could be found on Tumblr as of 2014.¹¹ Although some of the aforementioned organizations have since adopted social media accounts, such as Cutis and Dermatology News (@mdedgederm) on Instagram in 2018, these social media platforms remain largely untapped outlets for dissemination of information to the public by reputable sources.

#VerifyHealthcare

Although social media has offered many advantages to the field of dermatology, it also has brought about unique challenges such as blind authorship, lack of source citation, and presentation of opinion as fact.⁷ To compound the challenge, 90% of millennials aged 18 to 24 years reportedly trust health care information shared by others on social media.¹² Do we, as dermatologists, have a duty to take to social media to provide reputable health information? In an effort to address this emerging problem, popular Instagram influencer Dr. Austin Chiang (@austinchiangmd) initiated the #VerifyHealthcare movement, which called for physicians active on social media to practice transparency by providing users with their credentials.¹³ The goal of the movement is to help users differentiate medical information disseminated by trained medical professionals from misinformation by disreputable sources.

Final Thoughts

Despite its shortcomings, the emerging roles of social media in dermatology have proven to be a prominent force here to stay, providing new and innovative opportunities to dermatologists for social networking, dissemination of health information, motivation and inspiration, and marketing.