Tag Archives: Mohs surgery

Mohs — The Man, the Surgeon, the Superstar

The esteem that practitioners of Mohs micrographic surgery hold for the founder of the technique, the late Dr. Frederic E. Mohs, can’t be overestimated. Although he died in 2002 at the age of 92, the man and his accomplishments are still so admired that the American College of Mohs Surgery invited his son, Frederic E. Mohs, Jr., to share reminiscences of his father at the college’s annual meeting.

Hundreds of Mohs surgeons filled the conference hall. “Dad would have been totally shocked to walk in here and see this many people,” Mr. Mohs said, because there was a time when the only Mohs surgeons were ones that Dr. Mohs had trained himself. Today there are at least two Mohs professional organizations and thousands of physicians who offer Mohs surgery.

Frederic E. Mohs, Jr. (Photo by Sherry Boschert)

Mr. Mohs is not one of them. He is a lawyer and real estate specialist in the firm Mohs, MacDonald, Widder, and Paradise in Madison, Wisc., where Dr. Mohs lived and practiced for many years. And he is not, it seemed clear, an experienced public speaker. But the attention focused on him by the ballroom full of Mohs surgeons was so intense that you could have heard a pin drop throughout his entire talk. They listened partly out of respect and partly, I think, because our human nature is to want to know more about the people we admire.

Mr. Mohs said he came to talk about his father “as a person.” But he also provided some interesting historical context. The way his father came to be a surgeon and the inventor of Mohs micrographic surgery was “an accident,” Mr. Mohs said. His father had a passion for radio and hoped to become an engineer. To fund his college education, he worked in the University of Wisconsin’s biology department cleaning laboratory animals’ cages. The department chair noticed him and mentored him, explaining the lab’s cancer research and teaching Mohs Sr. to look at slides of skin cancer. It was during this period that Mohs Sr. visualized his now-famous techniques, and the department chair offered him a chance to pursue research as his assistant.

That almost didn’t happen, because Mohs Sr. was reluctant to give up his dream of being a radio engineer. But once he embraced the opportunity, he ran with it. He earned his bachelor’s degree in 3 years and entered medical school while continuing his laboratory experiments and cleaning rat cages. “He was a hard worker,” his son said understatedly.

Some characteristics of Dr. Mohs “the person” seem dated, while others may be inspiring, disappointing, or surprising, depending on your view. “From every account I ever heard, he was an incredibly wild driver” who once got his future wife grounded for a full year by slamming on the brakes and causing the car to spin in a circle in front of his future father-in-law, Mr. Mohs recalled.

Dr. Mohs was a devotee of Horatio Alger’s books, admiring their themes of hard work, ingenuity, and a scientific system of inquiry.

Once married and with a young family, he didn’t spend much time at home, it seems. He would leave home at 8 in the morning, return for dinner at 6 p.m., briefly read the newspaper, then go back to the hospital “every single night” and return late at night or even the next morning, his son said. When the family entertained visitors on weekends, most bored Dr. Mohs, so he would go back to the hospital.

None of that bothered his son. “He was an honest and good man. I don’t have a single complaint” about him, Mr. Mohs said. An older sibling once said that Mr. Mohs and a younger sibling “weren’t raised, you were just turned loose,” Mr. Mohs recalled. “It was true.”

Still, Dr. Mohs imparted his values to his son, who described them as, “Earn your own money, be honest, and don’t disturb property. Anything else is okay.”

The children usually took their school report cards to be signed by their mothers “because Dad was a little scary,” Mr. Mohs recalled. Once when he asked Dr. Mohs to sign a report card, his father signed it without looking at it, and handed it back. “Don’t you want to look at it?” his son asked. “No,” Dr. Mohs replied. “It’s your life. If you screw it up, it’s your own fault.”

Occasionally Dr. Mohs broke out of his routine, joining a geology club in one period, and a church’s board of directors in another. As his techniques gained recognition, he traveled quite a bit to give presentations or trainings, and often took the family with him.

In 1955 when he was invited to demonstrate his techniques in Moscow, he accepted in part out of a desire to improve international relations. Dr. Mohs went so far as to learn Russian and gave his entire presentation in Russian. Thereafter, the Russians “lionized him” and often sent surgeons to Madison to learn from him.

He is still lionized today. But for one hour, his professional descendants got to hear about the human being behind the public image.

Before Dr. Mohs died, he picked a simple bronze plate to mark his grave. “He liked the idea. Mowing was more efficient,” his son said.

–Sherry Boschert

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A Little Mohs Respect

The Mohs technician – a non-physician (often even a non-healthcare worker) – occupies a unique place in the medical pantheon.

The Mohs surgeon’s right hand must be as steady as the surgeon’s own, capable of working with the most minute wafers of tissue, just a cell or two thick. A natural tinkerer who can adjust a highly complicated machine whenever its temperamental temperament gets out of whack. A perfectionist whose urge for the precision can never be shaken by deadlines, fussy patients, or cranky docs who just want to get out of here already.

At a Mohs surgery training course, sponsored by the American Society of Mohs Surgeons,  I learned first-hand (no pun intended) about what the tech brings to this fascinating area of surgery.

Alexander Lutz, the owner of Travel Tech Mohs Services, Inc., Carson, Calif., put it well during his talk on the issue: “It’s a rare relationship between and physician and non-physician, even more so than a surgeon with his surgical nurse or tech. The nurse might be helping the surgeon, but you aren’t depending on them to complete the surgery. With a Mohs technician, you are.”

A physician who wants to learn Mohs surgery can choose to hire and train a formally educated lab tech or histotechnician – or pick a staff person to train. It can be a nurse or medical assistant, or even the office manager. 

Knitting could be a sign of tech talent.

Photo courtesy Loggie-log/Wikimedia Commons

Mr. Lutz gave some pointers on picking the right trainee. Two characteristics are key: manual dexterity and a perfectionist personality. “In my experience, good Mohs techs have these things in common. I always ask if they have a hobby that shows dexterity-like knitting, musical instruments, or even juggling.”

And though the perfectionist personality part might drive the doc nuts in a personal relationship, it  will serve both well in the surgical suite. The success of Mohs surgery – and even the life of a human being – depends on those beautiful clear margins. The surgeon can only create those margins if there are plenty of beautiful slides to guide the surgery. And only a dedicated, skilled technician can make those beautiful slides.

— Michele G. Sullivan (on Twitter @MGSullivan)

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Dismiss the Dogma and Close Mohs Surgery the Day After?

If you perform a lot of Mohs micrographic surgery in your dermatology practice, you probably close the majority of surgical wounds on the same day. 

Why? “It’s always done that way,” Dr. Andrew Weinstein said. This dogma exists, he said, because physicians who start and complete Mohs surgery on the same day are thought to be more efficient. Also, some dermatologists believe a surgical site left open overnight increases the risk for bleeding, pain, and infection.  

But these beliefs are not necessarily true, Dr. Weinstein said. 

Dr. Andrew Weinstein (photo by D. McNamara)

The serious infection rate is no different with delayed closure, Dr. Weinstein said. He reported nine infections in a series of 1,000 of his patients (0.9% rate). Eight occurred with delayed closure, but each was an uncomplicated infection. The only major infection arose in a patient closed on the same day. 

Benefits for the dermatologist include not feeling as rushed or tired after a full day of surgery. “Ease of repair is an advantage. You have a night to collect your thoughts and you can change your repair approach,” Dr. Weinstein said at the annual meeting of the Florida Society of Dermatologic Surgeons

Delayed closure and staggered scheduling allow Dr. Weinstein to perform 20% more Mohs surgeries each day. “It’s increased my efficiency.” His Mohs technician is more efficient as well, returning slides in as little as 10 minutes.

On a typical day in his private practice in Boynton Beach, Fla., Dr. Weinstein sees four patients at 1 p.m., three more at 2 p.m., and another three at 2:30 p.m. Results of the Mohs excisions for the first group are read before the second wave of patients arrive. The 1 p.m. patients with negative results go home immediately, typically within 45 minutes, he said. Patients with positive margins remain. “Then I [excise] the first stage of the second group and anything left over from first group.” The process is repeated once the third group of patients arrives as well.  

Dr. Weinstein places retention sutures postop and schedules most of his Mohs patients to return the next morning for complete wound closure. (There are still exceptions ; he closes some the same day if it is indicated.)

Although less convenient for patients, they end up waiting less time overall, Dr. Weinstein said. He has received “generally good reviews from patients,” including previous Mohs patients and new ones. 

Patients are scheduled for wound closure in 15 minute appointments the next morning. The suturing is generally done by 11:15 AM.  

Another dermatologist at the meeting asked Dr. Weinstein if his next-day approach was motivated in part by additional insurance payment. He started doing delayed closures before changes to insurance allowed him to collect more money for seeing the patient again the next day, he replied. “The reimbursement is not the reason for what I presented here today.” 

–Damian McNamara, @MedReporter on twitter

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Beyond ABCDs for Melanoma

The month of May marked 25 years since dermatologists began using the ABCD rule to help screen for melanoma, and advances in diagnosis since then have leaned toward newer and better use of imaging technology instead of clinical mnemonics.

Left side, top to bottom: melanomas showing (A) asymmetry, (B) irregular border, (C) unusual coloring, and (D) diameter that had changed in size. Right column: Normal moles. Images from National Cancer Institute via Skin Cancer Foundation, merged by WikiMedia Commons user Stevenfruitsmaak.

You do know your ABCDs, don’t you? Moles with “A” for asymmetry, “B” for border irregularity, “C” for uneven color, or “D” for diameter greater than 6 mm. If you see these, think melanoma.

Advances over the quarter-century since then have focused on helping physicians “see” melanoma better. Dr. Darrel Rigel described some of these at the annual meeting of the American Society for Mohs Surgery. Dermoscopy allowed non-invasive imaging of melanomas. Digital photography came along, and some dermatologists began using serial digital imaging to track changes in moles over time. Most recently, various groups have been trying to add assessments using infrared (non-visible) light through computer-aided programs to aide diagnosis.

As a woman of letters, I have to admit a fondness for the ABCDs. But the imaging advances do have more of a new-school, digital-age feel to them. I think both can happily co-exist in dermatology. Time will tell if that’s old-school thinking as the digital age advances.

—Sherry Boschert (@sherryboschert on Twitter)
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