SISRB program. In addition, the ACMS continues to approve and oversee international programs that are not eligible for ACGME accreditation. In the spring of 2011, there were 39 programs approved by the ACMS, 44 programs approved by the ACGME.

Not all dermatologists who perform Mohs surgery are fellowship trained. The American Society of Mohs Surgery administers a week-long didactic course in Mohs surgery and closures and maintains a preceptorship program of observation in a Mohs surgeon’s office for three separate weeks over 2 years. A few dermatology residency programs allow the resident to obtain extensive experience in the Mohs procedure [9]. Some dermatologists work with the Mohs surgeon in their practice to develop expertise. As with any skill, repeated practice, especially practice under supervision, increases expertise. Patient groups tell their constituents to ask their doctor how many times they have performed the procedure. Certainly, for Mohs surgeons, improvement with more experience and a larger number of cases is apparent to the individual learner both in the surgical procedure itself as well as proficiency in reading the histology. A longitudinal study of one fellow’s experience at a respected and busy Mohs practice documented that it required experience reading the histopathology of 1491 Mohs surgery cases in order to reduce the error rate to less than 1% [10].

Credentialing a physician to practice Mohs surgery at the current time depends on the site of practice, the insurance company paying for the service, and state regulations. Some institutions will only credential fellowship-trained Mohs surgeons while others will credential anyone of any specialty to do Mohs surgery depending on documentation of what the institution deems is adequate education and experience. The Mohs laboratory is subject to much greater regulation. In the USA, it requires at least a Clinical Laboratory Improvement Amendments (CLIA) certificate which is obtained with biannual site inspection by the state department of health and requires documentation of quality assurance programs and proficiency. Some institutions that are Joint Commission on Accreditation of Healthcare

Organizations (JCAHO) approved require College of American Pathologists (CAP) approval for the Mohs laboratory. In many foreign countries, a pathologist must read the slides.

In the current regulatory environment, there is a general movement toward the concept that the public interest is best served by increasing accreditation and oversight of medical facilities and more focused credentialing and recredentialing of providers of care. In this milieu, it is possible that in the future, physicians will be held to a high standard of education and expertise to practice specialized procedures such as Mohs surgery and that they will need to maintain robust quality improvement programs. If Dr. Mohs were alive today, he might be surprised at the amount of regulation surrounding his innovative procedure, but he would doubtlessly be pleased that there is robust interest in teaching and learning the technique and in creating innovative modifications to stretch its indications and efficacy.

References

1. Trost LB, Bailin PL. History of Mohs surgery. Dermatol Clin. 2011;29:135–9.

2. Picoto A, Camacho F, Walker NPJ, Camps-Fresneda A. Mohs micrographic surgery: European experience. In: Roenigk RK, Roenigk HH, editors. Surgical dermatology. St Louis: Mosby Publishers; 1992. p. 125–31.

3.Mohs FE. Chemosurgery for the microscopically controlled excision of cutaneous cancer. In: Epstein E, editor. Skin surgery. Springfield: Charles C Thomas; 1970. p. 309.

4.http://www.mohscollege.org/sisrb/ACMSCoreCurriculum.pdf. Accessed June 7, 2011

5.http://www.mohscollege.org/sisrb/FTPPoliciesProceduresGuidelines.pdf. Accessed June 7, 2011

6.http://www.sfmatch.org/. Accessed June 7, 2011

7.Nestler SP, Roenigk RK. Accreditation and certification in dermatologic surgery. Semin Cutan Med Surg. 2005;24:133–6.

8.http://www.acgme.org/acWebsite/downloads/RRC_pro- gReq/081_procedural_derm_07012010_1-YR.pdf. Accessed June 7, 2011

9. Lee EH, Nehal KH, Dusza SW, et al. Procedural training during dermatology residency: a survey of third year dermatology residents. J Am Acad Dermatol. 2011;64L:475–83.

10. Murphy ME, Brodland DG, Zitelli JA. Errors in the interpretation of Mohs histopathology sections over a 1-year fellowship. Dermatol Surg. 2008;34:1637–41.