Establishing a Mohs Practice

Summary: General Considerations

•One must decide whether to lease or build an office, as well as an ambulatory surgery center.

•The office should be large enough to allow for expansion.

39.1General Considerations

When establishing a Mohs practice, there are a number of decisions to make. For example, should one purchase a space or lease with or without an option to

P.G. Lang (*) • C.M. Geddis • J.L. Benenhaley Department of Dermatology Clinic, Charleston, SC, USA e-mail: pearonlang@bellsouth.net

M. Braun III

Department of Dermatology Clinic, George Washington

University, Washington, DC, USA

buy? Also, should one have an ambulatory surgery facility? Many factors impact one’s decision making, including the amount one must invest; the potential for appreciation; and whether or not there will be coinvestors or if there is the potential for other physicians using the facility. Ambulatory surgery facilities can be a good source of income but carry with them the need for inspections, certification, rules, regulations, and record keeping.

Office space comes at a premium, and thus, one does not want to have excess space which may not be used for years. On the other hand, one should not be so intent on being frugal that they find within a short period of time that they have outgrown their space. If one feels compelled to “start slow,” there should at least be the potential for expansion without relocating. Unless there is a large amount of unfurnished space, when one joins a preexisting practice, they may be limited in what they can design. However, there are certain minimum requirements, which must be satisfied if one is to have an efficient, patient-friendly practice.

There can never be enough storage space for supplies, samples, etc. It will be amazing how quickly “excess” storage space becomes filled.

Summary: The Electronic Medical Record

•Check with colleagues and organizations before selecting a vendor for your electronic medical record (EMR).

•EMRs can do much more than record patient data.

a state controlled substance number. Also make sure you have a valid NPI number.

When purchasing malpractice insurance, do not just look at cost but also consider the limits of coverage and whether or not you will need to purchase tail coverage when you close your practice.

Getting signed up with Medicare, Medicaid, and insurance companies may also require a considerable length of time. You will not get paid until you do and so, again you want to start working on this as soon as possible.

39.2The Electronic Medical Record

The electronic medical record (EMR) is here to stay and when one sets up an office, one should make provisions for this. Check with colleagues and organizations such as the AAD for tips and help. There are templates that can be created, which allows one to generate surgery notes with accompanying photographs and letters to referring physicians that saves time and the cost of transcription. Again, check with colleagues regarding programs they use. One advantage of the EMR is that it allows one to keep track of one’s data, e.g., types of cancer treated, repairs, complications, etc. Thus, if one wants to look at their infection rate for a given time period, this can be easily generated. Although maintaining a complication log is not currently required, at some point in the future it could be. Therefore, it would be good to start accumulating this data from the beginning. If you have an ambulatory surgery facility, this would be required.

Summary: Credentials, Licensure, and Malpractice

Insurance

•It is critical to start early getting credentialed and licensed, obtaining malpractice coverage, and getting signed up with third party carriers.

39.3Credentials, Licensure, and Malpractice Insurance

Obtaining a license may require a considerable amount of time, and thus one needs to apply as soon as possible. This also applies to obtaining a DEA number and

Summary: Quality Assurance

•A quality assurance (QA) program should be implemented from the very beginning.

•Colleagues can play a role in your QA program.

39.4Quality Assurance

Although not currently required, it would be good to have a quality assurance program in place if there is another Mohs surgeon in the practice or there is another Mohs surgeon in the same community. Randomly selected slides can be reviewed in terms of quality and correctness of diagnosis. Any discordance in opinion could be resolved by an independent pathologist/dermatopathologist. In the future, organizations such as the American College of Mohs Surgery could offer such a service.

Summary: Cameras

•Cameras are essential for documentation and preparing manuscripts and presentations.

39.5Cameras

Digital cameras are a must for documenting surgical procedures and biopsy sites. Ideally, there should be a camera in each room. The pictures can be incorporated into the Mohs surgery note or in the letter to the referring physician. They also can be incorporated into the EMR for later viewing. There are many “point and shoot” user-friendly digital cameras on the market. Again, check with colleagues for recommendations.

Summary: Care of Instruments

•Take care of your instruments. They are a significant investment and essential for your practice.

39.6Care of Instruments

Space and equipment for sterilization of instruments should be available. For instruments requiring gas sterilization, a nearby hospital or surgery center that has this capability can be utilized.

A small room or area needs to be designated for soiled instruments. In this area, surgical trays can be broken down and dirty instruments can be cleaned in preparation for sterilization.

A place for the storage of clean and sterile instruments needs to be available. This can be in the form of cabinetry or a room where extra instruments, suture material, sterile packs, dressing materials, etc., are stored.

Summary: Work Rooms

•Work rooms can be useful for storage and handling messages.

39.7Work Rooms

If possible, a small room, where nurses can take care of phone calls, is ideal since this ensures quietness and privacy. Such a room can also serve other purposes such as storage space for extra pamphlets and handouts or a secured area for controlled substances.

Summary: Microscopes

•A good microscope is essential for a Mohs practice.

•Do not economize.

39.8Microscopes

If one plans to do general dermatology in addition to Mohs surgery, it would be best not to use their Mohs microscope for KOHs. The histotechnicians will need

their own microscope for reviewing their sections and this can be used for KOHs as well. Since microscopic examination of the Mohs specimens is such an integral part of the procedure, this is not an area where one wants to “save money.” When selecting the objectives of the scope, it is not necessary to have an oil immersion lens. A low-power, scanning lens is essential for viewing large specimens and precisely mapping areas positive for residual tumor. Olympus makes a super wide field objective for this purpose, but there may be other manufacturers that offer something similar. Another useful, but not necessarily essential, accessory is an ocular micrometer for measuring the depth of invasion of melanomas and squamous cell carcinomas. If one is not obtaining these measurements themselves, however, it is important to have access to a pathologist/ dermatopathologist who will provide this information.

Another nice but nonessential accessory is a marking objective, which allows one to easily mark an area of concern, which a colleague can then review when another opinion is sought. If one anticipates publishing, one may also want to mount a digital camera on the scope. These are easy to use and yield high-quality photomicrographs.

If one anticipates teaching, a double-headed microscope is essential. A polarizer is a nice accessory, but one that is infrequently used.

The microscope for examining the Mohs specimens should be in close proximity to the Mohs lab. This provides for efficiency and ease of communication. One of the authors (PGL) has always preferred to have his microscope located in the laboratory.

Summary: Instrumentation

•To do surgery with ease and precision, one needs good instruments and high-quality ancillary supplies.

39.9Instrumentation

Just as with the microscope, it is important to invest in high-quality instruments. Gold-handled instruments, which denote tungsten carbide, are of high quality and very desirable, but one needs to be selective since these tend to be expensive. For example, one would not purchase such scissors for cutting sutures, but it is well

worth the extra money to have gold-handled Webster needle drivers.

The instruments used for Mohs surgery and repairs are basic and few in number. For a knife handle, the authors prefer a flat handle, which can be used for measuring and can accommodate #10, #11, and #15 surgical blades. Brown Adson tissue forceps are good for both Mohs surgery and for preparing a wound for repair and for excisions. Smooth (but serrated) Adson tissue forceps are useful for handling delicate tissues during Mohs surgery and for suture removal. Small, delicate toothed forceps are ideal for repairing wounds and can be used for obtaining tissue from delicate areas (e.g., the eyelid). These authors prefer single-pronged skin hooks, but others prefer double-pronged retractors. Supercut black-handled scissors are excellent tissue scissors and in the curved style are good for defatting full-thickness skin grafts.

If one is going to use large sutures with large needles, one needs to have on hand large needle carriers. Using regular size needle carriers to grab large needles will spring them, and they no longer will be useful when using small caliber sutures, e.g., 5-0, 6-0.

As regards needle carriers, do not purchase those with serrated jaws. Small caliber suture will slip through these. Also, they will fray the suture and cause it to break.

A useful instrument for helping to close large wounds, especially those of the scalp, is a towel clamplike tissue approximator.

Unless one is planning to do full face dermabrasions, drywall sandpaper can be used for dermabrading small areas. For full-face dermabrasions or when large areas are being treated, we prefer motorized dermabraders with diamond fraizes.

If one is going to obtain bone specimens or decorticate the calvarium, one needs bone rongeurs and a hammer and chisel (osteotome).

For nail surgery, one needs nail splitters and nail elevators.

A periosteal elevator is essential when it is necessary to obtain periosteum for microscopic examination.

Chalazion clamps provide hemostasis and immobilize areas such as the eyelid and lip. When working in the ear canal, a right angle Beaver blade facilitates removing tissue.

It is important to have eye covers, eye chambers, eye pads, and saran wrap when dressing periocular Mohs wounds along with either a topical antibiotic or petrolatum-based lubricant. For the surgery itself, eye-

shields may be needed. Plastic shields with short handles work well. If metal shields are used, they should be insulated since if they are touched with the electrocautery, this can damage the eye. The use of an eyeshield requires a topical anesthetic. When the shield is removed, the eye should be flushed with saline, and an antibiotic ointment or lubricant should be instilled.

When working on the penis and the tumor extends into the urethra, it may be necessary to insert a Foley catheter to ensure emptying of the bladder.

For open wounds, which want to ooze, hemostatic agents, such as Surgicel, may be helpful. This can also be wrapped around pedicles, which want to ooze. Xeroform gauze is also used to wrap pedicles and can be used for packing.

For large flap repairs, Penrose drains can be inserted to prevent hematomas and seromas.

Although everyone has their personal preferences for suture materials, we have found that chromic gut, Prolene, Monocryl, Vicryl, and silk suffice our everyday needs. A reversible cutting needle is preferable. A P-3 needle is used for most suturing, but a larger needle is used with larger suture. Chromic gut is desirable when one does not want to remove sutures, e.g., skin grafts, periocular area, ears, lips, and mucosa. Silk is useful around the eyes but is most commonly used on elderly patients who have such fragile skin that sutures such as Prolene tear through the skin.

Prolene sutures are ideal for running subcuticular suture. Prolene 3-0 is also useful for pulley stitches to help approximate the edges of large surgical defects.

For harvesting split thickness grafts, one can use a Padgett dermatome or a Weck knife (for small grafts). The donor site can be dressed with Opsite or Tegaderm, which can be left in place for a week. At that point, the patient can initiate wound care.

Summary: Regulations

•It is important to be knowledgeable about regulations.

39.10 Regulations

There are numerous regulations and regulatory bodies, which the physician and his staff need to be aware of, including HIPPA, CLIA, the Coding initiative, and the