only one slide to be loaded at a time and others that have a rack, which allows the continuous feeding of slides.

Summary: Coverslipping

•The mounting media and clearing agent must be miscible.

39.25 Coverslipping

Once the slides have been removed from the clearing agent, a drop of mounting media is carefully applied, along with a coverglass (24×60 mm), onto the slide. The mounting media and the clearing agent must be miscible. The back of the slides and the frosted edge are then wiped with a dry gauze. The slides are then placed on a tray, along with the map, and given to the surgeon for viewing.

Summary: At the End of the Day

• Disposal of tissue is strictly regulated.

39.26 At the End of the Day

Once each case becomes clear, place the slides on a tray to dry for 48 h.

According to who inspects your lab, there are different guidelines for saving tissue. For CAP, the thawed, wet tissue must be stored for 2 weeks after the report date in a fixative for frozen sections. For CLIA, the thawed tissue can be discarded in the lab’s biohazard trash receptacle.

Summary: Permanent Sections and Immunostains

•For certain tumors, paraffin embedded sections or immunostains may be helpful.

39.27Permanent Sections and Immunostains

Many Mohs surgeons still utilize paraffin embedded sections (permanent sections) when treating melanomas, as well as unusual and difficult tumors. The tissue from

this so-called slow Mohs may be processed in the Mohs lab or in a pathology or dermatopathology lab. Due to the additional expense and space and personnel requirements, most Mohs surgeons do not process this tissue in their laboratory, but instead rely on their pathology/ dermatopathology colleagues to provide this service.

39.27.1Immunostains

In many instances, immunostains have replaced the need for “slow Mohs,” especially when managing melanomas. They also may be useful when managing other difficult tumors such as perineural squamous cell carcinoma, extramammary Paget’s disease and Merkel cell carcinoma.

However, like paraffin sections, they require additional space, equipment, and expense and will tie up a technician. The immunostains themselves are expensive and may have a limited shelf life. For a small lab, with one technician, doing immunostains may not be productive or cost-effective. Again, one could possibly utilize a colleague in pathology or dermatopathology to provide this service.

Summary: Training of Laboratory Technicians

•Your technician should be well trained.

•Consultants are available to assist with training and setting up a lab.

•Ask the American College of Mohs Surgery for help.

39.28 Training of Laboratory Technicians

He who can find a fully trained Mohs technician is indeed blessed. However, many Mohs surgeons must be either satisfied with a histopathology certified technician or someone who has no background whatsoever in the preparation of slides. Although fully trained histotechnicians may initially have an advantage, neophytes can mature into excellent Mohs technicians and demand a lesser salary. Although the Mohs surgeon may choose to train the technician, there are consultants who can assist in the establishment of a laboratory and the training of technicians. The American College of Mohs Surgery has, as a member service,

designated trainers who can be of assistance in training a technician.

Acquiring and training a technician is a critical step in establishing a high-caliber Mohs practice. This is not where one wants to economize. A technician who is efficient and produces high-quality slides is worth their weight in gold. They will allow one’s practice to be more productive, enjoyable, and more free of headaches.

Summary: Inspections and Regulations

•Learn the regulations regarding disposal of tissue, slide storage, and laboratory safety.

39.29 Inspections and Regulations

Depending on whether or not the laboratory is hospital based or in an outpatient setting, the laboratory will be subjected to periodic inspection by either CAP (College of American Pathologists) or CLIA (Clinical Laboratory Improvement Amendments). Outpatient laboratories cannot bill Medicare or Medicaid unless they are certified by CLIA. CLIA inspections are prearranged but CAP inspections may be unannounced. Certificates issued by these entities are good for 2 years.

In order to pass an inspection, it will be necessary to keep logs that chart such things as room temperature and humidity, refrigerator temperatures, and record the specimens handled in the lab and equipment maintenance. Methods used to assure quality will also be assessed. It is also necessary to develop a manual that describes in detail all procedures performed in the laboratory.

Since it is necessary to retain slides and pathology reports up to 10 years, it will be necessary to have a designated storage area.

For more information, one can visit these regulatory bodies’ websites: www.cap.org and www.cms. hhs.gov/CLIA/downloads//CLIA.SA.pdf

There are also OSHA regulations that include having in place policies on dealing with chemicals, hazardous substances, and bloodborne pathogens. Personal protective equipment must be provided (gowns, gloves, masks, eyewear), and there must be an eyewash, fire extinguisher, shower, and a spill kit. Appropriate warning signs also need to be posted.

Summary: Marketing

•One can market their practice fairly inexpensively by making themselves known to the professional and lay community or can pay others considerable sums of money to market their practice.

39.30 Marketing

An endless amount can be spent on marketing, and thus, one must come up with a budget with which they can live. The Mohs College has developed a marketing kit, which is available to members and should be helpful.

There are many ways one can generate referrals inexpensively: (1) join the local hospital staff(s), go to their breakfasts and staff meetings, frequent the physician lounge, and offer to give presentations; (2) participate in free skin cancer screenings or have one in your office; (3) look for opportunities to speak to the public;

(4) contact local media regarding your willingness to be interviewed; (5) visit potential referral sources, including those with whom you might interact, e.g., oculoplastic surgeons and head and neck surgeons; (6) send letters to potential referral sources introducing yourself; (7) participate in local and state dermatologic meetings and functions; (8) if there is a dermatology department, volunteer your services and attend conferences; and (9) consider having a open house and giving a presentation on Mohs surgery.

Make sure you get your name in the white pages and yellow pages as soon as you have picked a location for your practice.

Consider placing announcements in the local newspaper(s).

Create a website and link it to the Mohs College and Skin Cancer Foundation.

When you get a referral, make sure you write a thank you note and give the referring physician followups at each visit. If the primary care physician is not the referring physician, make sure you copy the primary care physician on the letter to the referring physician and at each follow-up visit.

To let the referring physician know your level of expertise, it is nice if you can include pictures in your letter showing the lesion before Mohs surgery, the

Mohs defect, and the repair. These can be printed on the letter so that loose pictures do not need to be sent.

Summary: Preoperative Consultation

•The Mohs surgeon must decide which patients they need to see prior to surgery and how to best prepare the patients for surgery.

39.31 Preoperative Consultation

Whether or not the patient needs to be seen prior to Mohs surgery depends on a number of factors: (1) the Mohs surgeon’s preference, (2) how difficult it is for the patient to come for the visit, (3) the complexity of the case, (4) whether imaging studies are necessary, and (5) whether or not other physicians will be involved in the patient’s care.

For most cases, a separate preoperative consultation visit is not necessary. This can be handled over the phone by the Mohs surgeon or their assistant. However, it is ideal that some type of contact take place prior to the surgery to screen the patient in terms of medications and other health issues, as well as to educate them about Mohs surgery and what to expect.

In addition, it is ideal to have a brochure on Mohs surgery sent to the patient prior to the surgery in order to reinforce what to expect. The Mohs surgeon can prepare this, or the brochure from the Mohs College can be used. The brochure can also serve as a marketing tool.

Summary: Brochures and Handouts

•Brochures and handouts can be both educational and serve as marketing tools.

39.32 Brochures and Handouts

Brochures and handouts can be helpful for reinforcing verbal explanations and potentially could also serve as marketing tools. The brochures can be prepared by the Mohs surgeon or obtained from other sources, such as the Skin Cancer Foundation, the American Society for Dermatologic Surgery, or the American Academy of Dermatology.

Summary: Operative Consents

•Operative consents need to be specific and informative.

39.33 Operative Consents

Blanket consent forms should be avoided. Operative consents should be procedure specific and spell out all the potential complication. Avoid blanket statements such as “repair of the Mohs defect.” Instead use phrases such as “repair of Mohs defect with a full-thickness skin graft from the right preauricular area.”

Summary: Conclusion

•A well-planed office should be efficient; fully utilize all of the space, and allow for expansion.

•Purchase high-quality equipment.

•Personnel should be carefully selected and paid well.

•A well-equipped laboratory is essential to ensure high-quality sections.

•Billing, regulations, marketing, the development of educational materials, and electronic medical records are essential items that also require attention.

39.34 Conclusion

There are many things that go into setting up an office for and a practice in Mohs surgery. Much thought needs to go into the planning of the office in order to make sure it is designed properly for the best utilization of space and to make sure it will run efficiently. Future plans for expansion also need to be considered.

Equipment and instruments should be of good quality and considered a long-term investment. In the long run, equipment of high quality will save money, result in fewer headaches, and improve efficiency.

Paying a little extra for personnel will also pay off in terms of efficiency and fewer worries. Quality personnel can help enhance the reputation of the practice.

The laboratory is critical to the practice of Mohs surgery. High-quality sections are a must. To ensure

quality, the equipment and personnel need to be topnotch. One should not skimp on cost in this area.

Although the above are probably the more important issues to address, other essentials also require consideration, such as billing, medical records, marketing, regulations, and the development of educational materials.

Reference

1. McColloch M, Geddis C, Hetzer MR, Beck C, Fisher SC. Embedding techniques. In: Fish FS, editor. Manual of frozen section processing for Mohs micrographic surgery. Milwaukee: American College of Mohs Surgery; 2008. p. 601–88.