Mohs Fellowship

A few issues should be addressed before the candidate can start the Mohs training program.
Before starting the training program the candidate should arrange a day in which he or she accompanies an experienced Mohs surgeon to learn about the procedures during a Mohs day. All steps will be addressed and explained to the Mohs candidate.

Also, a the candidate should accompany the technician during one morning. By following the excised tissue from the operating room to the cryostat, a better spatial awareness will be developed which will help when the sections are being analyzed. With a better understanding of what the technician does with the tissue, a better awareness of how to prepare and deliver the tissue is being created. During this morning the Mohs word file will be addressed as well. The right way of how to fill out  the file and draw in the file with the proper color codes and conventions will be taught.

During the Mohs training program 200 mohs surgeries will have to be performed as first surgeon. This entails the first round, analysis of the slides and the reconstruction. Furthermore the candidate needs to have reviewed the slides of 500 mohs cases. This means 200 of their own cases, about 200 of the fellow candidate and around 100 of the day before (Which are always being double checked by the supervisor of the following day).

It is the candidate’s own responsibility to meet the criteria of the evaluations and assessments during the training. This includes the evaluation form after 40 and 100 mohs surgeries. When desired the candidate can ask for an additional evaluation with the supervisor. The supervisor as well can ask for an additional evaluation when thought necessary. The candidate is responsible that the evaluations are planned and that they actually take place.

The Mohs procedural assessment needs to be planned by the candidate as well and should be repeated until every aspect of the assessment is judged  ‘excellent’. During the training the candidate is expected to give a presentation to the residents and staff of the department about a subject within dermato-oncology or dermato-surgery, this can be: - A CAT (critically appraised topic) - Literature/ paper presentation - Guideline discussion The subject of the presentation should be approved by the supervisor first. After the presentation the scientific assessment form will be filled out. This form also is part of the personal portfolio that forms a tool of assessing the candidate.

One month before the end of the training the candidate should apply for the final assessment. After passing this test together with a portfolio that meets the requirements mentioned before, the candidate will receive a certificate of successful completion of the Erasmus MC Mohs fellowship.

Assessment 1: After about 3 months the first assessment will take place. This assessment will consist of the evaluation of the candidate according to the evaluation form and a theoretical assessment. The theoretical assessment tests the general knowledge of the candidate about anatomy, oncology guidelines, treatment procedures of the EMC and  Mohs procedures. The second part of the assessment will consist of the slides of 10 (first) rounds of mohs patients and pictures of these defects. In these pictures the tumors must be marked, the second incision round should be drawn and the tumor found should be named (including grow pattern). At least 6 of the pictures should be correctly filled out and tumor recognized. Both parts combined are used to calculate a final rating and a ‘go/no go’ verdict. Consequence can be that substandard performance may lead to a termination of the training program.

Assessment 2: At the end of the training a final evaluation will take place. To form a final judgement all assessment forms should be presented. This means the evaluation form of moment 1, the daily checklist, the Mohs procedural assessment and scientific assessment. Any additional assessments or evaluations done during the training should be presented as well together with the daily checklist and mohs logbook. All these forms are collected by the candidate and handed over to the supervisor in his or hers portfolio at the end of the training. A final theoretical assessment needs to be done as well. During this assessment the knowledge of the candidate will be tested about the mohs procedure, histology (pathology) and reconstruction techniques. Again the slides of 20 first mohs round will be collected with the pictures of the defect. As in assessment number 1, the candidate will be asked to mark the tumor, draw the second incision and name the tumor with subtype. To test the knowledge of the reconstruction techniques, a series of pictures of defects will be shown and the candidate needs to explain which reconstruction type can be used, which is the best and why.

During the entire training the decision can be made that the candidate should stop. This decision can be made by the supervisors or the candidate him/her self. If desired, the candidate and/or supervisor can request extra evaluation moments. When there are issues that cannot be discussed with the supervisor, the coordinator of the Mohs training is a neutral person to talk to.

The Erasmus MC (Rotterdam, The Netherlands) is among the largest Mohs Micrographic Surgery centers in Europe. They perform approximately 1700 MMS procedures annually and have a formal training program for MMS.