Mohs surgery is vilified, physicians again fail to respond effectively

An article published in the New York Times last weekend has been circulating widely on the Internet, and I feel that more than ever, physician voices are needed to reach the public and counter certain misconceptions put forth by the media.

The article, “Patients’ Costs Skyrocket; Specialists’ Incomes Soar,” charts the growth of specialist incomes in the past decade, using the case of a patient from Arkansas who had a $25,000 medical bill for Mohs surgery to demonstrate the prevalence of unnecessary and costly procedures.

It isn’t all bad — one big pro of this article written by internist Dr. Elisabeth Rosenthal is opening the line of communication between physician and patient regarding transparency of cost and necessity of certain procedures. That’s a great thing, and for doctors out there who are taking advantage of the system, perhaps this article can make them change their ways. That being said, I think the article was at times unfair and depicted a distorted view of dermatology and other subspecialty fields. There are a few important points to address here in response to the article, and a few things I would have liked to see as a response from the physician community.

First, the article simultaneously vilified and minimized the role of Mohs surgery in treating skin cancer. The Mohs technique, invented in 1938 by general surgeon Dr. Mohs while he was still a medical student at University of Wisconsin-Madison, is a process where thin layers of cancerous tissue are sliced off and immediately studied under the microscope. The surgery stops when the tissues are completely free of cancer at all borders. This process helps to ensure that the cancer is absolutely removed while taking the minimal amount of skin necessary to do so.

Mohs has been proven in certain cancers such as recurrent basal cell carcinoma to be  more effective than excision, and there is no doubt that it has saved countless lives while preserving tissue for reconstruction. The AAD put out guidelines in 2012 to classify which lesions require Mohs surgery to remove — certain types of tumors in certain types of patient populations, tumors that are very deep, in sensitive areas on the face or ear, or ones that are very large.

The article instead characterizes Mohs instead as a “go to procedure,” a sort of money making machine. It does not go into the details that many Mohs procedures take several hours to complete, as you go through and take stage after stage of tissue. It does not go into the fact that this procedure can be lifesaving. Most of all, this article implies that Mohs is unnecessary, which can have hugely dangerous implications for patients out there with early stage skin cancer.

Not all patients are like Ms. Little either. The patient in the article had a small basal cell carcinoma which was excised via Mohs surgery, and then she was sent to an oculoplastic surgeon for the repair. Her bill was over $25,000 because she was treated by a Mohs surgeon, an oculoplastic surgeon, and an anesthesiologist. She was billed $1,833 for the Mohs, $14,407 for the plastic surgeon, $1000 for the anesthesia, and $8774 in hospital costs. She later got the costs down to $1400 for the Mohs procedure, $1,375 for the plastic surgeon, $765 for the anesthesia, and $1050 in hospital costs.

Take a second and think about these numbers. The plastic surgeon cost was able to be reduced by 90% … ? Why exactly is this article targeting the Mohs surgeon again?  Aside from that fact, there are many patients who receive Mohs who do not have to get a repair from a plastic surgeon with an anesthesiologist. In fact, the norm is for Mohs surgeons to do the repair themselves. They are trained in it, and that is their job — they only refer out if they cannot handle the repair alone. I can’t speak for Ms. Little’s Mohs surgeon (and apparently, he can’t either, as he did not comment in the article), but most Mohs surgery clinics are a one-stop shop for excision and repair.

The article also lumps all payments together as if what you’re billed for is what the doctor pockets. That cannot be further from the truth. The article cites examples of a $915.46 bill for a mole removal in Oregon or a $500 wart freezing treatment at NYU Medical Center. I spoke to two dermatologists from Stanford who laughed and said they would never see payments like that in their practices at an academic center. That money goes into paying for nurses, hospital administrators, dermatologists, medical assistants, medical record handling, and much more.

What needs fixing in this system isn’t the physician salaries, but rather, more transparency of cost. If patients can get a more truthful breakdown of costs, they would realize that the physician is not the greedy money-hungry one in this scenario.  It takes a lot more to run a medical center than meets the eye.

To be honest, I have been disappointed in the response from the physician community thus far. Dr. Dirk Elston, president of the American Academy of Dermatology, wrote a letter to the editor that appeared in the Times.

Dr. Fosko of the American College of Mohs Surgery also wrote a letter to the editor on the same page.  The responses are well written and full of information, and are great for other physicians to read.

However, I don’t think it is the best way to reach the public. If I’ve learned anything at NBC, it is that you have to tell a patient story.

Find a patient, one who has had his life saved and his world changed by Mohs surgery. It can’t be hard to find one; there are stories like this around the country. Interview him. Interview his family and his physician. Interview many Mohs surgeons. Put statistics in the piece but they can’t be the focus; numbers are fleeting but a patient story makes an impression.  And really show the world how much good Mohs surgery can do. I know it, dermatologists and other physicians know it, but now it’s up to us to convince the rest of the world that it is a worthwhile and lifesaving procedure.

Joyce Ho is a medical student who blogs at Tea with MD.  She can be reached on Twitter @TeawithMD.

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