SAN DIEGO – If you want to receive a coveted "satisfactory" grade from peer reviewers of the American Society for Mohs Surgery, "keep it simple," advised Dr. Sharon F. Tiefenbrunn, a member of the ASMS peer review committee..
"The goal of this is to show us that you can recognize a perfect case and can produce a perfect case," she said at a meeting sponsored by the ASMS.
Highly complex or controversial cases are frequently "unreviewable," she noted.
Dr. Sharon F. Tiefenbrunn
"We don’t want your greatest case, where you worked until almost midnight, and it took 10 stages to clear, and the patient had to have a free flap to repair the defect, and you were ready to tear out your hair and swear off Mohs forever," stressed Dr. Tiefenbrunn, a procedural dermatologist in private practice in St. Louis.
Instead, peer reviewers want to see a stage II to III Mohs case, with tumor evident on stage I and a tumor-free final stage, she said.
Dr. Tiefenbrunn explained that the peer review program was launched in 2000, reviewing cases from the previous year. Its purpose is to improve the quality of Mohs surgery, track the organization’s success in teaching Mohs techniques, and provide practitioners with one of the two episodes of peer review required by the Clinical Laboratory Improvement Act (CLIA).
Cases are submitted to the ASMS administrative office and cycled to reviewers, who classify them as satisfactory, unreviewable, or "comments only."
A typical comment might be: "not enough overlap to determine clear margin." Such cases are sent to the peer review chairman, who forwards the case, along with a critique, back to the presenter.
In essence, a "comments" case fails to meet peer review standards, while an "unreviewable" case potentially might be corrected according to reviewers’ comments and resubmitted, said Dr. Tiefenbrunn.
Satisfactory cases demonstrate use of standard Mohs technique, have a minimal number of slides, and represent noncontroversial histology.
Some common reasons that cases are judged "unreviewable" include problems with the tumor map and ink legend, failure to mark the tumor on the map, unlabeled sections, confusing slide labeling, use of a nonstandard Mohs technique, bubbles, or a failure to identify tumor on stage I.
Dr. Tiefenbrunn reminded attendees of several cardinal rules, among them the need to include a complete skin edge (at least 90%), a complete deep margin, visible structural details, an adequate stain, visible ink for orientation, and a stage II showing a 2.5-mm margin in every direction.
Reviewers appreciate a legible presenter form; an orderly, precisely drawn map; well-packaged and well-organized slides; and simple explanations for anything on histology, such as actinic keratoses or nevi that might be mistaken for a tumor, said Dr. Tiefenbrunn.
"Presentation matters," she said. "Reviewers are your colleagues who are just as busy as you. We want to whip through these cases and just circle ‘satisfactory’ and go home."
Dr. Tiefenbrunn reported no relevant financial disclosures.