SAN DIEGO Most Mohs surgeons don't have the luxury of designing an ideal office from scratchthey must work with their preexisting office space, said Dr. James Del Rosso at a meeting sponsored by the American Society for Mohs Surgery.
Think of the acronym SPACE: Skills, Personnel, Area, Coordination, and Equipment, said Dr. Del Rosso of the University of Nevada, Las Vegas.
▸ Skills. To succeed as a Mohs surgeon, build on your basic surgical skills, and remember to start slow, small, and safe, Dr. Del Rosso said. Mohs involves a change in surgical technique with regard to removing skin cancer; the difference is in the conceptualization of lesion removal. Mohs surgeons consider tangential margin control, which calls for a different approach than a standard surgical excision. A dermatology residency, attendance at Mohs surgery courses, and observation of Mohs colleagues during procedures will help refine your skills.
▸ Personnel. Educate the office staff about Mohs surgery, what it involves, and why you have decided to offer it. Consider cross-training staff members so that they know how to cut tissue sections if the regular technician calls in sick, for example. Division of responsibility is crucial. You will also need to hire laboratory staff. Designate individuals for certain paperwork responsibilities, including logs on patient care and on instrument maintenance, and designate backup staff for all duties. In addition, educate staff about anatomical landmarks. "Make sure that everyone who is documenting procedures uses the same terminology," Dr. Del Rosso said. Also, train patients to be observers, and notice other problems.
Define office procedures, and document them in office manuals. "I recommend having someone in the office put together a short 'Cliff's Notes' version of one or two pages with highlights of the basic office procedures," he said.
▸ Area. Ideally, a Mohs surgeon can design an office space to specifications, but most surgeons work with the space they have. However, a standard surgical room that will be used for Mohs surgery should have eyewash stations, appropriately sized adjustable chairs for both the doctor and patient, and step stools for nurses or other staff who need a higher view of the procedures. If you have a step stool, make this rule: The person who uses it moves it out of the way when he or she is done. Kick bucketsbuckets on wheels that can be moved with the feet while the surgeon is gloved during a procedureare extremely helpful in a Mohs surgical suite.
▸ Coordination. Think about how the patients, the staff, and the specimens will flow through the office. A separate waiting room is ideal, but a separate section of the waiting room is the next best thing. Be sure that staff members know which patients are waiting between surgical sections, and that these patients are monitored and kept comfortable. "These patients will be waiting with bandages between layers, they may bleed and contaminate other patients, or they could faint, or become vasovagal," Dr. Del Rosso said.
▸ Equipment. The equipment for Mohs is expensive, and equipment maintenance goes without saying. "It is penny wise and pound foolish not to buy good surgical tools," Dr. Del Rosso said. "The way to save money is to make sure that equipment is properly cared for in the future." Establishing a Mohs laboratorywith its unique processing of specimens and methods of record keepingis one of the biggest challenges for beginning Mohs surgeons, as is interpreting the sections.
"I would plan for two cryostats, even if you don't have two in the beginning," he said. "You will also need to allow for an inking station." Use color-coded glass slides for different stages to help keep samples organized.
Keep a prepared tray with the entire collection of surgical equipment ready, including small cups with saline and peroxide to soak the instruments between sections. Make sure the trays are organized so that the instruments are easy to locate, and discourage staff from tossing gauze on the trays and obscuring the instruments. "Hemostats should be on every tray, whether it is a repair tray or a Mohs tray," Dr. Del Rosso noted.
His favorite instruments include tenotomy scissors, Bishop-Harmon forceps, and blunt-edged dedicated undermining scissors. Some surgeons use sharp scissors for undermining.
Although many surgeons use disposable blades, Dr. Del Rosso recommends purchasing good quality blades and either sharpening them on-site or sending them out for regular sharpening. "If your knives aren't kept sharp, you will have problems with the quality of your sections," he explained. Reusable blades are more cost effective and allow the surgeon greater control over the blade quality.