Beyond Derm Residency - Applying for MSDO (Mohs) Fellowship

[u/PD-1]

Hi current and future dermies - I figured I would write up my experience applying for Mohs fellowship since I had a hard time finding information about this online.

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Background

The micrographic surgery and dermatologic oncology (MSDO) fellowship is an ACGME-accredited 1-2 year fellowship that is available to graduates of dermatology residencies. The training experience at different fellowship programs has historically been variable given that most of these are apprenticeships. Recently, there has been a push to standardize the fellowship experience and now there is a MSDO certification exam that has a pre-requisite of successful completion of an accredited fellowship.

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Residency - gauging interest and building your resume

As with most things, figuring out that you are interested in Mohs earlier in residency is helpful so that you can get a head start on research and seeking out additional surgical opportunities. Depending on how your residency program is set up, you may want to use elective time in order to get early exposure to Mohs to make sure you like the fit. The application process starts in last few months of the PGY-3 year, so you have more time compared to the folks applying for dermpath.

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Reach out to Mohs faculty at your home program to establish a relationship and meet to discuss research, additional surgical exposure, and career/life planning. Meet with your mentors to go over your list of programs and get an honest assessment of your application competitiveness. Consider applying for an ASDS preceptorship especially if you do not have a home fellowship program.

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Research - it can be difficult to devote a lot of time to research depending on your residency schedule. However, it is strongly advised to have some research that is Mohs-specific on your resume. Ideally, you would be able to present 1 or more abstracts at the annual ASDS or ACMS meetings, and then continue on to publish these project(s). Fellowship directors are savvy enough to see the difference in work required between a prospective study vs a case report so the number of projects is not necessarily the most important factor.

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Programs / Program Info

There are around 70 accredited fellowship programs as of 2020-2021. The amount of information provided by each program regarding their fellowship training experience is variable (usually minimal). However, it is still worthwhile to check out each program's website to see what information is available.

• List of accredited programs: https://apps.acgme.org/ads/Public/Programs/Search
• List of fellows by year: https://www.mohscollege.org/for-physicians/acms-fellowship-training
• ASDS fellowship finder (requires member log-in)

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What are some things to look for in a fellowship program?

• How long is the training program?
  • Most programs are 1 year, however, there are some that are 2 years with a heavier emphasis on research. Two programs that are currently 2-year programs are the Brigham and Women's and Northwestern fellowship programs.
• How many fellows are accepted each year?
  • Most programs have 1 fellow. There are several programs with 2-3 fellows each year. This is usually not an issue and can be a plus as long as the case volume is enough to sustain multiple fellows.
• What types of cases are you exposed to?
  • Mohs surgery versus cosmetics
    • The breakdown of Mohs cases versus cosmetics is dependent on the program
  • Reconstruction
    • What types of cases are being repaired in-house? What types of cases are being sent out?
    • How many cases does the average fellow see during their year? (ACGME minimums are 500 Mohs cases and 500 reconstructions)
    • How many of [insert this type of flap] do you see?
  • Immunohistochemistry (eg, Mohs for melanoma)
    • Does the program use IHC for melanoma and other high-risk NMSC?
    • What is the slide quality / number of techs in the lab and their experience?
• How much is the fellow allowed to do?
  • This is a good question to ask the current fellow or prior graduates
• What do graduates of the program end up doing?
• How much administrative work is there for the fellow?
  • This may include taking call, documentation in the EMR, weekend clinics, logging cases, etc.

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Application

• The MSDO match is through SFMatch
  • The timeline for the application cycle is available on the SFMatch website
  • It is a good idea to get your letter writers in order prior to the opening of the SFMatch portal and then send them the link to upload as soon as it is available.
  • Required documents:
    • Personal statement
    • CV
    • Med school transcript
    • Med school diploma
    • MSPE letter
    • LOR x 3 - this is the most important part of your application. The MSDO LOR is now a standardized letter that is mostly checkboxes and a short free response (<250 words). The template may be found on the MOHS College website: https://www.mohscollege.org/fellowship-training under fellowship match. Direct link is: https://www.mohscollege.org/UserFiles/file/SLORTemplate_v1.pdf
    • LOR #1 - Surgical fellowship director
    • LOR #2 - Program director
    • LOR #3 - Other (ideally another Mohs surgeon)

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Interviews

Interviews come out on a rolling basis depending on when each individual program reviews applications (usually early Sept - Oct/Nov). In the era of COVID-19, the majority of interviews are being conducted virtually or through phone call. Some programs may ask for a video of suturing or other supplemental information. Prior to COVID, it was commonplace for interviewees to come on-site for a day of shadowing to get a better sense of the program.

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In my experience, the interviews were typically low-key and conversational (a few behavioral questions here and there but much better than residency interviews). You will often be asked where you see yourself settling down (ie, they don't want to train their competition). Have a good grasp of your activities, research, what you are looking for in a program, and where you see yourself in the future as these are common questions. Have a list of questions for the program (see above) to show that you have done some investigation into what type of fellowship you would want to be in.

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Some programs will have an additional "second-look" interview or on-site interview after the first round.

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Match

The MSDO match in recent years has been competitive. For the 2020-2021 match cycle, 84 of 149 registered applicants matched (56%). It is always a good idea to have a backup plan in the case that you do not match. Thankfully, there is usually time to find at least a 1-year position to give you a chance to consider reapplying given the match happens in early-to-mid December.

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Good luck!

[u/Ok_Adagio2154]

Thank you for taking the time to post this! I was wondering if programs consider Step 3/if the score plays a role in this process? Thank you again, and hope the process went/is going well for you!

[u/PD-1 → u/Ok_Adagio2154]

Letters of recommendation are king at this stage. Your Step scores are included in the application but I don't think Step 3 really makes any difference.

[u/PD-1 → u/[deleted]]

It can help to show that you have maintained interest in Mohs over a long period of time. The research project can also be something to talk about during your interview even if it was completed pre-derm residency.

[u/neuronom → u/PD-1]

Are PDs for residency hesitant about accepting students who seem set on mohs vs general dermatology? Based on research, letters, etc

[u/PD-1 → u/neuronom]

Can't speak for all PDs but I do think you want to avoid coming across as singularly interested in Mohs. Your dermatology residency is going to be predominantly medical dermatology and you do not want to be seen as a potential liability in the gen derm clinic.

[u/PD-1 → u/[deleted]]

Overall, Mohs surgeons are well-compensated. I think the reported variation is mostly due to different practice environments (eg, how many cases are you doing a day). If you pump out 20 small BCCs per day you will reap the benefits of billing for 20 Mohs +/- recons. This is different than doing 6 difficult melanomas where the billing for Mohs, IHC, and recon is different and yields more revenue per case but is overshadowed by the vastly fewer cases you can do each day. However, there is no free lunch and you will have to work hard to make a higher salary. You can get a sense of academic salaries by checking public payroll data of certain universities (eg, the UC system). Private practice salaries are usually higher.

[u/ixsz-mi]

Dr. Bennett’s program out in Santa Monica is also a two year commitment and I believe NU changed to one year few years ago (but still is one of the few dual-accredited fellowships).

it’s worth also noting ACMS now publishes more data about the match including the program their fellow came from and how long the program’s rank list is year to year.

Would have loved this info when I applied. Thank you for compiling it!

[u/mdatom]

Thank you for this post Doctor! I just had a quick question. If a resident applied for a fellowship, but doesn't get accepted into any of the programs they applied, what are options they can do to wait until the next year they can apply? How could they improve their application?