Originating in 1968, the dermatologic surgery fellowship is as young as many dermatologists in practice today. Not surprisingly, the blossoming fellowship has undergone its fair share of both growth and growing pains over the last 5 decades.
A Brief History
The first dermatologic surgery fellowship was born in 1968 when Dr. Perry Robins established a program at the New York University Medical Center for training in chemosurgery.1 The fellowship quickly underwent notable change with the rising popularity of the fresh tissue technique, which was first performed by Dr. Fred Mohs in 1953 and made popular following publication of a series of landmark articles on the technique by Drs. Sam Stegman and Theodore Tromovitch in the late 1960s and early 1970s. The fellowship correspondingly saw a rise in fresh tissue technique training, accompanied by a decline in chemosurgery training. In 1974, Dr. Daniel Jones coined the term micrographic surgery to describe the favored technique, and at the 1985 annual meeting of the American College of Chemosurgery, the name of the technique was changed to Mohs micrographic surgery.1
By 1995, the fellowship was officially named Procedural Dermatology, and programs were exclusively accredited by the American College of Mohs Surgery (ACMS). A 1-year Procedural Dermatology fellowship gained accreditation by the Accreditation Council for Graduate Medical Education (ACGME) in 2003.2 Beginning in July 2013, all fellowship programs in the United States fell under the governance of the ACGME; however, the ACMS has remained the sponsor of the matching process.3 In 2014, the ACGME changed the name of the fellowship to Micrographic Surgery and Dermatologic Oncology (MSDO).2 Fellowship training today is centered on the core elements of cutaneous oncologic surgery, cutaneous reconstructive surgery, and dermatologic oncology; however, the scope of training in technologies and techniques offered has continued to broaden.4 Many programs now offer additional training in cosmetic and other procedural dermatology. To date, there are 76 accredited MSDO fellowship training programs in the United States and more than 1500 fellowship-trained micrographic surgeons.2,4
Trends in Program and Match Statistics
As the role of dermatologic surgery within the field of dermatology continues to expand, the MSDO fellowship has become increasingly popular over the last decade. From 2005 to 2018, applicants participating in the fellowship match increased by 34%.3 Despite the fellowship’s growing popularity, programs participating in the match have remained largely stable from 2005 to 2018, with 50 positions offered in 2005 and 58 in 2018. The match rate has correspondingly decreased from 66.2% in 2005 to 61.1% in 2018.3
Changes in the Match Process
The fellowship match is processed by the SF Match and sponsored by the ACMS. Over the last decade, programs have increasingly opted for exemptions from participation in the SF Match. In 2005, there were 8 match exemptions. In 2018, there were 20.4 Despite the increasing popularity of match exemptions, in October 2018 the ACMS Board of Directors approved a new policy that eliminated match exemptions, with the exception of applicants on active military duty and international (non-Canadian) applicants. All other applicants applying for a fellowship position for the 2020-2021 academic year must participate in the match.4 This new policy attempts to ensure a fair match process, especially for applicants who have trained at a program without an affiliated MSDO fellowship.
The Road to Board Certification
Further growth during the fellowship’s mid-adult years centered on the long-contested debate on subspecialty board certification. In 2009, an American Society for Dermatologic Surgery membership survey demonstrated an overwhelming majority in opposition. In 2014, the debate resurfaced. At the 2016 American Society for Dermatologic Surgery annual meeting, former American Academy of Dermatology presidents Brett Coldiron, MD, and Darrell S. Rigel, MD, MS, conveyed opposing positions, after which an audience survey demonstrated a 69% opposition rate. Proponents continued to argue that board certification would decrease divisiveness in the specialty, create a better brand, help to obtain a Medicare specialty designation that could help prevent exclusion of Mohs surgeons from insurance networks, give allopathic dermatologists the same opportunity for certification as osteopathic counterparts, and demonstrate competence to the public. Those in opposition argued that the term dermatologic oncology erroneously suggests general dermatologists are not experts in the treatment of skin cancers, practices may be restricted by carriers misusing the new credential, and subspecialty certification would actually create division among practicing dermatologists.5
Following years of debate, the American Board of Dermatology’s proposal to offer subspecialty certification in Micrographic Dermatologic Surgery was submitted to the American Board of Medical Specialties and approved on October 26, 2018. The name of the new subspecialty (Micrographic Dermatologic Surgery) is different than that of the fellowship (Micrographic Surgery and Dermatologic Oncology), a decision reached in response to diplomats indicating discomfort with the term oncology potentially misleading the public that general dermatologists do not treat skin cancer. Per the American Board of Dermatology official website, the first certification examination likely will take place in about 2 years. A maintenance of certification examination for the subspecialty will be required every 10 years.6
Final Thoughts
During its short history, the MSDO fellowship has undergone a notable evolution in recognition, popularity among residents, match process, and board certification, which attests to its adaptability over time and growing prominence.