Skin in the Game: Research, Education and Mohs Surgery-Queen’s has it all

| 10 February 2015

Spoiler alert-this is a good news story (but it starts out with some depressing facts) When I was in Medical school (1977-81), Queen’s University had 3-4 dermatologists. When I returned to Queen’s late in 2012, a lot had changed. Hall and Oates no longer had 2 hits in the top 10, The Jeffersons were no longer “movin on up” on TV and Queen’s no longer had a Dermatology program. Although the population of Frontenac county (in which Kingston is situated) had increased from 105,000 to almost 150,000 there was now only one dermatologist, Dr. Ruth McSween, to serve the entire South East Local Health Integration Network (LHIN), one of 14 networks established by the province to plan, manage, and fund the health care system at the local and regional level.

The provision of one dermatologist for a population of ~500,000, 44% of whom are over 50 years of age, was a bad mismatch for the epidemiology of skin diseases. Many disfiguring skin diseases (like psoriasis) can now be treated using biological and phototherapies and rates of skin cancer are increasing. Of course I do a disservice to dermatology-there are many diseases that merit the attention of a Dermatologist (i.e. acne, eczema, cellulitis, nevi and the list goes on). A 2014 report from the Canadian Cancer Society noted, melanoma skin cancer is Canada’s most rapidly increasing type of cancer (6,500 new cases in 2014); however the other skin cancers are more numerous (76,100 cases of basal cell and squamous cell skin cancers predicted to occur in 2014). Clearly we were entering 2014 ill prepared. Based on documents from Canada’s Dermatology Society a service area the size of the SELHIN requires ~ 8 dermatologists; we had one. This shortage is not exclusively a local problem. In an article entitled, The amazing vanishing Canadian dermatologist: results from the 2006 Canadian Dermatology Association member survey. (J Cutan Med Surg. 2010 Mar-Apr;14(2):71-9.) Chow and Searles summarized the status of Canadian dermatology as a discipline that was failing to replenish itself, let alone grow to meet the expanding needs of the population. They surveyed Canada’s 602 Dermatologists (response rate 36%) and found that “The median age increased to 55 years; two-thirds of dermatologists are male. The median retirement age remained at 65 years. There was a shift from rural to urban practice locations. Three-fifths of dermatologists do mainly medical dermatology. Pediatric dermatology decreased 10%, whereas surgical dermatology increased 52% between surveys. Fewer practitioners perform noninsured services, and half as many perform research or hospital consultations or teach medical students. Training programs produce only 60% of new practitioners needed to replace retirees over the next 5 years. Existing training programs are at full capacity, and only the creation of new programs can expand training capacity.”: They concluded “The demographics of the Canadian baby boom generation will have a major negative impact on the effectiveness of Canadian dermatology in the service of the Canadian population. The attrition rate predicted in the 2001 survey and validated by the 2006 survey spotlights the critical imperative for the specialty to adapt to the future of a shrinking workforce in the face of expanding demand for its services.” With this in mind I approached the building of a Dermatology program with some trepidation, but a sense of purpose and urgency. Beginning in 2013 the Department of Medicine began a concerted effort to create an academic Division of Dermatology. While this initiative was challenging it had support from the Dean, Richard Reznick, the CEO of Hotel Dieu Hospital and Dr. David Pichora and Mike McDonald (Chief Patient Care, and Chief Nursing Officer) and ultimately support from Paul Huras in the SELHIN in the form of infrastructure support. Administratively I was ably supported by Margaret Atkinson from the Hotel Dieu Hospital

Dr. David Pichora, Dean Richard Reznick and Mr. Mike McDonald

The goal of the recruitment was to create a team that could provide advanced Dermatologic care, perform research and create a training program to ensure that Queen’s never again finds itself without a Dermatology program. We have been fortunate to recruit three absolutely outstanding dermatologists, including a Mohs surgeon. Clinical Care and Research: First to join was Dr. Yuka Asai. Dr. Yuka Asai joins the Division of Dermatology at Queen’s from McGill University where she was an Assistant Professor. A prairie native, she obtained her Bachelor of Science at the University of Alberta and her MD at the University of Saskatchewan. She completed her dermatology training at McGill University, from which she received an MSc in Epidemiology. Dr. Asai is pursuing her PhD. Meet Dr. Asai in this video clip

Dr. Yuka Asai

Clinical Care and Education: Next we recruited Dr. Mark Kirchhof, an MD/PhD with a mandate to build a Dermatology training program. Dr. Kirchhof completed a Bachelor of Science in Molecular Biology at McMaster University and an MD/PhD at Western University before completing his Dermatology residency at the University of British Columbia. His research interests are broad and include vasculitis, autoimmune diseases and inflammation, microbe-skin interactions, drug reactions and skin cancer. As an educator he has been invited to speak at several conferences for physicians and nurse practitioners. He is already busy organizing the dermatology curriculum for the undergraduate medical program and will soon be taking medical residents for clinical rotations.

Dr. Mark Kirchhof

Mohs Micrographic Surgery: Our third member joins us in April. Dr. Benvon Moran, joins us after training in Medicine (University College Cork) and Dermatology (Royal College of Physicians of Ireland). She spent a year completing a Mohs fellowship at the University of British Columbia. What, you ask, is Mohs surgery? Mohs is a technique to surgically remove non-melanoma skin cancers from sensitive areas (near the eyes, nose or on the genitalia, for example). It uses real-time confirmation of circumferential surgical margins to pare away the tumour removing only the minimum amount of tissue required to ensure disease free surgical edges (margins)

Dr. Benvon Moran

Mohs is named for Dr Frederic E. Mohs who envisioned the technique (called Mohs micrographic surgery) in the 1930’s, while working as an Assistant to Professor Michael F. Guyer, Chairman of the Department of Zoology at the University of Wisconsin. (Trost and Bailin Dermatol Clin 29 (2011) 135–139). In a review of Mohs Trost noted “They were studying the potential curative effects of injecting various substances into different neoplasms. During one experiment, a 20% solution of zinc chloride was injected and inadvertently caused tissue necrosis. Microscopic analysis showed that the tissue retained its microscopic structure as if it had been excised and processed for routine pathologic examination. Dr Mohs realized that this in situ fixation effect could be coupled with surgical excision to remove neoplasms in a microscopically controlled serial manner. In addition, he conceived of the idea of using horizontal frozen sections to evaluate 100% of the specimen margins (deep and peripheral) rather than traditional vertical sections or random step sections, which examine 0.05% of the total tumour volume”. During Mohs micrographic surgery, cancerous tissue is removed one layer at a time and examined under a microscope until the skin cancer has been completely removed. This leaves as much healthy tissue as possible in place and thereby avoids deformity. Despite the name, Mohs is performed under local anaesthesia, and does not require an operating room or an anaesthetist. The dermatologist functions both as the pathologist (reading the microscope slides to judge the margins and ensure they are tumour free) and as the surgeon.

The map below shows a star for each Mohs surgeon in Canada…not many!

All of our Dermatologists treat skin cancers, so when is Mohs surgery done? (see Table below)

Are their controversies in the world of Mohs? Yes there are…related to subjects of over use and over charging. However, these concerns are largely confined to the fee-for-service world of the USA. In America, indication-drift and large fees have clouded the advances that the Mohs technique has brought (http://www.nytimes.com/2014/01/19/health/patients-costs-skyrocket-speci… ). Brett M. Coldiron, MD, President of the American Academy of Dermatology, was quoted in a 18 January 2014 New York Times article as saying, “Mohs has a success rate approaching 99% for difficult-to-treat basal and squamous cell cancers and is a very cost-effective treatment option for nonmelanoma skin cancer,” He added, “Another benefit of Mohs surgery is that the entire margin of the tumour is examined for remaining cancer, essentially resulting in an extremely low rate of cancer recurrence.” How does Mohs differ from Plastic surgery? - in the scope of operations performed and the training of the physicians. In a patient-centred world, the disciplines are complementary. Fortunately at Queen’s this is the case. Our Mohs program would not be possible without the support our plastic surgeons, led by Dr. John Davidson.

…and our oncologists, led by Dr. Elizabeth Eisenhauer.

So what is next for Dermatology? In the crazy world of Academic Medicine, where Departments are the unity of Divisions, Where Heads hold Chairs it won’t surprise anyone to know that next on the shopping list is a Division Chair. We have built the Division from the base up…now we need a talented leader to continue to the quest to ensure Queen’s, Kingston, the Hotel Dieu and the SELHIN will, like Scarlett O’Hara in Gone With the Wind, “Never be poor again”. How can you help: If you are a donor seeking to advance skin care in Ontario I would love to talk to you about investing in a Chair in Dermatology…which would be an invaluable aid in assisting the recruitment of a Division Chair.