3-Step Approach to Increase Diversity in Mohs Micrographic Surgery

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Any views and opinions expressed are those of the author(s) and/or participants and do not necessarily reflect the views, policy, or position of The Dermatologist or HMP Global, their employees, and affiliates. 

As the US population becomes increasingly diverse, there have been efforts to increase provider representation. Race concordant visits are associated with enhanced patient satisfaction and adherence, leading to more cost-effective and efficient care.¹ Despite the majority of nonmelanoma skin cancer claims occurring from White patients, African American patients received Mohs micrographic surgery (MMS) in 44.2% of skin cancer visits compared with 9.6% for Caucasians.² Additionally, MMS defects were 17% larger among Hispanic/Latino patients compared with non-Hispanic White patients and defect sizes of squamous cell carcinomas compared with those of basal cell carcinomas were 80% larger among Hispanic/Latino patients compared with non- Hispanic White patients who only had a 25% larger defect size.³ These data highlight the need for diverse surgeons to serve our patient populations. 

Dermatology remains the second least diverse specialty, with Black physicians representing 3% of dermatologists in the United States and Hispanics comprising 4.2%. Recently, diversity trends in MMS were researched. In 2014, physicians underrepresented in medicine (URM) made up 4.5% of surgeons who were members of the American College of Mohs Surgery (ACMS).4 From 1986 to 2014, the percentage of URM Mohs surgeons ranged from 4.2% to 4.6%.⁴ The proportion of incoming Black and Hispanic MMS fellows has been steadily decreasing over the last decade. In fact, during the 2017 to 2018 and 2018 to 2019 match cycles, 0.0% of MMS fellows identified as Black or Hispanic.⁵ These trends are disconcerting when we consider that Hispanic and Black individuals represent over 18% and 13% of the US population, respectively.^4,5 In this article, we present a 3-step approach for increasing diversity in MMS. 

Step 1: Acknowledge the Presence and Role of Interpretive Lenses
Acknowledgement of inherent biases is a critical initial step that should first occur at a personal level. Due to societal experiences and conditioning, humans subconsciously act on inherent stereotypes and prejudices that are formed outside of their consciousness.⁶ Unconsciously, we learn to associate specific attributes with certain social groupings (such as men with career roles and women as caretakers) and preferential ranking of groups (such as preferences for White people over Black people).⁶ These unconscious rankings and groupings are shaped by factors such as familial beliefs, media messaging, and institutional policies. Physicians exhibit the same level of implicit bias as the general population,⁷ and this can have implications on diversity in small specialties such as MMS. 

Mohs surgeons in the ACMS have traditionally been White men and women.⁴ We may unconsciously associate Mohs surgeons with White physicians, and this may contribute to a lack of diversity. Those in positions to choose new fellows may gravitate toward individuals who look more like themselves. Acknowledging that it is normal to have these reflexive cognitive processes, which unintentionally influence our decision-making, allows us to embark on the journey toward positive change. This may take the form of taking implicit association tests or tackling these topics during Mohs conferences with sessions aimed at exploring individual interpretive lenses. 

Step 2: Dispel Myths and Stay Curious 
All people acquire values from external sources during development, and these values reflect social norms and attitudes that can be plagued with myths and inaccuracies. For example, one myth is that racial and ethnic minority students or residents may not match into desired specialties because they lack merit.⁸ In essence, this myth implies that these students are at fault because we live in a meritocracy where only the best minds move on.⁹ But “meritocracy” is not always meritocratic. Although merit in medicine may equate to intelligence plus effort, perceived merit may also be linked to wealth and influence. Medical students or residents seeking to match into competitive subspecialties can pay to “get an edge” and have the means to take expensive test preparation courses or unpaid research years, thus obtaining higher numbers of publications to bolster their credentials. Residents seeking an MMS fellowship must often travel to outside institutions to spend time with program directors and network. These endeavors can be prohibitively expensive and out of reach for minority, low-income learners despite their merits being similar to the merits of their peers. 

The idea that the lack of diversity is the result of too few people from URM groups entering certain fields by chance is also a myth; instead, there are multiple factors pushing these groups out and precluding them from pursuing certain specialties, including lack of mentorship or role models.^10,11

Dispelling these myths requires conscious effort and a curiosity to dig deeper into the “why” behind the current MMS demographic statistics. From 2011 to 2020, the average yearly rate of change for White applicants accepted into an MMS fellowship was +1.01% versus -0.77% for Black residents, -0.5% for Hispanic residents, and -0.05% for Native Hawaiian or Pacific Islanders residents.5 Reflecting on previously held beliefs and understanding the point of view of others can allow for change to occur. 

Step 3: Use Leadership Positions to Make Change
If we do not recognize the reality of the status quo, our inaction will uphold it. There is a growing effort to recruit URM physicians to dermatology, and this effort should also be applied to MMS. Incorporating the importance of diversity and inclusion into the mission statements of MMS programs may create a more welcoming environment for residents who identify as URM when reviewing fellowships. Surgeons can commit to mentoring residents who have different backgrounds and life experiences than they do. The ACMS began a diversity mentorship program in 2021, and expansion of this program will likely open the door for residents who previously believed that an MMS fellowship was out of reach. 

Additionally, being intentional during the fellow selection process is required. Rather than overemphasizing the importance of applicant test scores and publications, selection committees can incorporate other features of the applicant that are traditionally overlooked, such as their patient care values, grit, willingness to be an engaged learner, and commitment to service. This may require more time, but we believe the extra time is worth it and necessary. 

Conclusion
With data showing that patients with skin of color have higher morbidity and mortality from skin cancers despite lower incidence rates, it is time to reassess how our care is delivered and who is delivering that care. We need more Mohs surgeons from diverse backgrounds to serve our ever-more diverse US population. The proposed 3-step process outlined above may help move us toward that goal.  

References 
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2. Reeder VJ, Gustafson CJ, Mireku K, Davis SA, Feldman SR, Pearce DJ. Trends in Mohs surgery from 1995 to 2010: an analysis of nationally representative data. Dermatol Surg. 2015;41(3):397-403. doi:10.1097/DSS.0000000000000285 

3. Blumenthal LY, Arzeno J, Syder N, et al. Disparities in nonmelanoma skin cancer in Hispanic/Latino patients based on Mohs micrographic surgery defect size: a multicenter retrospective study. J Am Acad Dermatol. 2022;86(2):353- 358. doi:10.1016/j.jaad.2021.08.052 

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8. Backhus LM, Kpodonu J, Romano JC, Pelletier GJ, Preventza O, Cooke DT. An exploration of myths, barriers, and strategies for improving diversity among STS members. Ann Thorac Surg. 2019;108(6):1617-1624. doi:10.1016/j.athoracsur.2019.09.007 

9. Jablonski NG. Skin color and race. Am J Phys Anthropol. 2021;175(2):437-447. doi:10.1002/ajpa.24200 

10. Soliman YS, Rzepecki AK, Guzman AK, et al. Understanding perceived barriers of minority medical students pursuing a career in dermatology. JAMA Dermatol. 2019;155(2):252-254. doi:10.1001/jamadermatol.2018.4813 

11. Cooke DT, Olive J, Godoy L, Preventza O, Mathisen DJ, Prager RL. The importance of a diverse specialty: introducing the STS workforce on diversity and inclusion. Ann Thorac Surg. 2019;108(4):1000-1005. doi:10.1016/j.athoracsur.2019.07.007