Mohs Dermatology Landscape

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Mohs Dermatology Landscape

Key Takeaways

  • It is estimated that there are a minimum of 2,500 dermatologists performing Mohs surgery in the US.
  • In 2017, 94.1% of dermatologists in the US identified patient care as their primary professional activity, while the remaining 5.9% were in academia, research, or other dermatology activities.
  • It is estimated that at least 86% of US dermatology practices are in the small business category (less than 100 employees).
  • Both laser technology and the use of AI are expected to grow in the coming years, and both are expected to have a major impact on the dermatology field.


Introduction

Publicly available data on the number of Mohs surgeons in the US, a breakdown of US dermatologists by primary activity, and a breakdown of dermatology practices by business size are provided below. Research found that there was not any definitive data on the number of Mohs surgeons or a breakdown of businesses by size. Therefore, the team pivoted to provide data on the current state of Mohs surgeon certification in the US (which helps to explain the lack of available data), an estimate of the minimum number of Mohs surgeons, and a breakdown of the number of dermatology practices by number of practitioners. A complete explanation of the logic used can be found below in the Research Strategy section.

Also provided are two insights into expected changes in the dermatology field in the next 3-5 years. The expected changes covered are growth in laser technology and growth in the use of artificial intelligence (AI). Information specific to the possible impact of the new board certification option from the American Board of Dermatology (ABD) is covered as part of the analysis into the number of Mohs surgeons.


Number of Mohs Surgeons in the US

  • There is currently no requirement that dermatologists performing Mohs surgery be board certified in the US. This fact makes it virtually impossible to determine the true number of dermatologists performing Mohs surgery as there is no central repository that tracks them.
  • There are currently two main optional pathways to become "certified" as a Mohs surgeon, and, starting in October 2021, there is also now a third option to become "board certified" in the Micrographic Dermatologic Surgery (MDS) subspecialty.
  • The two organizations that offer Mohs "certification" are the American College of Mohs Surgery (ACMS) and the American Society for Mohs Surgery (ASMS). The ACMS has almost 1,500 members who have received "certification," while the ASMS has over 1,000 members.
  • If we assume there is no overlap between the two groups (which could not be verified) that would mean there are a minimum of 2,500 (1,500 + 1,000) Mohs practitioners in the US.
  • The American Academy of Dermatology states on their website that "most Mohs surgeons are dermatologists who have completed extensive training in Mohs surgery," which could be interpreted to mean that they are certified. Alternatively, the Mayo Clinic states that, "Many skin doctors (dermatologists) can perform Mohs surgery, since dermatologists learn about Mohs surgery in their medical training. Some Mohs surgeons have undergone specialized training — called a fellowship — to learn more about the procedure and become more proficient in Mohs surgery." This somewhat conflicting information shows why coming up with a definitive count is so challenging.
  • The newest certification pathway is offered by the American Board of Dermatology (ABD) and allows physicians to achieve board certification in the MDS subspecialty. This is a brand new certification and the first exam was scheduled to be given in October 2021, which means there are not currently any board certifications from the ABD.
  • Multiple articles were found indicating resistance to the ABD creating a new board certification for the MDS specialty, which could indicate that there is a significant number of dermatologists that are conducting Mohs surgeries that are not certified. However, it could also indicate that these are dermatologists who already have "certification" through one of the two optional pathways described above, and simply do not want to take the time and expense necessary to become board certified. There was no publicly available data that would allow for a definitive answer.
  • Examples of the push back regarding the ABD's board certification can be seen here, here, and here.
  • While board certification is not currently required to perform Mohs surgery, one expert in the dermatology field wrote in a viewpoint article that "private insurers and managed medicare insurers may over the next years begin to distinguish surgeons by board certification status and may eventually require board certification." If this were to happen, it is likely there would be more dermatologists becoming board certified which could make it easier to determine how many there are in the US.
  • In summary, it is reasonable to state that there are a minimum of 2,500 dermatologists performing Mohs surgery in the US.

Dermatologists by Major Professional Activity

  • According to data from the Association of American Medical Colleges (AAMC), there were 12,516 active physicians in the dermatology field in 2019. Of note, the American Medical Association reported there were 19,957 dermatologists in the US. Although it is not clear why there is a discrepancy, it could be due to the fact that the AAMC only counts active physicians. For purposes of this report, the active physician numbers are utilized.
  • Similar data found for 2017 provided additional details on the number of dermatologists broken out into one of four major professional activities: patient care, teaching, research, and other. By utilizing the 2017 data, estimates were made for 2019.
  • In 2017, of 12,051 active dermatologists:
    • 11,338, or 94.1% (11338/12051*100) stated patient care was their primary focus;
    • 97, or 0.8% (97/12051*100) stated it was teaching;
    • 100, or 0.8% (100/12051*100) stated it was research; and
    • 516, or 4.3% (516/12051*100) categorized their primary focus as other.
  • We assumed that dermatologists that had patient care as their primary focus were in private practice, while dermatologists in the other categories were in institutions/academia. Additionally, we assumed that the percentage of dermatologists in each professional area stayed the same from 2017 to 2019. Based on those assumptions, in 2019 there were approximately 11,778 (12516*94.1/100) dermatologists in private practice, with the remaining 738 (12516-11778) in institutions/academia.

Dermatology Practices by Size

  • IBISWorld reports that there are 5,391 dermatology businesses in the US in 2021.
  • There was no publicly available data on how those businesses are broken down by business size (small, medium, or enterprise).
  • An article from 2018 stated that 35% of dermatologists operate solo practices and 41% are in single-specialty group practices. While it is likely safe to assume that the solo practices would be considered small businesses, the group practices can't be classified so easily because there is no standard group size. One common way to categorize businesses is that small businesses have fewer than 100 employees, medium have between 100 and 999, and large/enterprise have more than 1,000.
  • This study published in April 2021 did look at the breakdown of dermatology practices based on the number of dermatologists in the practice. In 2017, only 5% of practices had more than 10 practitioners, which likely means that no more than 5% of practices could be considered large (although it seems likely that many of these would still be considered medium). Additionally, 86% (42%+44%) of practices had 5 or fewer doctors, which likely put them in the small business category.


Dermatology Market Future Insights

Growth of Laser Technology

  • Through 2025, the global dermatology medical lasers market is expected to grow at a CAGR of 16.0%. This compares to a CAGR of 10.9% for dermatologicals, 11.5% for dermatology devices, and 8.95% for dermatological therapeutics. So while it is clear that the industry as a whole will be growing, it appears that some of the largest growth will be in the area of laser technology.
  • Jill S. Waibel, MD, medical director and owner of Miami Dermatology and Laser Institute in Florida, subsection chief of dermatology at Baptist Hospital in Miami, and medical director of the Miami Cancer Institute’s Multidisciplinary Skin Cancer Clinic, stated in a late 2020 roundtable discussion, "I expect a huge jump in laser technology and devices that will go beyond the cosmetic arena into cancers and laser-assisted drug delivery, not just for dermatology, but for all specialties. We’ll also see innovation in other energy-based solutions."
  • According to a report by The Business Research Company, the primary driver of growth is expected to be "the growing demand for cosmetic procedures."
  • Excimer lasers are utilized to treat a wide variety of skin disorders including "rhinitis, Lichen planus, folliculitis, atopic dermatitis, granuloma annulare, and Leukoderma." In this area, growth is being driven by an increase in skin disorders. Globally, skin diseases are the fourth most common disease.
  • Lasers also are used to treat skin cancer, most often to treat precancerous lesions. With the "incidence of both non-melanoma and melanoma skin cancers" increasing over the past decades, the use of lasers has also increased which is a third driver of growth.

Artificial Intelligence

  • In May 2021, Google previewed their new artificial intelligence (AI) dermatology tool that allows people to take photos of skin conditions, and answer a few questions, in order to receive a list of potential matching conditions. According to a report by Next Steps in Derm, the technology is named Derm Assist.
  • An article published by Faezeh Talebi-Liasi, MD, and Orit Markowitz, MD, highlighted that while AI can assist in diagnosis, it is unlikely to replace doctors anytime soon. However, AI is having an impact in the areas of triaging and workflow.
  • Another study published in the Journal of Skin and Sexually Transmitted Diseases in April 2021 discussed several potential uses for AI in the field of dermatology, including classifying psoriasis, diagnosing onychomycosis, dermatopathology, education, and teledermatology.
  • While "there are currently no FDA-approved dermatology AI tools" in the US, one expert in the field, Roxana Daneshjou, dermatologist and AI researcher, believes that "AI has the potential to augment the ability of dermatologists."
  • Waibel also commented during the roundtable that, "Artificial intelligence will contribute significantly to our understanding of our specialty and provide an assistive tool for diagnostic accuracy."
  • A study published in Nature Medicine found that physicians supported by AI had better diagnostic accuracy than AI alone or physicians alone. This seems to support the idea that AI in dermatology has the potential to improve care and outcomes.
  • A survey conducted in 2019 found that almost half of dermatologists surveyed believed that AI would have a noticeable impact within 5 years.
  • Ronald Moy, MD, a board-certified dermatologist based in Los Angeles said in 2020 that "The combination of A.I. and teledermatology is the wave of the future."

Research Strategy

For this research on Mohs surgeons in the US, we leveraged the most reputable sources of information that were available in the public domain, including the American College of Mohs Surgery, the American Board of Dermatology, and the Mayo Clinic.

During our research, it quickly became apparent that any dermatologist can perform Mohs surgery as there is currently no required certification. Because of this, there is not currently a central location for data on all the dermatologists who perform the surgery. As an alternative, we researched the number of doctors who have received voluntary certification in order to provide a minimum number of surgeons.

Regarding the breakdown of dermatology practices by business size, we utilized reputable sources including IBISWorld, Dermatology Times, and Census.gov. Unfortunately, none of these resources provided the data requested. We then proceeded to search for information on consolidation in the dermatology field which led to some data on the size of dermatology practices based on the number of practitioners in the office and whether they were solo or group. This data allowed us to make some assumptions regarding practice size to provide some estimates.

Finally, in the Future Insights section of the report, the expected impact of the new ABD board certification was not covered, as it was previously covered when reporting on the number of Mohs surgeons.

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