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Enhancing Patient Satisfaction and Quality of Life With Mohs Micrographic Surgery: A Systematic Review of Patient Education, Communication, and Anxiety Management
Enhancing Patient Satisfaction and Quality of Life With Mohs Micrographic Surgery: A Systematic Review of Patient Education, Communication, and Anxiety Management
Mohs micrographic surgery (MMS)—developed by Dr. Frederic Mohs in the 1930s—is the gold standard for treating various cutaneous malignancies. It provides maximal conservation of uninvolved tissues while producing higher cure rates compared to wide local excision.1,2
We sought to assess the various characteristics that impact patient satisfaction to help Mohs surgeons incorporate relatively simple yet clinically significant practices into their patient encounters. We conducted a systematic literature search of peer-reviewed PubMed articles indexed for MEDLINE from database inception through November 2023 using the terms Mohs micrographic surgery and patient satisfaction. Among the inclusion criteria were studies involving participants having undergone MMS, with objective assessments on patient-reported satisfaction or preferences related to patient education, communication, anxiety-alleviating measures, or QOL in MMS. Studies were excluded if they failed to meet these criteria, were outdated and no longer clinically relevant, or measured unalterable factors with no significant impact on how Mohs surgeons could change clinical practice. Of the 157 nonreplicated studies identified, 34 met inclusion criteria.
Perioperative Patient Communication and Education Techniques
Perioperative Patient Communication—Many studies have evaluated the impact of perioperative patient-provider communication and education on patient satisfaction in those undergoing MMS. Studies focusing on preoperative and postoperative telephone calls, patient consultation formats, and patient-perceived impact of such communication modalities have been well documented (Table 1).3-8 The importance of the patient follow-up after MMS was further supported by a retrospective study concluding that 88.7% (86/97) of patients regarded follow-up visits as important, and 80% (77/97) desired additional follow-up 3 months after MMS.9 Additional studies have highlighted the importance of thorough and open perioperative patient-provider communication during MMS (Table 2).10-12
Patient-Education Techniques—Many studies have assessed the use of visual models to aid in patient education on MMS, specifically the preprocedural consent process (Table 3).13-16 Additionally, 2 randomized controlled trials assessing the use of at-home and same-day in-office preoperative educational videos concluded that these interventions increased patient knowledge and confidence regarding procedural risks and benefits, with no statistically significant differences in patient anxiety or satisfaction.17,18
Despite the availability of these educational videos, many patients often turn to online resources for self-education, which is problematic if reader literacy is incongruent with online readability. One study assessing readability of online MMS resources concluded that the most accessed articles exceeded the recommended reading level for adequate patient comprehension.19 A survey studying a wide range of variables related to patient satisfaction (eg, demographics, socioeconomics, health status) in 339 MMS patients found that those who considered themselves more involved in the decision-making process were more satisfied in the short-term, and married patients had even higher long-term satisfaction. Interestingly, this study also concluded that undergoing 3 or more MMS stages was associated with higher short- and long-term satisfaction, likely secondary to perceived effects of increased overall care, medical attention, and time spent with the provider.20
Synthesis of this information with emphasis on the higher evidence-based studies—including systematic reviews, meta-analyses, and randomized controlled trials—yields the following beneficial interventions regarding patient education and communication13-20:
- Preoperative and same-day postoperative telephone follow-up (TFU) do not show statistically significant impacts on patient satisfaction; however, TFU allows for identification of postoperative concerns and inadequate pain management, which may have downstream effects on long-term perception of the overall patient experience.
- The use of video-assisted consent yields improved patient satisfaction and knowledge, while video content—traditional or didactic—has no impact on satisfaction in new MMS patients.
- The use of at-home or same-day in-office preoperative educational videos can improve procedural knowledge and risk-benefit understanding of MMS while having no impact on satisfaction.
- Bedside manner and effective in-person communication by the provider often takes precedence in the patient experience; however, implementation of additional educational modalities should be considered.
Patient Anxiety and QOL
Reducing Patient Anxiety—The use of perioperative distractors to reduce patient anxiety may play an integral role when patients undergo MMS, as there often are prolonged waiting periods between stages when patients may feel increasingly vulnerable or anxious. Table 4 reviews studies on perioperative distractors that showed a statistically significant reduction in MMS patient anxiety.21-24
Although not statistically significant, additional studies evaluating the use of intraoperative anxiety-reduction methods in MMS have demonstrated a downtrend in patient anxiety with the following interventions: engaging in small talk with clinic staff, bringing a guest, eating, watching television, communicating surgical expectations with the provider, handholding, use of a stress ball, and use of 3-dimensional educational MMS models.25-27 Similarly, a survey of 73 patients undergoing MMS found that patients tended to enjoy complimentary beverages preprocedurally in the waiting room, reading, speaking with their guest, watching television, or using their telephone during wait times.28 Table 5 lists additional perioperative factors encompassing specific patient and surgical characteristics that help reduce patient anxiety.29-32
Patient QOL—Many methods aimed at decreasing MMS-related patient anxiety often show no direct impact on patient satisfaction, likely due to the multifactorial nature of the patient-perceived experience. A prospective observational study of MMS patients noted a statistically significant improvement in patient QOL scores 3 months postsurgery (P=.0007), demonstrating that MMS generally results in positive patient outcomes despite preprocedural anxiety.33 An additional prospective study in MMS patients with nonmelanoma skin cancer concluded that sex, age, and closure type—factors often shown to affect anxiety levels—did not significantly impact patient satisfaction.34 Similarly, high satisfaction levels can be expected among MMS patients undergoing treatment of melanoma in situ, with more than 90% of patients rating their treatment experience a 4 (agree) or 5 (strongly agree) out of 5 in short- and long-term satisfaction assessments (38/41 and 40/42, respectively).35 This assessment, conducted 3 months postoperatively, asked patients to score the statement, “I am completely satisfied with the treatment of my skin problem,” on a scale ranging from 1 (strongly disagree) to 5 (strongly agree).
Lastly, patient perception of their surgeon’s skill may contribute to levels of patient satisfaction. Although suture spacing has not been shown to affect surgical outcomes, it has been demonstrated to impact the patient’s perception of surgical skill and is further supported by a study concluding that closures with 2-mm spacing were ranked significantly lower by patients compared with closures with either 4- or 6-mm spacing (P=.005 and P=.012, respectively).36
Synthesis of this information with emphasis on the higher evidence-based studies—including systematic reviews, meta-analyses, and randomized controlled trials—yields the following beneficial interventions regarding anxiety-reducing measures and patient-perceived QOL21-36:
- Factors shown to decrease patient anxiety include patient personalized music, virtual-reality experience, perioperative informational videos, and 3-dimensional–printed MMS models.
- Many methods aimed at decreasing MMS-related patient anxiety show no direct impact on patient satisfaction, likely due to the multifactorial nature of the patient-perceived experience.
- Higher anxiety can be associated with worse QOL scores in MMS patients, and additional factors that may have a negative impact on anxiety include female sex, younger age, and tumor location on the face.
Conclusion
Many factors affect patient satisfaction in MMS. Increased awareness and acknowledgement of these factors can foster improved clinical practice and patient experience, which can have downstream effects on patient compliance and overall psychosocial and medical well-being. With the movement toward value-based health care, patient satisfaction ratings are likely to play an increasingly important role in physician reimbursement. Adapting one’s practice to include high-quality, time-efficient, patient-centered care goes hand in hand with increasing MMS patient satisfaction. Careful evaluation and scrutiny of one’s current practices while remaining cognizant of patient population, resource availability, and clinical limitations often reveal opportunities for small adjustments that can have a great impact on patient satisfaction. This thorough assessment and review of the published literature aims to assist MMS surgeons in understanding the role that certain factors—(1) perioperative patient communication and education techniques and (2) patient anxiety, QOL, and additional considerations—have on overall satisfaction with MMS. Specific consideration should be placed on the fact that patient satisfaction is multifactorial, and many different interventions can have a positive impact on the overall patient experience.
- Trost LB, Bailin PL. History of Mohs surgery. Dermatol Clin. 2011; 29:135-139, vii. doi:10.1016/j.det.2011.01.010
- Leslie DF, Greenway HT. Mohs micrographic surgery for skin cancer. Australas J Dermatol. 1991;32:159-164. doi:10.1111/j.1440 -0960.1991.tb01783.x
- Sobanko JF, Da Silva D, Chiesa Fuxench ZC, et al. Preoperative telephone consultation does not decrease patient anxiety before Mohs micrographic surgery. J Am Acad Dermatol. 2017;76:519-526. doi:10.1016/j.jaad.2016.09.027
- Sharon VR, Armstrong AW, Jim On SC, et al. Separate- versus same-day preoperative consultation in dermatologic surgery: a patient-centered investigation in an academic practice. Dermatol Surg. 2013;39:240-247. doi:10.1111/dsu.12083
- Knackstedt TJ, Samie FH. Shared medical appointments for the preoperative consultation visit of Mohs micrographic surgery. J Am Acad Dermatol. 2015;72:340-344. doi:10.1016/j.jaad.2014.10.022
- Vance S, Fontecilla N, Samie FH, et al. Effect of postoperative telephone calls on patient satisfaction and scar satisfaction after Mohs micrographic surgery. Dermatol Surg. 2019;45:1459-1464. doi:10.1097/DSS.0000000000001913
- Hafiji J, Salmon P, Hussain W. Patient satisfaction with post-operative telephone calls after Mohs micrographic surgery: a New Zealand and U.K. experience. Br J Dermatol. 2012;167:570-574. doi:10.1111 /j.1365-2133.2012.11011.x
- Bednarek R, Jonak C, Golda N. Optimal timing of postoperative patient telephone calls after Mohs micrographic surgery: a randomized controlled trial. J Am Acad Dermatol. 2021;85:220-221. doi:10.1016 /j.jaad.2020.07.106
- Sharon VR, Armstrong AW, Jim-On S, et al. Postoperative preferences in cutaneous surgery: a patient-centered investigation from an academic dermatologic surgery practice. Dermatol Surg. 2013;39:773-778. doi:10.1111/dsu.12136
- Xu S, Atanelov Z, Bhatia AC. Online patient-reported reviews of Mohs micrographic surgery: qualitative analysis of positive and negative experiences. Cutis. 2017;99:E25-E29.
- Golda N, Beeson S, Kohli N, et al. Recommendations for improving the patient experience in specialty encounters. J Am Acad Dermatol. 2018;78:653-659. doi:10.1016/j.jaad.2017.05.040
- Patel P, Malik K, Khachemoune A. Patient education in Mohs surgery: a review and critical evaluation of techniques. Arch Dermatol Res. 2021;313:217-224. doi:10.1007/s00403-020-02119-5
- Migden M, Chavez-Frazier A, Nguyen T. The use of high definition video modules for delivery of informed consent and wound care education in the Mohs surgery unit. Semin Cutan Med Surg. 2008;27:89-93. doi:10.1016/j.sder.2008.02.001
- Newsom E, Lee E, Rossi A, et al. Modernizing the Mohs surgery consultation: instituting a video module for improved patient education and satisfaction. Dermatol Surg. 2018;44:778-784. doi:10.1097/DSS.0000000000001473
- West L, Srivastava D, Goldberg LH, et al. Multimedia technology used to supplement patient consent for Mohs micrographic surgery. Dermatol Surg. 2020;46:586-590. doi:10.1097/DSS.0000000000002134
- Miao Y, Venning VL, Mallitt KA, et al. A randomized controlled trial comparing video-assisted informed consent with standard consent for Mohs micrographic surgery. JAAD Int. 2020;1:13-20. doi:10.1016 /j.jdin.2020.03.005
- Mann J, Li L, Kulakov E, et al. Home viewing of educational video improves patient understanding of Mohs micrographic surgery. Clin Exp Dermatol. 2022;47:93-97. doi:10.1111/ced.14845
- Delcambre M, Haynes D, Hajar T, et al. Using a multimedia tool for informed consent in Mohs surgery: a randomized trial measuring effects on patient anxiety, knowledge, and satisfaction. Dermatol Surg. 2020;46:591-598. doi:10.1097/DSS.0000000000002213
- Vargas CR, DePry J, Lee BT, et al. The readability of online patient information about Mohs micrographic surgery. Dermatol Surg. 2016;42:1135-1141. doi:10.1097/DSS.0000000000000866
- Asgari MM, Warton EM, Neugebauer R, et al. Predictors of patient satisfaction with Mohs surgery: analysis of preoperative, intraoperative, and postoperative factors in a prospective cohort. Arch Dermatol. 2011;147:1387-1394.
- Vachiramon V, Sobanko JF, Rattanaumpawan P, et al. Music reduces patient anxiety during Mohs surgery: an open-label randomized controlled trial. Dermatol Surg. 2013;39:298-305. doi:10.1111/dsu.12047
- Hawkins SD, Koch SB, Williford PM, et al. Web app- and text message-based patient education in Mohs micrographic surgery-a randomized controlled trial. Dermatol Surg. 2018;44:924-932. doi:10.1097/DSS.0000000000001489
- Higgins S, Feinstein S, Hawkins M, et al. Virtual reality to improve the experience of the Mohs patient-a prospective interventional study. Dermatol Surg. 2019;45:1009-1018. doi:10.1097 /DSS.0000000000001854
- Guo D, Zloty DM, Kossintseva I. Efficacy and safety of anxiolytics in Mohs micrographic surgery: a randomized, double-blinded, placebo-controlled trial. Dermatol Surg. 2023;49:989-994. doi:10.1097 /DSS.0000000000003905
- Locke MC, Wilkerson EC, Mistur RL, et al. 2015 Arte Poster Competition first place winner: assessing the correlation between patient anxiety and satisfaction for Mohs surgery. J Drugs Dermatol. 2015;14:1070-1072.
- Yanes AF, Weil A, Furlan KC, et al. Effect of stress ball use or hand-holding on anxiety during skin cancer excision: a randomized clinical trial. JAMA Dermatol. 2018;154:1045-1049. doi:10.1001 /jamadermatol.2018.1783
- Biro M, Kim I, Huynh A, et al. The use of 3-dimensionally printed models to optimize patient education and alleviate perioperative anxiety in Mohs micrographic surgery: a randomized controlled trial. J Am Acad Dermatol. 2019;81:1339-1345. doi:10.1016/j.jaad.2019.05.085
- Ali FR, Al-Niaimi F, Craythorne EE, et al. Patient satisfaction and the waiting room in Mohs surgery: appropriate prewarning may abrogate boredom. J Eur Acad Dermatol Venereol. 2017;31:e337-e338.
- Kossintseva I, Zloty D. Determinants and timeline of perioperative anxiety in Mohs surgery. Dermatol Surg. 2017;43:1029-1035.
- Kruchevsky D, Hirth J, Capucha T, et al. Triggers of preoperative anxiety in patients undergoing Mohs micrographic surgery. Dermatol Surg. 2021;47:1110-1112.
- Kokoska RE, Szeto MD, Steadman L, et al. Analysis of factors contributing to perioperative Mohs micrographic surgery anxiety: patient survey study at an academic center. Dermatol Surg. 2022;48:1279-1282.
- Long J, Rajabi-Estarabadi A, Levin A, et al. Perioperative anxiety associated with Mohs micrographic surgery: a survey-based study. Dermatol Surg. 2022;48:711-715.
- Zhang J, Miller CJ, O’Malley V, et al. Patient quality of life fluctuates before and after Mohs micrographic surgery: a longitudinal assessment of the patient experience. J Am Acad Dermatol. 2018;78:1060-1067.
- Lee EB, Ford A, Clarey D, et al. Patient outcomes and satisfaction after Mohs micrographic surgery in patients with nonmelanoma skin cancer. Dermatol Sur. 2021;47:1190-1194.
- Condie D, West L, Hynan LS, et al. Patient satisfaction with Mohs surgery for melanoma in situ. Dermatol Surg. 2021;47:288-290.
- Arshanapalli A, Tra n JM, Aylward JL, et al. The effect of suture spacing on patient perception of surgical skill. J Am Acad Dermatol. 2021;84:735-736.
Mohs micrographic surgery (MMS)—developed by Dr. Frederic Mohs in the 1930s—is the gold standard for treating various cutaneous malignancies. It provides maximal conservation of uninvolved tissues while producing higher cure rates compared to wide local excision.1,2
We sought to assess the various characteristics that impact patient satisfaction to help Mohs surgeons incorporate relatively simple yet clinically significant practices into their patient encounters. We conducted a systematic literature search of peer-reviewed PubMed articles indexed for MEDLINE from database inception through November 2023 using the terms Mohs micrographic surgery and patient satisfaction. Among the inclusion criteria were studies involving participants having undergone MMS, with objective assessments on patient-reported satisfaction or preferences related to patient education, communication, anxiety-alleviating measures, or QOL in MMS. Studies were excluded if they failed to meet these criteria, were outdated and no longer clinically relevant, or measured unalterable factors with no significant impact on how Mohs surgeons could change clinical practice. Of the 157 nonreplicated studies identified, 34 met inclusion criteria.
Perioperative Patient Communication and Education Techniques
Perioperative Patient Communication—Many studies have evaluated the impact of perioperative patient-provider communication and education on patient satisfaction in those undergoing MMS. Studies focusing on preoperative and postoperative telephone calls, patient consultation formats, and patient-perceived impact of such communication modalities have been well documented (Table 1).3-8 The importance of the patient follow-up after MMS was further supported by a retrospective study concluding that 88.7% (86/97) of patients regarded follow-up visits as important, and 80% (77/97) desired additional follow-up 3 months after MMS.9 Additional studies have highlighted the importance of thorough and open perioperative patient-provider communication during MMS (Table 2).10-12
Patient-Education Techniques—Many studies have assessed the use of visual models to aid in patient education on MMS, specifically the preprocedural consent process (Table 3).13-16 Additionally, 2 randomized controlled trials assessing the use of at-home and same-day in-office preoperative educational videos concluded that these interventions increased patient knowledge and confidence regarding procedural risks and benefits, with no statistically significant differences in patient anxiety or satisfaction.17,18
Despite the availability of these educational videos, many patients often turn to online resources for self-education, which is problematic if reader literacy is incongruent with online readability. One study assessing readability of online MMS resources concluded that the most accessed articles exceeded the recommended reading level for adequate patient comprehension.19 A survey studying a wide range of variables related to patient satisfaction (eg, demographics, socioeconomics, health status) in 339 MMS patients found that those who considered themselves more involved in the decision-making process were more satisfied in the short-term, and married patients had even higher long-term satisfaction. Interestingly, this study also concluded that undergoing 3 or more MMS stages was associated with higher short- and long-term satisfaction, likely secondary to perceived effects of increased overall care, medical attention, and time spent with the provider.20
Synthesis of this information with emphasis on the higher evidence-based studies—including systematic reviews, meta-analyses, and randomized controlled trials—yields the following beneficial interventions regarding patient education and communication13-20:
- Preoperative and same-day postoperative telephone follow-up (TFU) do not show statistically significant impacts on patient satisfaction; however, TFU allows for identification of postoperative concerns and inadequate pain management, which may have downstream effects on long-term perception of the overall patient experience.
- The use of video-assisted consent yields improved patient satisfaction and knowledge, while video content—traditional or didactic—has no impact on satisfaction in new MMS patients.
- The use of at-home or same-day in-office preoperative educational videos can improve procedural knowledge and risk-benefit understanding of MMS while having no impact on satisfaction.
- Bedside manner and effective in-person communication by the provider often takes precedence in the patient experience; however, implementation of additional educational modalities should be considered.
Patient Anxiety and QOL
Reducing Patient Anxiety—The use of perioperative distractors to reduce patient anxiety may play an integral role when patients undergo MMS, as there often are prolonged waiting periods between stages when patients may feel increasingly vulnerable or anxious. Table 4 reviews studies on perioperative distractors that showed a statistically significant reduction in MMS patient anxiety.21-24
Although not statistically significant, additional studies evaluating the use of intraoperative anxiety-reduction methods in MMS have demonstrated a downtrend in patient anxiety with the following interventions: engaging in small talk with clinic staff, bringing a guest, eating, watching television, communicating surgical expectations with the provider, handholding, use of a stress ball, and use of 3-dimensional educational MMS models.25-27 Similarly, a survey of 73 patients undergoing MMS found that patients tended to enjoy complimentary beverages preprocedurally in the waiting room, reading, speaking with their guest, watching television, or using their telephone during wait times.28 Table 5 lists additional perioperative factors encompassing specific patient and surgical characteristics that help reduce patient anxiety.29-32
Patient QOL—Many methods aimed at decreasing MMS-related patient anxiety often show no direct impact on patient satisfaction, likely due to the multifactorial nature of the patient-perceived experience. A prospective observational study of MMS patients noted a statistically significant improvement in patient QOL scores 3 months postsurgery (P=.0007), demonstrating that MMS generally results in positive patient outcomes despite preprocedural anxiety.33 An additional prospective study in MMS patients with nonmelanoma skin cancer concluded that sex, age, and closure type—factors often shown to affect anxiety levels—did not significantly impact patient satisfaction.34 Similarly, high satisfaction levels can be expected among MMS patients undergoing treatment of melanoma in situ, with more than 90% of patients rating their treatment experience a 4 (agree) or 5 (strongly agree) out of 5 in short- and long-term satisfaction assessments (38/41 and 40/42, respectively).35 This assessment, conducted 3 months postoperatively, asked patients to score the statement, “I am completely satisfied with the treatment of my skin problem,” on a scale ranging from 1 (strongly disagree) to 5 (strongly agree).
Lastly, patient perception of their surgeon’s skill may contribute to levels of patient satisfaction. Although suture spacing has not been shown to affect surgical outcomes, it has been demonstrated to impact the patient’s perception of surgical skill and is further supported by a study concluding that closures with 2-mm spacing were ranked significantly lower by patients compared with closures with either 4- or 6-mm spacing (P=.005 and P=.012, respectively).36
Synthesis of this information with emphasis on the higher evidence-based studies—including systematic reviews, meta-analyses, and randomized controlled trials—yields the following beneficial interventions regarding anxiety-reducing measures and patient-perceived QOL21-36:
- Factors shown to decrease patient anxiety include patient personalized music, virtual-reality experience, perioperative informational videos, and 3-dimensional–printed MMS models.
- Many methods aimed at decreasing MMS-related patient anxiety show no direct impact on patient satisfaction, likely due to the multifactorial nature of the patient-perceived experience.
- Higher anxiety can be associated with worse QOL scores in MMS patients, and additional factors that may have a negative impact on anxiety include female sex, younger age, and tumor location on the face.
Conclusion
Many factors affect patient satisfaction in MMS. Increased awareness and acknowledgement of these factors can foster improved clinical practice and patient experience, which can have downstream effects on patient compliance and overall psychosocial and medical well-being. With the movement toward value-based health care, patient satisfaction ratings are likely to play an increasingly important role in physician reimbursement. Adapting one’s practice to include high-quality, time-efficient, patient-centered care goes hand in hand with increasing MMS patient satisfaction. Careful evaluation and scrutiny of one’s current practices while remaining cognizant of patient population, resource availability, and clinical limitations often reveal opportunities for small adjustments that can have a great impact on patient satisfaction. This thorough assessment and review of the published literature aims to assist MMS surgeons in understanding the role that certain factors—(1) perioperative patient communication and education techniques and (2) patient anxiety, QOL, and additional considerations—have on overall satisfaction with MMS. Specific consideration should be placed on the fact that patient satisfaction is multifactorial, and many different interventions can have a positive impact on the overall patient experience.
Mohs micrographic surgery (MMS)—developed by Dr. Frederic Mohs in the 1930s—is the gold standard for treating various cutaneous malignancies. It provides maximal conservation of uninvolved tissues while producing higher cure rates compared to wide local excision.1,2
We sought to assess the various characteristics that impact patient satisfaction to help Mohs surgeons incorporate relatively simple yet clinically significant practices into their patient encounters. We conducted a systematic literature search of peer-reviewed PubMed articles indexed for MEDLINE from database inception through November 2023 using the terms Mohs micrographic surgery and patient satisfaction. Among the inclusion criteria were studies involving participants having undergone MMS, with objective assessments on patient-reported satisfaction or preferences related to patient education, communication, anxiety-alleviating measures, or QOL in MMS. Studies were excluded if they failed to meet these criteria, were outdated and no longer clinically relevant, or measured unalterable factors with no significant impact on how Mohs surgeons could change clinical practice. Of the 157 nonreplicated studies identified, 34 met inclusion criteria.
Perioperative Patient Communication and Education Techniques
Perioperative Patient Communication—Many studies have evaluated the impact of perioperative patient-provider communication and education on patient satisfaction in those undergoing MMS. Studies focusing on preoperative and postoperative telephone calls, patient consultation formats, and patient-perceived impact of such communication modalities have been well documented (Table 1).3-8 The importance of the patient follow-up after MMS was further supported by a retrospective study concluding that 88.7% (86/97) of patients regarded follow-up visits as important, and 80% (77/97) desired additional follow-up 3 months after MMS.9 Additional studies have highlighted the importance of thorough and open perioperative patient-provider communication during MMS (Table 2).10-12
Patient-Education Techniques—Many studies have assessed the use of visual models to aid in patient education on MMS, specifically the preprocedural consent process (Table 3).13-16 Additionally, 2 randomized controlled trials assessing the use of at-home and same-day in-office preoperative educational videos concluded that these interventions increased patient knowledge and confidence regarding procedural risks and benefits, with no statistically significant differences in patient anxiety or satisfaction.17,18
Despite the availability of these educational videos, many patients often turn to online resources for self-education, which is problematic if reader literacy is incongruent with online readability. One study assessing readability of online MMS resources concluded that the most accessed articles exceeded the recommended reading level for adequate patient comprehension.19 A survey studying a wide range of variables related to patient satisfaction (eg, demographics, socioeconomics, health status) in 339 MMS patients found that those who considered themselves more involved in the decision-making process were more satisfied in the short-term, and married patients had even higher long-term satisfaction. Interestingly, this study also concluded that undergoing 3 or more MMS stages was associated with higher short- and long-term satisfaction, likely secondary to perceived effects of increased overall care, medical attention, and time spent with the provider.20
Synthesis of this information with emphasis on the higher evidence-based studies—including systematic reviews, meta-analyses, and randomized controlled trials—yields the following beneficial interventions regarding patient education and communication13-20:
- Preoperative and same-day postoperative telephone follow-up (TFU) do not show statistically significant impacts on patient satisfaction; however, TFU allows for identification of postoperative concerns and inadequate pain management, which may have downstream effects on long-term perception of the overall patient experience.
- The use of video-assisted consent yields improved patient satisfaction and knowledge, while video content—traditional or didactic—has no impact on satisfaction in new MMS patients.
- The use of at-home or same-day in-office preoperative educational videos can improve procedural knowledge and risk-benefit understanding of MMS while having no impact on satisfaction.
- Bedside manner and effective in-person communication by the provider often takes precedence in the patient experience; however, implementation of additional educational modalities should be considered.
Patient Anxiety and QOL
Reducing Patient Anxiety—The use of perioperative distractors to reduce patient anxiety may play an integral role when patients undergo MMS, as there often are prolonged waiting periods between stages when patients may feel increasingly vulnerable or anxious. Table 4 reviews studies on perioperative distractors that showed a statistically significant reduction in MMS patient anxiety.21-24
Although not statistically significant, additional studies evaluating the use of intraoperative anxiety-reduction methods in MMS have demonstrated a downtrend in patient anxiety with the following interventions: engaging in small talk with clinic staff, bringing a guest, eating, watching television, communicating surgical expectations with the provider, handholding, use of a stress ball, and use of 3-dimensional educational MMS models.25-27 Similarly, a survey of 73 patients undergoing MMS found that patients tended to enjoy complimentary beverages preprocedurally in the waiting room, reading, speaking with their guest, watching television, or using their telephone during wait times.28 Table 5 lists additional perioperative factors encompassing specific patient and surgical characteristics that help reduce patient anxiety.29-32
Patient QOL—Many methods aimed at decreasing MMS-related patient anxiety often show no direct impact on patient satisfaction, likely due to the multifactorial nature of the patient-perceived experience. A prospective observational study of MMS patients noted a statistically significant improvement in patient QOL scores 3 months postsurgery (P=.0007), demonstrating that MMS generally results in positive patient outcomes despite preprocedural anxiety.33 An additional prospective study in MMS patients with nonmelanoma skin cancer concluded that sex, age, and closure type—factors often shown to affect anxiety levels—did not significantly impact patient satisfaction.34 Similarly, high satisfaction levels can be expected among MMS patients undergoing treatment of melanoma in situ, with more than 90% of patients rating their treatment experience a 4 (agree) or 5 (strongly agree) out of 5 in short- and long-term satisfaction assessments (38/41 and 40/42, respectively).35 This assessment, conducted 3 months postoperatively, asked patients to score the statement, “I am completely satisfied with the treatment of my skin problem,” on a scale ranging from 1 (strongly disagree) to 5 (strongly agree).
Lastly, patient perception of their surgeon’s skill may contribute to levels of patient satisfaction. Although suture spacing has not been shown to affect surgical outcomes, it has been demonstrated to impact the patient’s perception of surgical skill and is further supported by a study concluding that closures with 2-mm spacing were ranked significantly lower by patients compared with closures with either 4- or 6-mm spacing (P=.005 and P=.012, respectively).36
Synthesis of this information with emphasis on the higher evidence-based studies—including systematic reviews, meta-analyses, and randomized controlled trials—yields the following beneficial interventions regarding anxiety-reducing measures and patient-perceived QOL21-36:
- Factors shown to decrease patient anxiety include patient personalized music, virtual-reality experience, perioperative informational videos, and 3-dimensional–printed MMS models.
- Many methods aimed at decreasing MMS-related patient anxiety show no direct impact on patient satisfaction, likely due to the multifactorial nature of the patient-perceived experience.
- Higher anxiety can be associated with worse QOL scores in MMS patients, and additional factors that may have a negative impact on anxiety include female sex, younger age, and tumor location on the face.
Conclusion
Many factors affect patient satisfaction in MMS. Increased awareness and acknowledgement of these factors can foster improved clinical practice and patient experience, which can have downstream effects on patient compliance and overall psychosocial and medical well-being. With the movement toward value-based health care, patient satisfaction ratings are likely to play an increasingly important role in physician reimbursement. Adapting one’s practice to include high-quality, time-efficient, patient-centered care goes hand in hand with increasing MMS patient satisfaction. Careful evaluation and scrutiny of one’s current practices while remaining cognizant of patient population, resource availability, and clinical limitations often reveal opportunities for small adjustments that can have a great impact on patient satisfaction. This thorough assessment and review of the published literature aims to assist MMS surgeons in understanding the role that certain factors—(1) perioperative patient communication and education techniques and (2) patient anxiety, QOL, and additional considerations—have on overall satisfaction with MMS. Specific consideration should be placed on the fact that patient satisfaction is multifactorial, and many different interventions can have a positive impact on the overall patient experience.
- Trost LB, Bailin PL. History of Mohs surgery. Dermatol Clin. 2011; 29:135-139, vii. doi:10.1016/j.det.2011.01.010
- Leslie DF, Greenway HT. Mohs micrographic surgery for skin cancer. Australas J Dermatol. 1991;32:159-164. doi:10.1111/j.1440 -0960.1991.tb01783.x
- Sobanko JF, Da Silva D, Chiesa Fuxench ZC, et al. Preoperative telephone consultation does not decrease patient anxiety before Mohs micrographic surgery. J Am Acad Dermatol. 2017;76:519-526. doi:10.1016/j.jaad.2016.09.027
- Sharon VR, Armstrong AW, Jim On SC, et al. Separate- versus same-day preoperative consultation in dermatologic surgery: a patient-centered investigation in an academic practice. Dermatol Surg. 2013;39:240-247. doi:10.1111/dsu.12083
- Knackstedt TJ, Samie FH. Shared medical appointments for the preoperative consultation visit of Mohs micrographic surgery. J Am Acad Dermatol. 2015;72:340-344. doi:10.1016/j.jaad.2014.10.022
- Vance S, Fontecilla N, Samie FH, et al. Effect of postoperative telephone calls on patient satisfaction and scar satisfaction after Mohs micrographic surgery. Dermatol Surg. 2019;45:1459-1464. doi:10.1097/DSS.0000000000001913
- Hafiji J, Salmon P, Hussain W. Patient satisfaction with post-operative telephone calls after Mohs micrographic surgery: a New Zealand and U.K. experience. Br J Dermatol. 2012;167:570-574. doi:10.1111 /j.1365-2133.2012.11011.x
- Bednarek R, Jonak C, Golda N. Optimal timing of postoperative patient telephone calls after Mohs micrographic surgery: a randomized controlled trial. J Am Acad Dermatol. 2021;85:220-221. doi:10.1016 /j.jaad.2020.07.106
- Sharon VR, Armstrong AW, Jim-On S, et al. Postoperative preferences in cutaneous surgery: a patient-centered investigation from an academic dermatologic surgery practice. Dermatol Surg. 2013;39:773-778. doi:10.1111/dsu.12136
- Xu S, Atanelov Z, Bhatia AC. Online patient-reported reviews of Mohs micrographic surgery: qualitative analysis of positive and negative experiences. Cutis. 2017;99:E25-E29.
- Golda N, Beeson S, Kohli N, et al. Recommendations for improving the patient experience in specialty encounters. J Am Acad Dermatol. 2018;78:653-659. doi:10.1016/j.jaad.2017.05.040
- Patel P, Malik K, Khachemoune A. Patient education in Mohs surgery: a review and critical evaluation of techniques. Arch Dermatol Res. 2021;313:217-224. doi:10.1007/s00403-020-02119-5
- Migden M, Chavez-Frazier A, Nguyen T. The use of high definition video modules for delivery of informed consent and wound care education in the Mohs surgery unit. Semin Cutan Med Surg. 2008;27:89-93. doi:10.1016/j.sder.2008.02.001
- Newsom E, Lee E, Rossi A, et al. Modernizing the Mohs surgery consultation: instituting a video module for improved patient education and satisfaction. Dermatol Surg. 2018;44:778-784. doi:10.1097/DSS.0000000000001473
- West L, Srivastava D, Goldberg LH, et al. Multimedia technology used to supplement patient consent for Mohs micrographic surgery. Dermatol Surg. 2020;46:586-590. doi:10.1097/DSS.0000000000002134
- Miao Y, Venning VL, Mallitt KA, et al. A randomized controlled trial comparing video-assisted informed consent with standard consent for Mohs micrographic surgery. JAAD Int. 2020;1:13-20. doi:10.1016 /j.jdin.2020.03.005
- Mann J, Li L, Kulakov E, et al. Home viewing of educational video improves patient understanding of Mohs micrographic surgery. Clin Exp Dermatol. 2022;47:93-97. doi:10.1111/ced.14845
- Delcambre M, Haynes D, Hajar T, et al. Using a multimedia tool for informed consent in Mohs surgery: a randomized trial measuring effects on patient anxiety, knowledge, and satisfaction. Dermatol Surg. 2020;46:591-598. doi:10.1097/DSS.0000000000002213
- Vargas CR, DePry J, Lee BT, et al. The readability of online patient information about Mohs micrographic surgery. Dermatol Surg. 2016;42:1135-1141. doi:10.1097/DSS.0000000000000866
- Asgari MM, Warton EM, Neugebauer R, et al. Predictors of patient satisfaction with Mohs surgery: analysis of preoperative, intraoperative, and postoperative factors in a prospective cohort. Arch Dermatol. 2011;147:1387-1394.
- Vachiramon V, Sobanko JF, Rattanaumpawan P, et al. Music reduces patient anxiety during Mohs surgery: an open-label randomized controlled trial. Dermatol Surg. 2013;39:298-305. doi:10.1111/dsu.12047
- Hawkins SD, Koch SB, Williford PM, et al. Web app- and text message-based patient education in Mohs micrographic surgery-a randomized controlled trial. Dermatol Surg. 2018;44:924-932. doi:10.1097/DSS.0000000000001489
- Higgins S, Feinstein S, Hawkins M, et al. Virtual reality to improve the experience of the Mohs patient-a prospective interventional study. Dermatol Surg. 2019;45:1009-1018. doi:10.1097 /DSS.0000000000001854
- Guo D, Zloty DM, Kossintseva I. Efficacy and safety of anxiolytics in Mohs micrographic surgery: a randomized, double-blinded, placebo-controlled trial. Dermatol Surg. 2023;49:989-994. doi:10.1097 /DSS.0000000000003905
- Locke MC, Wilkerson EC, Mistur RL, et al. 2015 Arte Poster Competition first place winner: assessing the correlation between patient anxiety and satisfaction for Mohs surgery. J Drugs Dermatol. 2015;14:1070-1072.
- Yanes AF, Weil A, Furlan KC, et al. Effect of stress ball use or hand-holding on anxiety during skin cancer excision: a randomized clinical trial. JAMA Dermatol. 2018;154:1045-1049. doi:10.1001 /jamadermatol.2018.1783
- Biro M, Kim I, Huynh A, et al. The use of 3-dimensionally printed models to optimize patient education and alleviate perioperative anxiety in Mohs micrographic surgery: a randomized controlled trial. J Am Acad Dermatol. 2019;81:1339-1345. doi:10.1016/j.jaad.2019.05.085
- Ali FR, Al-Niaimi F, Craythorne EE, et al. Patient satisfaction and the waiting room in Mohs surgery: appropriate prewarning may abrogate boredom. J Eur Acad Dermatol Venereol. 2017;31:e337-e338.
- Kossintseva I, Zloty D. Determinants and timeline of perioperative anxiety in Mohs surgery. Dermatol Surg. 2017;43:1029-1035.
- Kruchevsky D, Hirth J, Capucha T, et al. Triggers of preoperative anxiety in patients undergoing Mohs micrographic surgery. Dermatol Surg. 2021;47:1110-1112.
- Kokoska RE, Szeto MD, Steadman L, et al. Analysis of factors contributing to perioperative Mohs micrographic surgery anxiety: patient survey study at an academic center. Dermatol Surg. 2022;48:1279-1282.
- Long J, Rajabi-Estarabadi A, Levin A, et al. Perioperative anxiety associated with Mohs micrographic surgery: a survey-based study. Dermatol Surg. 2022;48:711-715.
- Zhang J, Miller CJ, O’Malley V, et al. Patient quality of life fluctuates before and after Mohs micrographic surgery: a longitudinal assessment of the patient experience. J Am Acad Dermatol. 2018;78:1060-1067.
- Lee EB, Ford A, Clarey D, et al. Patient outcomes and satisfaction after Mohs micrographic surgery in patients with nonmelanoma skin cancer. Dermatol Sur. 2021;47:1190-1194.
- Condie D, West L, Hynan LS, et al. Patient satisfaction with Mohs surgery for melanoma in situ. Dermatol Surg. 2021;47:288-290.
- Arshanapalli A, Tra n JM, Aylward JL, et al. The effect of suture spacing on patient perception of surgical skill. J Am Acad Dermatol. 2021;84:735-736.
- Trost LB, Bailin PL. History of Mohs surgery. Dermatol Clin. 2011; 29:135-139, vii. doi:10.1016/j.det.2011.01.010
- Leslie DF, Greenway HT. Mohs micrographic surgery for skin cancer. Australas J Dermatol. 1991;32:159-164. doi:10.1111/j.1440 -0960.1991.tb01783.x
- Sobanko JF, Da Silva D, Chiesa Fuxench ZC, et al. Preoperative telephone consultation does not decrease patient anxiety before Mohs micrographic surgery. J Am Acad Dermatol. 2017;76:519-526. doi:10.1016/j.jaad.2016.09.027
- Sharon VR, Armstrong AW, Jim On SC, et al. Separate- versus same-day preoperative consultation in dermatologic surgery: a patient-centered investigation in an academic practice. Dermatol Surg. 2013;39:240-247. doi:10.1111/dsu.12083
- Knackstedt TJ, Samie FH. Shared medical appointments for the preoperative consultation visit of Mohs micrographic surgery. J Am Acad Dermatol. 2015;72:340-344. doi:10.1016/j.jaad.2014.10.022
- Vance S, Fontecilla N, Samie FH, et al. Effect of postoperative telephone calls on patient satisfaction and scar satisfaction after Mohs micrographic surgery. Dermatol Surg. 2019;45:1459-1464. doi:10.1097/DSS.0000000000001913
- Hafiji J, Salmon P, Hussain W. Patient satisfaction with post-operative telephone calls after Mohs micrographic surgery: a New Zealand and U.K. experience. Br J Dermatol. 2012;167:570-574. doi:10.1111 /j.1365-2133.2012.11011.x
- Bednarek R, Jonak C, Golda N. Optimal timing of postoperative patient telephone calls after Mohs micrographic surgery: a randomized controlled trial. J Am Acad Dermatol. 2021;85:220-221. doi:10.1016 /j.jaad.2020.07.106
- Sharon VR, Armstrong AW, Jim-On S, et al. Postoperative preferences in cutaneous surgery: a patient-centered investigation from an academic dermatologic surgery practice. Dermatol Surg. 2013;39:773-778. doi:10.1111/dsu.12136
- Xu S, Atanelov Z, Bhatia AC. Online patient-reported reviews of Mohs micrographic surgery: qualitative analysis of positive and negative experiences. Cutis. 2017;99:E25-E29.
- Golda N, Beeson S, Kohli N, et al. Recommendations for improving the patient experience in specialty encounters. J Am Acad Dermatol. 2018;78:653-659. doi:10.1016/j.jaad.2017.05.040
- Patel P, Malik K, Khachemoune A. Patient education in Mohs surgery: a review and critical evaluation of techniques. Arch Dermatol Res. 2021;313:217-224. doi:10.1007/s00403-020-02119-5
- Migden M, Chavez-Frazier A, Nguyen T. The use of high definition video modules for delivery of informed consent and wound care education in the Mohs surgery unit. Semin Cutan Med Surg. 2008;27:89-93. doi:10.1016/j.sder.2008.02.001
- Newsom E, Lee E, Rossi A, et al. Modernizing the Mohs surgery consultation: instituting a video module for improved patient education and satisfaction. Dermatol Surg. 2018;44:778-784. doi:10.1097/DSS.0000000000001473
- West L, Srivastava D, Goldberg LH, et al. Multimedia technology used to supplement patient consent for Mohs micrographic surgery. Dermatol Surg. 2020;46:586-590. doi:10.1097/DSS.0000000000002134
- Miao Y, Venning VL, Mallitt KA, et al. A randomized controlled trial comparing video-assisted informed consent with standard consent for Mohs micrographic surgery. JAAD Int. 2020;1:13-20. doi:10.1016 /j.jdin.2020.03.005
- Mann J, Li L, Kulakov E, et al. Home viewing of educational video improves patient understanding of Mohs micrographic surgery. Clin Exp Dermatol. 2022;47:93-97. doi:10.1111/ced.14845
- Delcambre M, Haynes D, Hajar T, et al. Using a multimedia tool for informed consent in Mohs surgery: a randomized trial measuring effects on patient anxiety, knowledge, and satisfaction. Dermatol Surg. 2020;46:591-598. doi:10.1097/DSS.0000000000002213
- Vargas CR, DePry J, Lee BT, et al. The readability of online patient information about Mohs micrographic surgery. Dermatol Surg. 2016;42:1135-1141. doi:10.1097/DSS.0000000000000866
- Asgari MM, Warton EM, Neugebauer R, et al. Predictors of patient satisfaction with Mohs surgery: analysis of preoperative, intraoperative, and postoperative factors in a prospective cohort. Arch Dermatol. 2011;147:1387-1394.
- Vachiramon V, Sobanko JF, Rattanaumpawan P, et al. Music reduces patient anxiety during Mohs surgery: an open-label randomized controlled trial. Dermatol Surg. 2013;39:298-305. doi:10.1111/dsu.12047
- Hawkins SD, Koch SB, Williford PM, et al. Web app- and text message-based patient education in Mohs micrographic surgery-a randomized controlled trial. Dermatol Surg. 2018;44:924-932. doi:10.1097/DSS.0000000000001489
- Higgins S, Feinstein S, Hawkins M, et al. Virtual reality to improve the experience of the Mohs patient-a prospective interventional study. Dermatol Surg. 2019;45:1009-1018. doi:10.1097 /DSS.0000000000001854
- Guo D, Zloty DM, Kossintseva I. Efficacy and safety of anxiolytics in Mohs micrographic surgery: a randomized, double-blinded, placebo-controlled trial. Dermatol Surg. 2023;49:989-994. doi:10.1097 /DSS.0000000000003905
- Locke MC, Wilkerson EC, Mistur RL, et al. 2015 Arte Poster Competition first place winner: assessing the correlation between patient anxiety and satisfaction for Mohs surgery. J Drugs Dermatol. 2015;14:1070-1072.
- Yanes AF, Weil A, Furlan KC, et al. Effect of stress ball use or hand-holding on anxiety during skin cancer excision: a randomized clinical trial. JAMA Dermatol. 2018;154:1045-1049. doi:10.1001 /jamadermatol.2018.1783
- Biro M, Kim I, Huynh A, et al. The use of 3-dimensionally printed models to optimize patient education and alleviate perioperative anxiety in Mohs micrographic surgery: a randomized controlled trial. J Am Acad Dermatol. 2019;81:1339-1345. doi:10.1016/j.jaad.2019.05.085
- Ali FR, Al-Niaimi F, Craythorne EE, et al. Patient satisfaction and the waiting room in Mohs surgery: appropriate prewarning may abrogate boredom. J Eur Acad Dermatol Venereol. 2017;31:e337-e338.
- Kossintseva I, Zloty D. Determinants and timeline of perioperative anxiety in Mohs surgery. Dermatol Surg. 2017;43:1029-1035.
- Kruchevsky D, Hirth J, Capucha T, et al. Triggers of preoperative anxiety in patients undergoing Mohs micrographic surgery. Dermatol Surg. 2021;47:1110-1112.
- Kokoska RE, Szeto MD, Steadman L, et al. Analysis of factors contributing to perioperative Mohs micrographic surgery anxiety: patient survey study at an academic center. Dermatol Surg. 2022;48:1279-1282.
- Long J, Rajabi-Estarabadi A, Levin A, et al. Perioperative anxiety associated with Mohs micrographic surgery: a survey-based study. Dermatol Surg. 2022;48:711-715.
- Zhang J, Miller CJ, O’Malley V, et al. Patient quality of life fluctuates before and after Mohs micrographic surgery: a longitudinal assessment of the patient experience. J Am Acad Dermatol. 2018;78:1060-1067.
- Lee EB, Ford A, Clarey D, et al. Patient outcomes and satisfaction after Mohs micrographic surgery in patients with nonmelanoma skin cancer. Dermatol Sur. 2021;47:1190-1194.
- Condie D, West L, Hynan LS, et al. Patient satisfaction with Mohs surgery for melanoma in situ. Dermatol Surg. 2021;47:288-290.
- Arshanapalli A, Tra n JM, Aylward JL, et al. The effect of suture spacing on patient perception of surgical skill. J Am Acad Dermatol. 2021;84:735-736.
Enhancing Patient Satisfaction and Quality of Life With Mohs Micrographic Surgery: A Systematic Review of Patient Education, Communication, and Anxiety Management
Enhancing Patient Satisfaction and Quality of Life With Mohs Micrographic Surgery: A Systematic Review of Patient Education, Communication, and Anxiety Management
PRACTICE POINTS
- When patients are treated with Mohs micrographic surgery (MMS), thorough in-person dialogue augmented by pre- and same-day telephone follow-ups can help them feel heard and better supported, even though follow-up calls alone may not drive satisfaction scores.
- Increased awareness and implementation of the various factors influencing patient satisfaction and quality of life in MMS can enhance clinical practice and improve patient experiences, with potential impacts on compliance, psychosocial well-being, medical outcomes, and physician reimbursement.
- Patient satisfaction and procedural understanding can be improved with video and visual-based education. Anxiety-reducing methods help lower perioperative stress.