Skin Cancer Surgery’s Leadership Still Lags on Racial Diversity, 30-Year Study Finds

Dermatology has long carried an uncomfortable distinction: it is one of the least racially and ethnically diverse specialties in American medicine. A new short report in the Archives of Dermatological Research suggests that this pattern extends deep into one of its most competitive subspecialties, Mohs micrographic surgery and dermatologic oncology, and that three decades of gradual change have reshaped the leadership pipeline in some ways while leaving others strikingly unchanged. The study, led by Ross O’Hagan, Olivia McGeough, Kristina Navrazhina, Alexandra Elder and Jesse M. Lewin of the Icahn School of Medicine at Mount Sinai, compared the racial and ethnic composition of fellows and fellowship directors in two five-year windows: 1996 to 2000 and 2021 to 2025.

Mohs micrographic surgery is a highly precise technique for treating skin cancer. Surgeons remove visible tumor in thin layers, examine each layer under a microscope in real time, and continue excising until the margins are completely clear of cancer cells. The approach spares healthy tissue while maximizing cure rates, which is why it has become the standard of care for many high-risk skin cancers, including melanomas and aggressive basal and squamous cell carcinomas on the face and other cosmetically and functionally critical sites. Training in this field is exceptionally competitive: after dermatology residency, physicians must match into a dedicated fellowship, now formally designated micrographic surgery and dermatologic oncology, or MSDO. Whoever leads those fellowship programs effectively controls the gatekeeping of the entire subspecialty workforce.

The researchers asked a deceptively simple question: has the population of people entering and leading these programs become more representative of the United States over the past quarter century? To answer it, they compiled rosters of fellows and program directors across the two study periods and quantified the proportions of Asian, Black, Hispanic and White individuals in each group, then tested whether the differences between eras reached statistical significance. The data source was the public directory of fellowship training maintained by the American College of Mohs Surgery, which lists trainees and program leadership over time.

Among fellows, the clearest signal was a significant rise in Asian representation. In the 1996 to 2000 cohort, 25.1 percent of Mohs fellows were Asian; by 2021 to 2025, that figure had climbed to 32.6 percent, a statistically significant increase. The proportions of Black fellows (16.4 percent versus 12.6 percent), Hispanic fellows (7.2 percent versus 8.4 percent) and White fellows (51.3 percent versus 46.4 percent) shifted in both directions across the decades, but none of those changes was statistically significant. Taken together, non-White fellows rose from 48.7 percent of the earlier cohort to 53.6 percent of the recent one, an aggregate gain that also fell short of statistical significance.

The leadership picture told a more dynamic story. The proportion of Asian program directors increased significantly, from 15.5 percent in 1996 to 2000 to 25.2 percent in 2021 to 2025. Hispanic directors also rose significantly, from 1.4 percent to 4.5 percent. Meanwhile, the share of White program directors declined significantly, from 70.4 percent to 54.1 percent. Black representation among directors moved from 12.7 percent to 16.2 percent, but this change was not statistically significant. In other words, the leadership of MSDO fellowships has diversified meaningfully over three decades, yet the gains have been concentrated in specific groups rather than distributed evenly across all communities underrepresented in medicine.

Why does the demographic makeup of a surgical subspecialty matter for patients? The authors point to a substantial body of evidence linking patient-physician concordance, the degree to which patients and doctors share personal or ethnic dimensions of identity, with trust, communication quality, satisfaction and clinical outcomes. Skin cancer is an area where this matters acutely. Dermatologic oncology care involves decisions about disfiguring surgery on visible parts of the body, and patients from historically marginalized groups have documented reasons for wariness toward a medical system that has not always served them equitably. A workforce in which patients can more often see their own experiences reflected may improve rapport, adherence to surveillance and, ultimately, outcomes in skin cancer care. Representation among the educators who train the next generation compounds this effect, because program directors shape not only who enters the field but also the culture, mentorship networks and recruitment practices of the specialty.

The study’s central caveat is methodological, and the authors are unusually candid about it. For most of the thirty-year study period, self-reported racial and ethnic backgrounds of fellows and directors were simply not available. To fill the gap, the researchers used a name-based inference approach, employing the rethnicity R package, a tool that predicts race and ethnicity from personal names using probabilistic statistical models. The method has been validated on large voter registration datasets and demonstrates strong predictive accuracy, but its probabilistic design means misclassifications are inevitable, particularly for individuals whose names do not conform to common patterns associated with particular groups.

To gauge how much error this introduces, the team validated the name-based predictions against self-reported data from the Accreditation Council for Graduate Medical Education, or ACGME, for the overlapping 2011 to 2025 period. The comparison showed directionally consistent trends, meaning the inferred data captured the same overall patterns as the self-reported figures, but with a mean absolute difference of 10.5 percentage points. That is a substantial margin, and it means the specific percentages reported in the study should be read as estimates of magnitude rather than exact counts. Still, the authors argue, name-based inference provides a practical and reproducible way to evaluate datasets when self-reported demographic data are unavailable, opening a window on longitudinal trends that would otherwise remain entirely unexamined. Without such methods, the demographic history of the MSDO pipeline from the 1990s onward would be largely invisible.

The broader context of the findings is a specialty that continues to grow in scope and importance. Skin cancer incidence in the United States remains high, and Mohs surgery has expanded accordingly, making the demographic trajectory of its workforce a matter of increasing public health relevance. Prior research cited by the authors has documented the low diversity of the broader Mohs workforce, examined trends in matching among underrepresented minority applicants, and identified barriers that deter such applicants from pursuing the fellowship in the first place. The new report adds a longitudinal dimension to that literature, showing that while the leadership tier has diversified significantly, the fellowship cohort itself has not changed in ways that reach statistical significance for most groups.

The bottom line, the authors conclude, is that representation of individuals underrepresented in medicine among MSDO fellows and fellowship directors remains persistently low, and that efforts to diversify the pipeline must remain a priority as the specialty continues to expand. The significant gains among Asian and Hispanic program directors demonstrate that change is possible within a single generation of leadership, but the flat trends for Black fellows and the modest, statistically insignificant shifts elsewhere suggest that structural barriers in recruitment, mentorship and access to the specialty have not dissolved on their own. As Mohs surgery takes on a growing share of the nation’s skin cancer burden, the demographic composition of the surgeons who perform it, and of the educators who train them, will increasingly shape who trusts, seeks and receives the highest standard of dermatologic oncology care.

Subject of Research: Racial and ethnic diversity trends among Mohs micrographic surgery and dermatologic oncology fellows and fellowship directors

Article Title: Trends in racial and ethnic diversity among micrographic surgery and dermatologic oncology (MSDO) fellows and fellowship directors

Article References: O’Hagan, R., McGeough, O., Navrazhina, K., Elder, A., & Lewin, J. M. (2026). Trends in racial and ethnic diversity among micrographic surgery and dermatologic oncology (MSDO) fellows and fellowship directors. Archives of Dermatological Research, 318(1), Article 394. https://doi.org/10.1007/s00403-026-04866-3

Image Credits: AI Generated

DOI: 10.1007/s00403-026-04866-3

Keywords: Mohs micrographic surgery, dermatologic oncology, MSDO fellowship, racial diversity, ethnic diversity, underrepresented in medicine, program directors, dermatology workforce, name-based ethnicity inference, health equity, skin cancer surgery, medical education