Feedback after Completing 2024 MDS Exam

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Warning: I finished the 2024 MDS exam ~2 hours ago & decided I wanted to submit relevant comments about the exam and the qBank.  Please ignore this if you don't want to read a long-winded piece.  Although I am writing this on the day I took the test (Wednesday), I am submitting this Sunday after the last exam has been given (Saturday Sep 28th).

I am a Mohs surgeon practicing in the U.S. for the past 21 years (completed ACMS-accredited fellowship 2003).  Like many here, I feel I provide good if not excellent care to the patients I serve on a daily basis for the past 2 decades.

For 2023, I returned from my annual early September trip and studied for ~2 weeks using the ACMS guide and took the MDS exam.  I was stunned by the PearsonVue process, but more importantly, I was stunned by the questions.  Shocked is probably more accurate.

I did not pass.  ABD exam report: 475/500.  When I asked the ABD if 100% would have been 600 or 1000 (maybe suggesting if I was close to passing or not), I was told that information is not available.  Fine.  I figured I would re-take the MDS exam again in 2024 and be serious about studying.  No summer or September trip this time.

I have been studying for well over nearly four months consistently.  Usually 3 full days per week (8-9 hour days) plus evenings. I used the ACMS guide, the ASDS course, StatPearls questions (inadequate with wrong information at times), MohsSurgeryGuide (thank you Dr. Ron Johnston), and most importantly the Mohs qBank.  Yes this adds up to ~$3000 including the exam cost plus the lost weekends and trips with my family.  But I was focused.

Here is feedback for the question bank and the exam for test-takers:

First, the question bank (Numbers 1-4)

1) Thank you thank you thank you!! to the question writers and editors for putting this resource together AND most importantly the explanation sections of each question.  It has expanded my knowledge especially of more recent developments.  I believe it will actually make me a better surgeon in the long run and I am indebted to your service when you return back and update things via the comment section.  Your patience with us test takers/studiers is admirable.

2) Relevance.  I did not take the MDS exam in 2021 or 2022, however, unfortunately, based on the 2023 & 2024 exams I have taken, I believe the questions you have in the bank may not be as relevant as they could be or should be.  Here are some examples:

- I counted the number of histopathology images shown during the exam with aberrant artifacts: 15. I really do wish I had seen more images in relation to this.  I tried to get my Mohs histotech to produce some for me, but he's so good (16 years with me and going strong) he actually found it difficult to "mess up" the slides in the ways that I asked him: "Dr!  Why would I do that?!" 

- Genodermatoses & genetic mutations: There might have been ~3 questions maximum.  I do not mind memorizing this information, but this was a very small part of the test.

- Identifying tumors on a Mohs slide: I tried counting the total number of these as well and found them very appropriate: ~15.  By the way, one thing they try to trick you on is that the image you look at is actually oriented differently from the answers.  You have to look for the inking very carefully.  It's helpful to actually draw the map yourself with the pen and laminated sheets the PearsonVue Center provides during the exam.

- Flaps: While the question bank does have a LOT on flaps and it certainly helps, the exam has even more and expects you to know eponym flaps (which I feel is *not* appropriate).  I'm glad I reviewed my out-of-print Flaps&Grafts text from 25 years ago.

- Melanoma: I do not get it, but I counted only 4 questions on melanoma. I believe the qBank should keep the melanoma questions for educational purposes but anyone taking this test would think we Mohs surgeons do not even take care of melanoma.  There were more questions related to cosmetic procedures than melanoma.  It is definitely a sad day in my opinion.  No guarantee that 2025 will not have more melanoma questions though.

3) Some areas where the question bank & explanations are definitely relevant and very helpful/educational: anatomy, chemo/radiation, immunotherapy, mechanisms of action, coding (5+ questions - know complex repair rules cold and your modifiers!), surgical complications, rare tumors (3 questions on mucinous carcinoma!), regulatory authorities (5+ questions), nail surgery, scar revision.

4) Technical suggestion for the qBank: Try to mimic the way the actual MDS exam is with more detailed histopathology images one can click on and see up close at an even higher resolution that you currently offer.  Instead of using the arrow keys to advance/navigate questions, maybe use the same keyboard prompts as the exam (Alt-N for Next, Alt-P for Previous).  Marking and reviewing is also done differently (Alt-W for Strikeout, Alt-J? for Highlight - hard to do with your mouse in the exam).  Finally, the timing on Timed qBank tests seemed easier for some reason.  I believe the qBank may give slightly more time for each question than the exam.  qBank gives 91min for 100 questions where I believe the exam is 80 minutes (not sure?).  May not seem like much but it makes a difference.

Second, the actual examination (Lettered A-D):

A) For those of you who feel that some of the qbank's questions are harder than the actual test, unfortunately, I believe you are sadly mistaken.  The foils and little tricks written into question stems and answers are also within the actual test albeit often for different material (see above).  Don’t think you need to memorize the rarest of side effects of an immunotherapy you have never prescribed before?  You thought wrong.

B) The histopathology sections of the exam are overall excellent when it is in a pop-up image; however, be prepared for inadequate pathology images when they are only in the question stem which you cannot look at more carefully. There is a good amount of histopath including benign findings on Mohs slides so ignore this at your peril.  In addition, some of the clinical images can be poor as well.

C) Operative images: I believe this may be the one area where I have a real problem with the MDS exam.  Taking the exam last year, I had a sinking suspicion that this exam is partially just a showcase for boastful Mohs surgeons to show off the crazy stuff they do, but after this year, I know that this is clearly the case: the Mohs Bros are overpowering here.  Try to ignore the outrageous images they provide you as much as you can (sawed-off digits, exposed brain tissue, large flap undermining in sensitive areas, etc).  At one point, behind me a social worker who was taking some licensing test was departing the test area for a break and must have glanced at my screen as they exited: I heard an audible yelp through my earplugs and a shocked expletive.  Often, the images have nothing to do with the question and are only there to amaze you at the prowess (and gumption) of the Mohs surgeon involved.  Maybe I am wrong about this and more of you out there do cases as depicted - my apologies.  However, the bottom line is this: if they have managed to convince the ABMS to restrict Mohs to only us ACMS-fellowship trained surgeons (who pass this silly exam), to me they appear to want to show off why.  The needlessness of this sickens me.  The more it gets restricted the more likely our Plastics & ENT colleagues will continue to take care of more tumors than we do as a whole.  And in the end, as we all know, patient care suffers.  How can this be condoned?

D) Minutiae: just keep reading and re-reading study materials as much as you can and hope that something/everything sticks in some part of your brain.  They *will* ask the most useless bit of information about anything they feel like, just to make you feel small and insignificant.  Do you really need to know a rare fatal side effect for a systemic medication used off-label rarely for rare metastasis of a rare skin tumor? How many “rare”s do you need us to know?  Kinda like the original ABD exam I took 23 years ago, this test is full of the most esoteric information and questions about things that really have no relevance to our clinical lives (or even academic lives).  Yes, certainly ask questions about lidocaine toxicity and cancer histopathology!  Sadly, those reasonable (but hard) questions are only ~50%.

I will get off my soap-box now.  My final word: if I do not pass this year, I really do not know what more I could do so I’m pretty certain I will not do this again, regardless of the result.  Maybe by the time the ACMS lobbies Medicare (the RUC or whatever) to restrict Mohs to only those who have passed this exam I would have possibly retired.  Yes a person can still do Mohs, but I would argue that it’s a sad state of affairs when Mohs fellowship graduates feel this way.  Ever so gradually, our specialty shoots itself in the foot.  Or maybe saws it off after a nerve block like they do in the exam.

Good luck to all and again a big thank you to the question writers and editors.  Instead of wishing you “happy studies”, I will part with this: keep taking great care of the patients!

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