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Dermatology Times:Article on the Use of PAs and NPs in Dermatology

Posted 4 years, 3 months ago by Dave Mittman Acute Care/Emergency Medicine, Dermatology, Emergency Medicine and Family Medicine

September 1, 2010
Dermatology physician assistants’ ranks, responsibilities grow
By Karen Nash
Mid-level caregivers are taking on an ever-larger role in dermatologic care.

According to professional organizations, about 11,500 board-certified dermatologists practice in the United States. In addition, there are about 3,000 dermatology physician assistants and 1,650 nurse practitioners working in dermatology offices — or the equivalent of about one mid-level dermatological caregiver for every 2.5 dermatologists.

Karen Nash
A few years ago, dermatologists might have told On Call their practice group consisted of, for instance, three to five dermatologists. But in recent years, those numbers more often have been three dermatologists and two PAs, or one dermatologist and one physician assistant, etc.
On Call talked to dermatologists around the county about how and why they use physician extenders in their practices, and how they feel about the growing role of these mid-level providers.

Some dermatologists say they like to keep tight control over what their physician extenders are doing, but they acknowledge that the longer they work with their assistants, the more confident they become in these mid-level providers’ abilities.

Opinion expands

Robert K.P. Chow, M.D., is an 11-year practitioner with a solo practice in Burien, Wash. He’s added two physician extenders in recent years, and he acknowledges that working with them has expanded his opinion of what they can do.

Dr. Chow
“I generally see all new patients and referrals, if possible, and the mid-levels mostly see follow-ups,” he says. “By adding the physician extenders, patients who want to see me can be scheduled in about six to eight weeks. When they see the mid-levels, they can get in within a few days.
“Before they joined me, it took longer to get in, and every day meant trying to fit people in, running overtime, and staying very, very late,” he says.

Dr. Chow admits he didn’t expect the extenders to handle as much as they do.

Dr. Kern
“I’m going to sound like a hypocrite, but before I hired the nurse practitioner, I was conflicted,” he says. “I really didn’t feel they should be doing as much as I heard they were. When I had to bring mid-levels on board, I figured on supervising them very carefully. I probably still supervise them more than a lot of other practices, but they do more than I had originally thought they could.”
Dr. Chow says his nurse practitioner has been with the practice longer, but has less experience. “She does biopsies, but not procedures, unless they’re very simple; whereas my PA, who has 10 years of dermatology experience, is capable of doing most everything I do, including excisional surgeries,” he says.

“As long as that degree of supervision takes place, I’m OK with it.”

Dr. Chow offers his definition of supervision.

“I’m always available for, and they are constantly reminded, that if there’s anything they aren’t sure of,” the practitioners should check with him, he says. “I would rather fall behind by a few minutes than have something happen.”

Some limit role

Dr. Krell
Christopher Buckley, D.O., recently started a procedural fellowship in Fort Lauderdale, Fla., after practicing for a year in Lexington, Ky., with another physician and four PAs. Although Dr. Buckley describes the PAs as “rather autonomous,” he says their role was somewhat limited.
“Normally, the doctors saw new patients, and extenders saw patient follow-ups, as long as they weren’t too complicated — eczema, psoriasis. If anything confusing came in, we were on the same floor and could step in and provide oversight.

“Our PAs did IVs and biopsies. Anything more complicated, we did,” he says. “For instance, we handled surgical incisions. They did some noninvasive cosmetic procedures such as Botox and some facial fillers, but not a lot.”

Dr. Tyring
Dr. Buckley says the doctors reviewed the PAs’ charts at the end of the day, a system he believes is important, as is the PAs’ willingness to ask for help when needed.
“They were competent to manage the things they were managing, and were judicious about asking about issues they were uncomfortable with,” he says. “I don’t think that’s always the case. Some physicians just let the mid-levels cope, and, sometimes, they get in over their head.”

Dr. Buckley isn’t completely comfortable with the idea of physician extenders performing surgical procedures on their own.

“The depth of their knowledge isn’t extensive enough to perform procedures in an unsupervised fashion. I don’t think they have the anatomy background or experience that we do as physicians,” he says.

In Brigantine, N.J., Frank Kern, M.D., is semi-retired after 36 years in practice, but he employed PAs for nearly a decade before cutting back on his workload.

He is a fan.

“Years ago, a woman applied to be a PA in our practice,” he says. “She had been the director of the first physician extenders training program at Duke when I was a student there. They didn’t call them physician assistants then, but that’s what the program morphed into. My partner wouldn’t hire her because, after all, she wasn’t a doctor.

“To make a long story short, nearly 10 years later, when I was solo, I hired her — and she was unbelievable. She was bright; she was an RN PA; she was just fabulous. She was so good that, two years later, I hired a second PA,” he says.

“I am all in favor of physician extenders.”

Training is key

For Dr. Kern, however, the key is training the PA, and he says that isn’t a short-term proposition.

“By training, I don’t mean having the PA follow the doctor around. I mean buying a textbook and sitting down every week to read and go over a chapter and talk about all the patients that fit that category — a real didactic experience.”

Dr. Kern says most of what a dermatologist does can be taught in about 18 months, but there are still a few things he doesn’t believe in handing off, even if the PA is capable.

“My PA did everything except surgery on the face. She removed off-the-face basal and squamous cell carcinomas, and I handled the melanomas, facial excisions and cosmetic procedures.”

He says facial procedures offer their own set of potential complications, not all of which are medical.

“My feeling is that cosmetic patients are a little more demanding. If anything is not perfect, they complain. The expectations are different. I think it’s better for the doctor to handle those,” he says.

Five dermatologists and two PAs practice in the office of James M. Krell, M.D., of Birmingham, Ala. One works almost exclusively with the practice’s Mohs surgeon.

Dr. Krell says in some ways, the PAs in Alabama don’t have all of the options PAs in many other states have. He says those duties don’t seem to be expanding very quickly.

“The reimbursement rate for PAs is about 75 to 85 percent of what the physician gets. And I believe there are limits on the dermatologic surgical procedures, so they can’t do as much as they can in some of the states around us,” he says. “They’re not even allowed to administer Botox (onabotulinumtoxinA, Allergan) for hyperhidrosis. So, it is limited.”

Scheduling to advantage

Dr. Krell says, however, that practices know how to cope with those restrictions.

“We use our PAs to the best extent we can to get the best reimbursement out of them. For us it makes much more sense for the physicians to do removals and have the PAs close both (incisions or removals), than to have the PA do one procedure and the doctor the other. That’s financially more advantageous.”

Dr. Krell, in practice for 18 years, agrees with Dr. Kern that training is the key to developing PAs that the physician can trust.

“Our one PA was our nursing assistant before she went to PA school. She knew tons of dermatology before school, and was pretty adept,” he says.

“Our other PA spent a year with us, doing nothing but studying and watching us and learning before we let her see patients.”

While Texas has the third-highest number of PAs in the United States, Stephen Tyring, M.D., says they aren’t practicing in Houston — or, at least, not many are in dermatology.

“Few dermatologists in Houston have physician extenders in their offices,” he says. “It just seems more cost-effective to have an additional dermatologist and more medical assistants — they have less education, and take notes rather than treat patients.”

Fewer PAs in Houston

Dr. Tyring does a lot of clinical research and is a clinical professor at the University of Texas Health Science Center. He believes the three dermatology training programs in Houston may contribute to the scarcity of dermatology PAs.

“Even though a limited number of dermatologists are trained each year, we seem to have no difficulty finding dermatologists to work with us,” he says. “We just don’t have as rich a supply of PAs in Houston as we do dermatologists.

“There must be some dermatologists who have a PA in Houston, but it certainly seems to be the exception rather than the rule. With all of the residency programs here, having a dermatologist treat patients, rather than a PA, has probably just become the standard of care.”

One reason some dermatologists give for hiring PAs is that it cuts down scheduling time — the patient doesn’t have to wait months for an appointment, and the doctor doesn’t have to schedule as far out.

Some dermatologists suggest that adding PAs has at least one advantage over adding another dermatologist to a practice. Dr. Chow and Dr. Kern agree that it can be easier to work with a physician extender than with a physician.

“I hired several doctors, and my partner hired doctors, and too many of them wanted all of the privileges of being a doctor with none of the responsibility,” Dr. Kern says. “That issue doesn’t come up with PAs. I would never take another partner.”

Karen Nash, a print and broadcast media medical reporter and former TV medical news reporter, has been writing On Call for more than 20 years. Contact her at [welshman@sio.midco.net]

Posted in:
  • PA/NP Advocacy
Specialties
  • Acute Care/Emergency Medicine
  • Dermatology
  • Emergency Medicine
  • Family Medicine
Keywords

Discussion

  1. bblumm
    4 years, 3 months ago

    well Dave, I hate the mid level moniker as well as the extender one, both used in the article but what remains uncontested is that we produce much more than they expected and some are willing to say that they can do everything that the Derm doc does, which is not an exageration. Most Derm doctors do small excisions and leave the larger ones for plastic surgery. With experience, I think the Derm PAs and NPs can easily REPLACE most Dermatologists.
    Bob

  2. bblumm
    4 years, 3 months ago

    well Dave, I hate the mid level moniker as well as the extender one, both used in the article but what remains uncontested is that we produce much more than they expected and some are willing to say that they can do everything that the Derm doc does, which is not an exageration. Most Derm doctors do small excisions and leave the larger ones for plastic surgery. With experience, I think the Derm PAs and NPs can easily REPLACE most Dermatologists.
    Bob

  3. bblumm
    4 years, 3 months ago

    well Dave, I hate the mid level moniker as well as the extender one, both used in the article but what remains uncontested is that we produce much more than they expected and some are willing to say that they can do everything that the Derm doc does, which is not an exageration. Most Derm doctors do small excisions and leave the larger ones for plastic surgery. With experience, I think the Derm PAs and NPs can easily REPLACE most Dermatologists.
    Bob

  4. jacquelyn_pa
    4 years, 3 months ago

    I agree, Bob.  I work in Surgery and do most of the excisions and biopies at my facility.  I work for a VA so, our closest dermatologist to refer to is 4 hours away, so we do what we can at our facility.  It has been very effective having most of these cases come through me first and then if needed, they will be referred to derm, plastics, or our general surgeon.  I would say less than 25% of the consults end up needed to be referred on.

  5. jmonroe9@cox.net
    4 years, 3 months ago

    Dave and Bob, et al: Karen Nash always does a good job on these, sometimes having to quote what to us are questionable comments on the part of derms. The comments I’m about to make are my own and do NOT reflect the opinions of the SDPA leadership.
    The truth is, if current rates of PA utilization continue in dermatology (and there’s no reason to think otherwise), PAs will constitute the bulk of clinical derm providers within 10 years, maximum. There are only about 8.500 dermatology physicians who do clinical (i.e., non-cosmetic) dermatology, and with about 3,000 derm PAs currently in practice, it doesn’t take long to see the trend. Our challenge is to be ready when the opportunity arises. I hope we do this with derms, but the way things are going, it wouldn’t surprise me to see them virtually all wander off into cosmetic practices and leave the clinical to us. Right now the average derm income is 350 K /year. Dy’a think there’s a little slack there for PAs to hold forth and still make a very good living?
    What virtually all dermatologists discover when they hire a PA is that we’re walking goldmines, AND we radically reduce the stress level in the practice (of getting same day pts seen, reducing waiting times, etc). As all of already know, the key word here is not “training” (not to minimize the need for it). Instead, the key word is “trust”, as in trusting the PA to ask for help when needed, but also in trusting him or her to do most things germane to the specialty, including (yes) surgery on the face, even extensive surgery at times. Derm PAs don’t have to have a dermatologist train them - we can read and learn from the patients, the exact same way they do in their residencies.
    When I read about a derm saying things like “well, I think they’re fine to see follow-up patients for acne, warts and eczema, but not for new patients”, I wonder if they’re aware of all the things PAs do in other specialties which are far more complex than most derm problems. But even with rare derm problems, what’s to keep a PA from learning about them? I saw a case of HHT (hereditary hemorrhagic telangiectasias, aka Osler-Weber-Rendu) this morning, something my doc had never seen (because he hasn’t been around long enough to see this rare disease.) I knew about it for the same reason that any physician knows about it: because I went to the trouble to learn about it. It’s astonishing to me that a physician, of any kind, would think that anything is beyond a PA’s ability to learn. But that’s what ego and ignorance will do for you. All of us know all about that.
    Does that mean that PAs are as good as a dermatologist? I wouldn’t make that case, but I would say that the things we do, we do as well as they do, or we shouldn’t be doing it. Not all dermatologists (or surgeons, or any other physician) practice at a superior level, nor would they claim to, so why would they hold us to that impossible standard?
    The other thing I see a lot of is this: a lot of derms, for public consumption, talk about how short a leash they keep their PA on, when the truth is, his PA function almost entirely autonymously for the simple reason that they don’t need much help. But the derms know some of their colleagues might take exception with this, so they prevaricate.

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