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.
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.
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.
“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.
“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
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. 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.”