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At first, John Ashley, MD, a dermatologist at the multispecialty group Springer Clinic in Tulsa, Okla., resisted hiring a physician extender or another nonphysician provider. But after five years of unsuccessfully trying to recruit another dermatologist to the practice, he began entertaining the thought.
Ashley would arrive to work before 8 a.m. and see patients through lunch until after 6 p.m. He was backed up two to three months with appointments, and there was no end in sight.
"It was wearing on me personally," Ashley says. "I felt the desperate need for help."
About four years ago, Ashley hired Joe R. Monroe, PA-C, MPAS, a physician assistant specializing in dermatology. Monroe had experience working in a multispecialty practice.
"I hate to use an expression like 'tickled pink,' but it has really been a big plus to our clinic and me personally to have Joe here, because he is so well trained," Ashley says.
Today, Ashley comes in a little later, goes home a little earlier, and even has time for lunch. Patients are happy, too. They don't have to wait as long. The backlog of patients has been reduced to a few weeks.
Ashley admits that, at first, some of the referring physicians resisted making referrals to Monroe and some patients preferred to see the doctor. Once the physicians became comfortable with Monroe's competence, however, their reluctance vanished. And most patients who expressed concern at first, changed their view once they had met Monroe, according to Ashley.
There are growing numbers of physician assistants and nurse practitioners working at dermatology practices throughout the country. According to a 2002 practice profile survey by the American Academy of Dermatology, 33 percent of respondents reported they used physician extenders.
According to Nancy Hughes, vice president of communications and information services for the American Academy of Physician Assistants (AAPA), there has been an increase both in percentages and numbers of PAs in dermatology practices.
The AAPA does an annual census survey of all PAs in the United States — not just physician assistants who are members of the academy. In 1999, the survey showed that 1.1 percent of all clinically practicing PAs (just over 34,000 individuals at the time) worked in dermatology. In 2003, the AAPA reported that 2.7 percent of the 50,000 PAs in the workforce were in dermatology.
"I think what has happened is that the demand for dermatology services has grown so much in relation to the available number of dermatologists. I have clients who have been looking for an associate for three years," says Sharon Andrews, consultant and owner of Derm Resources, a Pensacoloa, Fla.-firm that specializes in startup consultation and coding services specifically for dermatology practices. "So some dermatologists who might not have thought about it four or five years ago, now feel [hiring a PA] is the only way to continue to serve their population."
How nonphysician providers operate greatly depends on state law. What is most important to many dermatologists, however, are not the legal boundaries but rather the professional ramifications and patient care issues associated with the use of nonphysician providers.
According to Keith Borglum of Professional Management and Marketing, a healthcare consulting company from Santa Rosa, Calif., physician extenders can make diagnoses, but in many dermatology practices the physician will limit the extender's diagnosing to lower level treatments or more common types of problems, such as acne or the management of chronic conditions.
"Many dermatology practices are comfortable having the extender do both diagnosis and treatment in those areas," Borglum says.
Monroe, who has nearly 20 years' experience in dermatology, makes diagnoses and performs biopsies and surgery.
"About 30 percent to 35 percent of my practice is surgery," Monroe says. "There are places where I draw some lines, although they are somewhat arbitrary — the state doesn't require it. I choose not to prescribe the new category of drugs for psoriasis called the biologics. It's just that I don't have much experience with them, I'm not likely to get that much experience with them; therefore, I'll just leave that to the dermatologist."
According to Harold Brody, MD, a dermatologist and clinical professor at Emory University School of Medicine in Atlanta, it is crucial that physician assistants always operate in dermatologists' offices under the direct onsite supervision of physicians. If the dermatologist is not in the office in the afternoon, the PA should not be seeing patients in the doctor's absence.
"If you always have direct supervision and your physician assistant finds it prudent and necessary to call you on important issues, then you are doing the right thing in your office," Brody says.
"The most important thing is stressing that physician assistants practice as a team with physicians," says Hughes. "[PAs] are in favor of supervision but also believe that supervision should be appropriate to the individual PA's experience and education. They, as health providers, have the ability to make autonomous decisions within the treatment and diagnosis arena but still they do it with supervision. Supervision is not a four letter word."
One way to determine whether a practice needs another provider to care for patients, according to Borglum, is by determining if a dermatologist or group of dermatologists is booked more than 75 percent of the time for more than two weeks in advance. If this is the case with your dermatology practice, you have to look at the type of provider that would best complement the practice. If it's general dermatologic care you want to provide, a nonphysician might be the answer.
When the fit is right — the nonphysician provider integrates with the practice philosophy, understands its level of care, and receives adequate supervision and support — the result often is higher patient satisfaction and a better quality of work life for the physician.
According to Andrews, it's important that dermatologists interview carefully, progress slowly, and determine where the extender's strengths and weaknesses lie and what the extender is comfortable doing.
Borglum says dermatologists should be diligent about verifying training, checking licensure, and doing the normal prescreening of skills and personality before hiring a nonphysician provider into the practice.
Dermatologists should train nonphysician providers by progressively increasing the responsibilities of these new hires, starting them with the basic skills in which they have demonstrated competence, and then giving them more responsibility as they are trained in other modalities.
"That will normally take at least two or three months," says Borglum. Allan S. Wirtzer, MD, a dermatologist who practices in Sherman Oaks, Calif., employs two physician assistants who see medical dermatology patients.
Wirtzer says that one of the most important elements is that there should be compatibility in the working relationship, just as if you were working with a fully trained dermatologist. "It's important to select someone carefully."
The advantage to having a physician assistant or nurse practitioner is that the dermatologist can mold that person to practice as the dermatologist does. That's more difficult when you try to integrate a dermatologist who has been trained and worked elsewhere, says Wirtzer.
"I think the usefulness of having them in our offices allows us to deal with the dermatologist shortage, because it allows patients access rather than forcing patients to go to nondermatologists for their skin treatments," Wirtzer says.
Joe R. Monroe, PA-C, MPAS, a physician assistant at the multispecialty Springer Clinic in Tulsa, Okla., tells dermatologists that nonphysician providers are not their problem — they're the solution to their problems. "We're really the only answer to questions like, 'How do I stay sane?' and 'How do I keep up with office demand?'"
Monroe may be on to something. According to a 2002 American Academy of Dermatology survey, 33 percent of respondents reported using physician extenders. It's a growing trend in a specialty that is growing itself by leaps and bounds. With patient loads increasing and wait times expanding dramatically, dermatology practices that truly want to provide the best care to their patients need to look for a new solution. Nonphysician providers might just be it.
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Disclaimer: The material above has been prepared by Physicians Practice. It has not been reviewed by the DermQuest Editorial Board for its accuracy or reliability. Reference to any products, service, or other information does not constitute or imply endorsement, sponsorship, or recommendation by members of the Editorial Board.