For Healthcare Professionals Only
In “The Dermatology Workforce Shortage,” published by the Journal of the American Academy of Dermatology in January 2004, survey data pointed to a shortage of dermatologic services in many communities. The mean wait time for new patient appointments was over a month, but in some states the wait time stretched to 120 days. The authors of the article concluded that “it appears there is an inadequate supply of dermatologists to meet the demand for services."
This is surely no surprise to many practicing dermatologists, many of whom see this imbalance firsthand. Some are improving patient access to their practices by adding physician assistants to help ease patient wait times and improve the quality of care.
The American Academy of Physician Assistants (AAPA) estimates 1,650 dermatology PAs now in clinical practice and another 120 estimated to enter the workforce this year. Yes, it’s a relatively small number, but according to the Bureau of Labor Statistics, PAs “can provide diagnostic, therapeutic, and preventive healthcare services, as delegated by a physician … they take medical histories, examine and treat patients, order and interpret laboratory tests and X-rays, make diagnoses, and prescribe medications.”
Given those responsibilities, a physician assistant can be a good option to ensure that your dermatology patients receive the most appropriate care possible, helping you spend time with more complicated cases. Some dermatologists have found great success working with a PA; still others believe in a “proceed with caution” approach.
Michelle DiBaise has been a PA for almost 15 years, 10 of those years assisting dermatologist Kristie Hayes at the University of Nebraska Medical Center. “I see both new and established patients and occasionally I see consults,” says DiBaise. “I do a lot of triage and make decisions over the phone as to whether I can see someone as a walk-in or whether I need to get the patient in … with one of the doctors.”
DiBaise says dermatology PAs commonly perform punch biopsies, shave biopsies, and simple excisions. “What we do as PAs depends on a combination of state regulations and the degree of autonomy that our physician wants to grant us. We can help out in a clinic much the same way that a resident or fellow might in terms of seeing patients and presenting them, or we could even have our own clinic with our own patients so that more patients are seen overall."
She and Hayes work at opposite ends of a hallway and, even during DiBaise’s limited hours, working together they can see 50 percent more patients than Hayes would be able to see on her own. But DiBaise emphasizes that when it comes to clinical matters, she follows her dermatologist’s lead; by state law, DiBaise must physically be with her physician 20 percent of the time.
"By herself on a normal day, my dermatologist might be able to see 10 patients in the morning,” explains DiBaise. “If I’m working with her and we have no residents or students, we can see 15 in the same period of time. I see the patients, I present them to her, she leaves and goes to the next patient and I stay and start typing in the prescriptions."
With the patients she does see, DiBaise says she spends a lot of time on education. “That’s one of the biggest boons to our practice — our ability to spend time with the patient, to explain what we are doing, what medications we’re using, and why,” notes DiBaise. “A lot of what we do is education about sunscreens, sun protection, mole checks, and so on. We have the ability to spend time with the patients. That’s one big benefit that we have for dermatologists.”
Palm Beach, Fla. dermatologist Kenneth Beer, MD, doesn’t have any qualms about physician assistants helping with patient education, but the idea of PAs running their own practices under what he considers minimal dermatologist supervision does make him nervous.
“I think the correct and appropriate role for a physician assistant in a dermatology office is to perform very simple procedures,” says Beer. “I don’t think they should be allowed to diagnose and treat patients in an unsupervised fashion. To allow them to function in that way belittles the education that dermatologists have — which is currently the most competitive medical specialty to enter.”
Beer believes that physician assistants can help a dermatologist to provide better patient care in certain situations. “I think it’s reasonable to allow PAs to do skin biopsies and to draw blood,” he says. “It’s reasonable to have PAs take an initial patient history, conduct the physical examination, and perform the bulk of the writing to save a dermatologist time. These activities all involve PAs acting as assistants — the role they are ostensibly supposed to play.
“There are some things that consume a disproportionate amount of a physician’s time that present ideal opportunities for PAs to assist a dermatologist,” Beer continues. When he worked with a PA, Beer recalls how nice it was to have the assistant spend 10 or 15 minutes explaining post-operative care to a MOHS patient while he went on to the next MOHS procedure. He also likes the idea of training a PA to help with routine acne care and freezing warts.
Though the dermatologist employer has responsibility for at least checking the charts of the patients that PAs see, Beer fears that seeing the record is no substitute for seeing the patient in person.
“If you look at the accuracy of even the best academic dermatologist in diagnosing melanoma, it’s not as good as we’d like to be,” he points out. “I think it’s bad for patient care to have people who have not been board certified in dermatology making decisions about what does and does not get biopsied.”
That’s not to say that Beer doesn’t think that PAs can help a dermatology practice give better patient care. He acknowledges many dermatologists use PAs for a broader range of patient care activities, and many PAs themselves feel they have the skills to contribute in a more comprehensive fashion.
Joe Monroe has worked as a PA for almost 30 years and spent about 20 of those years at dermatology practices. “In the majority of cases, we don’t actually assist anybody,” he says. “PAs have evolved over the years into dependent practitioners of medicine and surgery. The key word in a dermatologist-PA relationship is trust. The dermatologist comes to trust that the PA will ask for help when it’s needed.”
Monroe says that PAs who have won that trust can help alleviate patient care bottlenecks. “We see patients. We represent access,” he says. “In effect, we take what might be a three-month waiting time for a patient with a routine problem and we help the dermatologist to cut that wait time in half.”
In addition, says Monroe, “We’re trained to emphasize patient education, and in a lot of situations we naturally fall into that role … . It’s a nice extra bonus” for the dermatologist.
Hiring a physician assistant is a great way to add relationship-based services many patients crave, and to allow the dermatologist to focus on patients who may have more complex needs. But before you hire:
CONTENT PROVIDED BY:
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.