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Opinions on Practice Management

Barry Ginsburg, MD

Behind Every Great Dermatologist

Barry Ginsburg

Thursday, June 11, 2009

A physician's assistant (PA) can be a valuable addition to your practice. One of the most valuable assets of a PA is the flexibility in their role and function. Because of their broad medical education, they can be utilized in many ways. What's more, they also provide another skilled set of hands, eyes and ears, to ultimately expand the services you can provide to your patients.

When used appropriately, a PA can increase revenue, improve patient satisfaction, improve efficiency, and increase your capabilities and value for your patients.

Most of what I will discuss in this article comes from my personal experience of working with my PA and from talking to colleagues about their working relationships with their own PAs.

My Experiences With Having a PA

I hired my PA straight out of school. She had received her Masters at the University of South Alabama. I was fortunate in that she did a clinical rotation at my office during her last year of school and she was able to work for me for a month. While here she was able to perform minor procedures, take histories and perform physical examinations on patients. This gave me the opportunity to see her work and see how she interacted with patients and staff members.

I had recently downsized my practice from a four-physician practice to a solo practice. I needed help but didn't know in what form it would take. My practice is about 40% cosmetic and 60% medical surgical. I practice Mohs surgery, and repairs, as well as handling most medical dermatologic problems. I perform liposuction, fillers, Botox and peels. When my PA came to the office, I was not looking to hire a PA. She completed the rotation, and when I saw how well we worked together I made the decision to hire her. My goal was to have someone to help me see my medical patients so that I could spend more time with my cosmetic patients. I spent time training her to do biopsies and later to perform closures. She worked and studied hard, and is now a capable diagnostician. Below I mention my recommendations for hiring and training a PA; however, I did not follow these steps as I didn't plan on hiring my PA initially. I did not have to decide ahead of time what experience was necessary. Fortunately it worked out well for me, but if I had to advertise I would follow my recommendations outlined below.

I decided that I had no desire for her to practice cosmetic procedures, and she had no desire to learn them. I think that this is one of the most important points to decide upon up front. A PA skilled in cosmetic injections can be a very valuable asset, but she could be lured away by someone who does not practice cosmetic surgery or indeed someone who does not practice medical dermatology, and be more valuable to them.

We started her training by having her shadow me. For one month, my PA observed how I performed biopsies and cryosurgery. Then, for another month, I stayed with her in the room and observed her work. Within a short time, we would assess a patient together; I would leave the room and she would perform the biopsies. She also assisted me during surgery, and she was soon doing closures and sewing on grafts. Eventually, once I got clear margins on my Mohs cases, she was able to do the closures by herself. In complicated closures, she would consult with me prior to performing the closure. She is not shy about asking for help, and I am always available when she needs me. I still shadow my PA on occasion while she does procedures. I do not have a strict evaluation procedure - I don't carry out yearly written evaluations. However, I have given her raises each year.

We work side-by-side and I see every patient that she does. Sometimes, I see patients just for a few seconds on a follow-up visit, and other times for longer with a new patient that needs a treatment plan.


I personally believe that we are discrediting dermatology by allowing PAs to practice by themselves. I think when a patient has an appointment with a dermatologist, he or she should see a dermatologist. When a PA is alone in a satellite office they are essentially practising dermatology, but they are not dermatologists. I believe that a non-dermatologist should not advertise that they practice dermatology, and therefore I clearly do not approve of a non-physician practicing dermatology on their own. 

I consult with every patient that my PA sees, but it should be noted that some dermatologists allow their PA's to consult with patients on their own during follow-up visits when the dermatologist is in the office. An assistant is just that: someone who offers assistance; however, I realize that this is not the way many others feel, and I respect their viewpoint. Many believe we are discrediting dermatology by allowing a PA to practice on their own, but with the shortage of new associates in many areas, I understand that some feel they have no alternative. The specific guidelines for credentialing, billing and supervision are available on the American Academy of Physician's Assistants (AAPA) website.1

Recommendations For Hiring a PA

Before you hire a PA, you should first know your practice needs and acknowledge where a PA will be most beneficial. You should develop a job description that sets out clear duties and expectations. When writing this the dermatologist should be aware of the laws regarding supervision of a PA in their state and review the information from the American Academy of Dermatology (AAD) and AAPA.

You might want to consider some of the following points:

  • Will the PA work with you side-by-side, and from a single schedule or will they have their own patients that you will supervise?
  • Will they work on-site or at a satellite office?
  • What type of patients and/or diseases will the PA assess?
  • Will they assist in surgery?
  • Will they make hospital rounds?
  • Will they take messages and calls when you are out of the office?


Some Considerations Before You Advertise For a PA:

  • Do you want someone with experience in dermatology, or do you want to train someone up?
  • Do you want to hire someone fresh out of school or someone who has prior experience in another field?
  • How will you supervise your PA?

Supervision does not necessarily mean you will be on-site with your PA. It is imperative, however, that the supervising physician is or can be in contact with the PA by phone.1

There are no strict guidelines for you to follow with regards to whom you choose to hire and how you want them to work with you. Your personality and your business needs are more important than their strict job description.

When Hiring, There Are A Number of Different Scenarios

I chose to hire someone with no dermatology experience. I trained her from the ground up and she practices dermatology exactly as I would. But you may want to hire a PA who has already worked for a dermatologist. This has many advantages. They will require much less training, but they will join you with the knowledge and experience that they have learned from someone else. If your views differ, you will either have to accept their views or teach them how you want them to practice. Since you are ultimately responsible for your patients' treatment, you must approve of their treatment plan. You can learn from them and, if you are flexible and open to change, you can accept the differences in the way you practice. There are so many gray areas in medicine that a different approach to a problem can be very helpful and beneficial. We must accept the fact that we do not know everything and we must be willing to be educated by others, even patients. This is good patient care. If a PA can teach us something we didn't know, we should welcome the information.


Alternatively, you can hire a PA who has previous experience, but not in dermatology. This can be an ideal situation. You can train them in dermatology and they can provide their experience and knowledge in another field, which can be very helpful. If they have worked in family practice, then their knowledge of general medicine can be a big help to you, because most dermatology patients have medical problems. A better understanding of a patient's medical history and treatments is a very important part of the treatment regimen that you plan.

How My PA and I Work Together

When a patient visits my practice, if both of us are available, my PA goes into the room and performs an assessment. If she feels biopsies are needed, she will mark the areas with a pen. Once she has finished her assessment and charted the results, I then review her notes and examine the patient. I usually agree with her assessment, and she proceeds to perform the biopsies. If they are a medical patient, my PA carries out the assessment and then decides on a treatment plan. We then go into the room together and enact the plan. I might accept her plan or alter it. A prescription is written and the patient leaves.

This might sound complicated or cumbersome, but we have worked out a rhythm that allows me to see almost twice the number of patients that I could see if I worked alone. I have never formally surveyed my patients regarding their satisfaction or the care given by me or my PA, but I have rarely had any complaints. I do have a few patients that request to see me and have me perform the biopsies rather than my PA, but these are very rare. They are usually patients that I have been consulting with for many years. We are not two providers, we are a team. I don't think my patients feel that we are splitting their care. I feel that to be able to see more patients is a positive, if I am able to do so, without compromising the quality of care they receive.

There are a few other ways that dermatologists use PAs. A very common practice is to schedule the PA her own patients when you are in the office. These could be follow-up visits. The PA performs the entire visit, and you are available if needed, but generally the PA does the entire encounter themselves. I think that this is the most common way that dermatologists employ a PA in their practice.

Another way to work with a PA is to have the PA at a satellite office, with you available by some means of communication. However, in some states, such as New Jersey, such an arrangement is illegal*, guidelines for which are available from the state medical boards and the AAPA web site. There are also guidelines for billing and supervision outlined on the AAPA web site.1

Working via a satellite office is not the way I would choose to practice, and I do not think that this was the intention of the AAD or the AAPA . I believe the position of a PA has evolved over the years. The first PA's were actually surgical assistants, they assisted in surgery and helped the doctor in the office. I don't think the intention was to have them practice surgery on their own, which I think, is the same role as a dermatologist.

So much depends on personalities; I am very fortunate in working with someone that fits my needs perfectly. The relationship between a physician and a PA is based on mutual respect and understanding and in many ways is comparable with a marriage. Both need to be willing to adapt to the needs and expectations of each other.

I hired my PA 7 years ago, and the partnership has been very valuable for both of us. She has also taken on many administrative duties. We have developed mutual respect and trust, which I feel is key to any successful relationship.

Reference

  1. American Academy of Physicians Assistants, www.aapa.org, accessed 23rd March 2009.

 *The author is not a lawyer and this article does not constitute legal advice.

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