Behind Every Great Dermatologist
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
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
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
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
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
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)
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
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
- 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
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.
- American Academy of Physicians Assistants, www.aapa.org, accessed 23rd March
*The author is not a lawyer and this article does not
constitute legal advice.