by Terry Arnold, MA, PA-C
Advanced Practice Consultants, LLC, Tulsa, Oklahoma
Although physician assistants have played a key role in the delivery of medical care since the mid-1960s, their utilization in the dermatology specialty has been a more recent occurrence. Dermatology physician assistants have experienced tremendous growth over the last 10 years, largely due to the imbalance between patient demand for skin care services and a lack of supply in residency-trained dermatologists. Working under the supervision of dermatologists, physician assistants have been able to extend the reach of the physician and improve patient access to quality dermatologic care.
(J Clin Aesthetic Derm. 2008;1(2):28–31)
The history of the physician assistant (PA) profession in the United States can be traced back to 1959, when the US Surgeon General identified a shortage of medically trained personnel to care for a rapidly growing populace. Later, in 1961, Dr. Charles Hudson proposed the concept of a “mid-level” provider profession to be developed from the ranks of former military corpsmen. By the mid-1960s, Dr. Eugene Stead, Jr. (widely considered the father of the PA profession) decided these ex-military corpsmen with their previous training and experience would be suitable candidates for a two-year experimental PA training program. From that first class of four PA students, the profession was born and has experienced tremendous growth, development, and acceptance over the last 40 plus years. Originally conceived as primary care providers, PAs can now be found in virtually all medical and surgical specialties.
According to data compiled by the American Academy of Physician Assistants, there are 79,706 people eligible to practice as PAs in the United States, and 68,124 PAs in clinical practice as of March 2008. The number of PAs working in the dermatology specialty has been difficult to establish with precision, but is thought to be in the range of 1,800 to 2,000. According to data from the 2007 Workforce Survey by the Society of Dermatology Physician Assistants (SDPA), there were 1,805 “Fellow” status members of the Society, all of whom were employed by board-certified or board-eligible dermatologists. This number has grown considerably over the last 10 years. There were fewer than 250 Fellow members of the SDPA in 2001. Based on the results from the 2007 Dermatology Practice Profile survey, 30 percent of dermatology practices now utilize PAs or nurse practitioners.
Physician assistant education is designed in the medical model of care to complement the training of physicians. These intensive training programs have highly competitive entrance standards and are accredited by the Accreditation Review Commission on Education for the Physician Assistant. There are currently 140 accredited programs across the United States, many of which are affiliated with university medical schools. The length of each program varies, but averages 26 months. The PA curriculum consists of one year of didactic instruction in medical and behavioral sciences (anatomy, physiology, pharmacology, pathophysiology, history and physical examination technique, laboratory sciences, and ethics). This is followed by 12 to 18 months of clinical rotations in internal medicine, family practice, obstetrics/gynecology, general surgery, emergency medicine, pediatrics, and geriatrics.
Like medical students, PA students with an interest in dermatology can complete an elective rotation in the specialty. According to the SDPA 2007 Workforce Survey, nearly all PAs working in dermatology receive regular training from their supervising physicians.10 This training takes a variety of forms and is provided at the discretion of the supervising physician. This training typically consists of structured reading programs, journal article reviews, patient evaluations and discussions, and grand rounds presentations. Presently, there is one postgraduate training program for dermatology PAs at the University of Texas Southwestern Medical Center in Dallas, Texas.
Beyond PA school training, all PAs are required to accumulate 100 hours of continuing medical education (CME) every two years. PAs are also required to successfully complete a comprehensive general medical examination every six years, regardless of the specialty in which they work. This exam is administered by the National Commission on the Certification of Physician Assistants (NCCPA).
Presently, no credentialing examination for dermatology PAs beyond the NCCPA exam exists. However, in response to a request from former American Academy of Dermatology (AAD) President Diane Baker, the SDPA has collaborated with the University of Texas—Southwestern Medical Center and Coria Laboratories, Ltd., to create the Distance Learning Initiative (DLI). This web-based training program includes modules designed by dermatology thought leaders as a standardized curriculum of education for all PAs working in dermatology. This program is scheduled to launch in 2008 and will require approximately 100 hours of concentrated study for successful completion.
Continuing Medical Education
A characterization shared by almost all dermatology PAs is a desire for more education and information related to the diseases they treat. PAs understand the need to keep current, not only in their chosen specialty, but also in general medicine. In fact, all PAs, regardless of primary specialty or experience, are required to successfully complete a recertification exam every six years, administered by the NCCPA. This general medical exam includes questions from virtually all specialties, with emphasis on primary care topics.
Dermatology CME is delivered in a variety of different forms, including live event conferences and meetings; online, web-based learning; audio CDs/tapes; teleconferences; journal articles and post-tests; and podcasts. As previously stated, PAs are required to complete 100 hours of CME every two years to maintain certification from the NCCPA. With the abundance of offerings that are available and a great demand for education, most PAs have no trouble keeping up with this requirement.
Many PAs also participate in journal clubs and grand rounds presentations hosted by their local dermatology PA organizations, physician groups, and university dermatology departments. These are excellent opportunities for physicians and PAs to discuss interesting and difficult dermatology cases in a collegial environment that enhances and extends dermatology care.
Physician supervision is the cornerstone of the PA profession. PAs by definition are dependent medical providers who only practice medicine under the supervision of a licensed physician. This basic tenant of PA practice is ingrained in every PA from the first day of training. PAs are taught (and continuously reinforced) to learn their diagnostic and procedural limitations and to practice within those limitations. PAs also appreciate the collegial relationship they enjoy with their supervising physicians and have great appreciation for their place on the contemporary healthcare team.
The specific requirements for PA supervision are governed by each state’s laws, statutes, and rules. PAs typically fall under the state board of medicine, rather than a separate allied health or nursing board. This further illustrates the dependent legal relationship that PAs have with their supervising PAs. These state statutes define how many PAs a given physician can supervise, what medications the PA can and can not prescribe, and what constitutes direct and indirect supervision, as well as many other issues. Physicians interested in utilizing PAs should familiarize themselves with their individual state statutes before entering into an employment agreement.
The supervision of dermatology PAs does not vary from that of other specialties. While some procedures, especially those utilizing lasers and light-based therapies, might be specifically delineated for dermatology PAs, other rules and regulations are similar to those in other specialties. PAs can only practice medicine that is within the scope of services provided by their supervising physician; therefore, a PA would not be able to work in another specialty and simultaneously provide dermatology services. To do so would most likely represent a violation of state law.
Position papers on the physician-PA supervision have been established by the AAD and the SDPA. These documents help to describe each organization’s concept of appropriate supervision, but do not supersede state law nor do they attempt to establish a legal standard of care. All parties would agree that appropriate supervision is established by state law and the supervising physician is ultimately responsible for coordinating and managing the treatment of patients under his or her care. Delegation of responsibility is also given at the discretion of the supervising physician, so long as the delegated privileges and responsibilities are within the bounds of state law.
Roles and Responsibilities of Dermatology PAs
The roles and responsibilities of dermatology PAs vary somewhat from practice to practice, and are largely dictated by the training and experience of the PA as well as the preferences of the supervising physician. It is expected that new graduates and experienced PAs that are new to the specialty should complete an initial training period designed and monitored by their supervising physician. As stated previously, these programs can take a variety of forms, typically lasting 3 to 12 months in duration. Many supervising physicians consider this training to be essential to practice success and tantamount to the delivery of quality dermatologic care.
The vast majority of dermatology PAs work in medical dermatology settings, evaluating and treating common skin disorders such as acne, rosacea, atopic dermatitis, contact dermatitis, psoriasis, and warts. After the initial training period is complete, PAs will often see patients and present cases to the supervising physician for discussion and decision making. Typically after a certain period of time and experience, the supervising PA will delegate responsibility for certain diseases or patient types to the PA, but remain available for consultation on complex cases or in situations when the diagnosis is in question.
PA roles and responsibilities are also largely dictated by state rules, laws, and statutes and vary from state to state. However, virtually all states require that PAs only provide services that are within the scope of care of the supervising physician. It would be wholly inappropriate and probably illegal for PAs to provide dermatology services beyond that expected from a general practitioner, unless working under the supervision of a dermatologist.
Most PAs have received surgical training as part of their PA school curriculum, including some of the more common dermatologic minor procedures, such as liquid nitrogen destruction; electrocautery use; and shave, punch, and incisional/excisional biopsies. PAs are also trained in sterile technique and have sound surgical skills in performing excisions and minor repairs. Advanced surgical training is often provided by the supervising physician and a growing number of dermatology PAs assist in Mohs surgery and perform repairs with complex closures, including flaps and grafts. Again, this training is the responsibility of the supervising physician and can only be delegated to the PA if the skill falls within the standards established by state statute.
Another growing area for dermatology PAs is the provision of laser and other light-based therapies. Some states have established rules and regulations that define which laser treatments can be performed by “non-physicians” and what the level of supervision shall be.
PAs can also be trained to provide cosmetic services, including botulinum toxin injections, fillers, and chemical peels.
Physician assistants are authorized to prescribe medication in all 50 states. Approximately one-fifth of those states impose some type of prescribing formulary, and virtually all states establish guidelines and limitations for the prescription of controlled substances. The Drug Enforcement Agency (DEA) has established a specific registration category for PAs and other “mid-level” practitioners who are authorized by state law to prescribe controlled substances. Again, the supervising physician is ultimately responsible for the prescribing actions of their PA and many states require a letter of delegation from the supervising physician to the PA to be kept on file.
A variety of different compensation schedules have been used by supervising physicians. The most basic of these is a straightforward base salary, without productivity bonuses. This type of contract is sometimes used for PAs that are new to the dermatology specialty while they are completing a training program designed by the supervising physician. Typically, these PAs are not seeing patients without direct physician supervision, so they are unable to generate their own billings/collections to produce a productivity bonus.
A more common and mutually beneficial contractual arrangement is the base salary plus productivity bonus. These bonuses can be paid out at agreed upon intervals (quarterly, semiannually, or annually) and are usually based on collections. Less commonly, bonuses are based upon amounts billed or some other criteria.
Salary amounts vary greatly and are usually based upon general medical experience, dermatology-specific experience, hours worked in a given day/week, procedures performed, nature of the practice, additional duties, and geography. The largest PA salaries are typically seen in high-volume practices where a variety of surgical and cosmetic procedures is performed. These PAs typically have several years of experience and a billing/collections history that supports their salary desires.
Salary averages and the appropriate structure of a productivity bonus are beyond the scope of this article, but will be addressed in a future publication.
Beyond salary and bonuses, almost all dermatology PAs receive allowances for CME, professional society dues, and state licenses. PAs are usually considered employees of the practice and participate in health and disability coverage, retirement plans, and vacation and sick-time allowances, as well as other employee benefits. Malpractice coverage for dermatology PAs is very reasonable in comparison to physician premiums and is usually paid for by the employer.
The Future of Dermatology Physician Assistants
The future is indeed quite bright for dermatology PAs in the United States. Given the shortage of residency-trained dermatologists and the increased demand for both medical and cosmetic services, PAs are ideally positioned to enhance the delivery of care their supervising physician provides. This demand shows no signs of waning and will most likely continue to increase with the aging of the “Baby Boomer” population.
Despite some early challenges, many dermatologists recognize the value of PAs and appreciate that they are dependent practitioners who are trained in a model similar to what they experienced in medical school. According to data from the AAD, nearly 30 percent of dermatology practices in the United States currently employ at least one PA.
The PA concept started in primary care and later spread to specialty medicine. An entire generation of patients has now been exposed to the PA profession in government agencies such as the VA, all branches of the armed services, private medical practices, hospitals, and still other nontraditional settings. Most patients understand the roles of PAs in contemporary medicine and appreciate the extra time and attention they are able to provide.
Reimbursement for PA services is provided by Medicare, state-sponsored Medicaid plans, and third-party commercial carriers. The reimbursement is 100 percent of the rate billed by the supervising physician, when billed under the provisions of “incident-to” services. Office visits that do not meet the “incident-to” criteria are billed at 85 percent of the physician fee schedule. A thorough explanation of this criteria system is beyond the scope of this article, but will be covered in a future publication.
Physician assistants have been a fixture in contemporary medicine for nearly 40 years. Originally conceived as an answer to a shortage of primary care providers, the PA profession has made tremendous strides in public recognition and physician acceptance since inception. Physicians appreciate their medical model of training that is similar in structure to their own medical school experience, and further appreciate that PAs are dependent practitioners that are only licensed to practice medicine under their supervision.
Over the last 10 years, PAs have branched out to virtually every specialty of medicine, including dermatology. Given the current and future shortage of dermatologists in the United States and a growing demand for dermatologic services, PAs are again extending and enhancing access to those services.
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