By John Carruthers, assistant editor, November 01, 2013
With the advent of the Affordable Care Act (ACA), an already-thin dermatology workforce finds itself stretched by millions of new insured patients. As funding for graduate medical education holds level and an increasing number of students enroll in physician assistant and nurse practitioner programs, dermatologists have begun to plan for a future where providing necessary care to patients involves making the best use of all members of the care team, including non-physician clinicians.
A growing demographic
While the number of dermatologists entering the specialty from residency more or less mirrors the number of dermatologists leaving the field each year, the number of physician assistants (PAs) and nurse practitioners (NPs) is rapidly growing, and is projected to continue doing so in the future. The U.S. Bureau of Labor Statistics projects a 30 percent growth in employment opportunities for physician assistants from 2010 through 2020, representing roughly 24,700 new opportunities created. Similarly, the number of nurse practitioners is steadily growing, with approximately 14,000 new NPs completing academic programs each year, according to the American Academy of Nurse Practitioners. And dermatology, according to Portland nurse practitioner Lakshi Aldredge, MSN, ANP-BC, is an especially attractive specialty for PAs and NPs.
“There’s record enrollment in NP and PA programs. And dermatology itself is a very appealing specialty for both,” Aldredge said. “It’s an appealing lifestyle as compared to primary care or internal medicine, but it’s also a very fascinating field with high demand. You have a lot of NPs and PAs interested in going into dermatology.” [pagebreak]
The increase in non-physician clinician numbers and continued demand for dermatology services is what, in part, led David Pariser, MD, a former American Academy of Dermatology president, to begin integrating non-physician clinicians into his six-location Virginia practice. He now employs seven PAs and an NP in addition to the 11 dermatologists in the practice.
“Several years ago, my practice decided to engage these non-physician clinicians, because frankly we couldn’t get another dermatologist,” Dr. Pariser said. “We have six office locations and last year saw approximately 100,000 patients. In order to see more patients in a high quality fashion, we found that PAs were a tremendous help to us.”
The rapidly growing number of non-physician clinicians in dermatology, Dr. Pariser said, indicates a demographic shift that dermatologists simply cannot ignore.
“The number of non-physician clinicians is only going to increase, whereas the number of dermatologists is not. If we don’t fold them into our practices, there will be more of them than us in the career span of a lot of our colleagues. And that will cause a lot of problems in terms of demographic makeup and who gets to call the shots,” said Dr. Pariser, who currently serves as chair of the AAD’s Dermatology Care Team Implementation Workgroup. “The Academy is making inroads into a team care approach with dermatologists as captains of the dermatology care team. If there’s no team built, then what will we be captains of?”
One of the more controversial aspects of the rise of non-physician clinicians is the debate over appropriate scope of practice and supervision of PAs and NPs. Nurse practitioners hold prescribing privileges in all 50 states and the District of Columbia, with controlled substance prescribing power in 48 states, as well as the ability to practice independently in a number of states. Physician assistants, in part due to varying scope of practice and supervision laws state to state, often hold great responsibility, sometimes overseeing satellite clinics for an off-site supervising physician. Taken in tandem with the growing workforce shortage, these factors portend change in the practice of not just dermatology, but medicine in general. [pagebreak]
“The dermatology shortage preceded the shortage created by the ACA because of the limited residency slots. So many dermatologists are looking for another physician to come into the practice, and I don’t think we can ever solve the shortage with physicians alone,” said practice management consultant Keith Borglum. “The bolus of the baby boomers moving through the system means there will be at least 20-30 years before there’s any normalcy in our population.”
This demand for services, according to Scottsdale, Ariz., dermatologist W. Patrick Davey, MD, MBA, makes it essential that dermatologists define the proper scope of practice for their allied PAs and NPs. If non-physician clinicians can be properly trained to handle stable post-diagnosis follow-ups and simple medical dermatology, dermatologists can be freed up to handle complex medical cases, surgical procedures, and even cosmetic services.
“A properly trained PA or NP can free up a dermatologist to approach more of the type of cases or procedures they find interesting or rewarding,” Dr. Davey said. “When it’s routine follow-up or patient education, it can be a better use of the dermatologist’s time to employ a PA or NP and leave themselves open for a more complicated case.”
Dermatologist Risa Jampel, MD, of Owings Mills, Md., agrees that as partners in treating patients, PAs and NPs offer great efficiency when properly supervised.
“They don’t have the same depth of knowledge and awareness of the subtleties of diagnoses,” she said. “We all know how much training and experience it takes to diagnose an amelanotic melanoma or connective tissue disease. It is important in training a PA or NP to stress that they must always seek the physician’s guidance if there is any question about the diagnosis. If I see a patient with a cyst or an abnormal mole, my PA is very good at performing the excision, once I’ve made the diagnosis. In addition, she does a great job with teenagers with routine acne. However it is my responsibility as a physician to see an adult woman with acne, hair loss, and a possible endocrine problem,” Dr. Jampel said. “My PA is quite good, but I supervise her closely, because I feel like my name is on the line. I review every chart and every laboratory and pathology report. That way I’m certain that I’ve seen everything.” [pagebreak]
Dr. Jampel offers patients the opportunity of having their excision or other procedure performed by the PA or herself. “We never tell patients that they have to see the PA and not me,” she said. “They may have to wait longer, but I still give them that choice.”
While he appreciates the flexibility to devote dermatologist time to more complex cases or procedures, Dr. Pariser also offers his patients the same choice. In reality, he said, most patients are content with seeing a non-physician clinician for most issues. This, he said, gives patients more interaction during the visit.
“What this enables us do with this additional flexibility is have more patients get more time with the provider. Almost none of our patients ever say I don’t want to see the PA, I want to see the doctor,’” Dr. Pariser said. “We sometimes get I don’t need to see the doctor, I can see the PA.’ Sometimes that’s okay, depending on the nature of their condition.”
At its core, Dr. Pariser said, effective supervision is about multiplying the effect of a physician’s skill and training to the largest part of the patient population possible.
“I don’t need to spend 45 minutes educating a patient with psoriasis if the PA is able to do the education and assist in treatment,” he said. “What’s troubling is the dermatologist with satellite offices where the doctor never visits the location or sees any of the patients. There’s nothing illegal about it, but it’s not to the Academy standard of care. It’s hard to find someone who will back them up on that.” [pagebreak]
Standardizing education, properly training
The efficient system in Dr. Pariser’s practice came only after years of considering and refining the education and training of their employed non-physician clinicians. At present, he said, each new hire undergoes a minimum six months of training before approaching anything like a normal day seeing patients. Intensive, thorough training is needed, he said, because most PAs and NPs, despite recent growth in educational offerings, do not undergo derm-specific training during their time in school.
“They need on-the-ground training. And in my practice, we train them for six months. For that time, they behave like a dermatology resident would. For the first three months, we have them shadow the docs, attend teaching conferences at the local medical school, observe some lab and surgical sessions, and then follow us,” Dr. Pariser said. “After three months, they get their own very limited schedule of follow-up patients, and we see every single patient with the PA no matter what.”
After another three months, Dr. Pariser said, he personally decides whether or not clinicians are ready for their own schedule. Afterward, they’re supervised according to Academy guidelines (see sidebar).
“I personally decide when each PA is ready, and that’s my own subjective decision,” Dr. Pariser said. “After that, they’re not in an office by themselves, they have a dermatologist on site who is available to see any patient.”
At present, standard education and curricula for dermatology-specific PA and NP training is still in the formative stage. The Lahey Clinic in Burlington, Mass., and the University of South Florida both offer dermatology NP residency programs. The Dermatology Nurses Association offers educational sessions and resources for the growing number of dermatology NPs. For PAs, the Society of Dermatology Physician Assistants offers a diplomate program and educational meetings. Both societies, as well as the American Academy of Dermatology, are actively working on expanding offerings and further developing the team-based care model in dermatology.
Dr. Jampel believes that as the number of non-physician clinicians in the specialty grows, the expansion and standardization of education can only be a good thing.
“To pretend that they’re going to go away doesn’t make sense. Standardizing education for PAs and NPs in dermatology, on the other hand, is a great idea,” Dr. Jampel said. “We have our education, and our boards, and our journals, and our CME programs. We should work to expand those opportunities that allow them better training and education.” [pagebreak]
Training the competition?
One of the common complaints from those leery of expanding the care team is the idea that a dermatologist bringing in a PA or NP is essentially training his or her future competition. This idea can be especially pronounced in areas of the country where PAs or NPs are allowed greater autonomy under the state’s medical regulations. NPs have significant independence in most states, and PAs, while not allowed autonomous practice, are the beneficiaries of loose supervisory laws in many states. The worry, according to Aldredge, is that a dermatologist will spend the time and resources training a PA or NP in dermatology, only to see them leave for more money or more autonomy across town. A restrictive covenant or non-compete clause, according to Dr. Pariser, can help alleviate much of that anxiety.
“We have a non-compete for our PAs, just as we do for our physicians,” Dr. Pariser said.
While the applicable laws vary by state, Dr. Davey said, physicians are more or less able to include language in employment contracts that preclude a PA or NP from leaving the practice for a higher-paying or more independent practice situation in a defined geographical area surrounding the dermatologist’s practice.
In the near term, Borglum argued, competition is less of a problem for most dermatology practices than their wait times. Indeed, he’s done the math to figure out how many new providers an area can absorb before the current providers face a shortage of patients.
“If you have a solo physician in a small town and they’re booked two weeks in advance most of the time, if a second physician moves into the town, some patients will go there,” Borglum said. “Roughly, you now have two physicians in town with a one-week wait. Both are full, patients are still having to wait, but there’s no real negative impact on that first practice. When you look at a community, for every two weeks wait, there’s room for another provider. It won’t balance out quite that evenly because of various preferences and prejudices, but mathematically, that’s the way it works out.”
One fact often forgotten by physicians anxious about potentially training their competition, according to Aldredge, is that PAs and NPs, just like dermatologists, crave stability and a healthy work environment. In short, she said, most don’t actually want to leave in the first place. [pagebreak]
“Leaving does happen. But the majority of PAs and NPs want to work with a provider they’re comfortable with. It’s not easy, or desirable, to move from practice to practice,” she said. “They look for a good setting with camaraderie, a staff that gets along well, and a measure of autonomy to practice to the level they feel comfortable. But they want to have a supervising dermatologist to work with for complications or complex cases. The ACA has sent a message that they want us to work to the full extent of our licensure.”
At present, over 40 percent of all dermatology practices employ a PA or NP (see sidebar). Physicians coming out of residency have increasingly interacted with PAs and NPs at some point during their training. The demographics of the specialty, according to Aldredge, are already changing.
“As new dermatologists come on board, who are younger and have had more exposure to PAs and NPs, I think the old-school thought that this is about competition will be less of a concern. They’ll see that it frees up dermatologists for more of the activities they value, whether it’s surgery or something like more time with their families,” Aldredge said. “The whole mentality is changing. There’s no way that we can meet the dermatology needs of the general public without engaging PAs and NPs, but there need to be clear guidelines from all the professional societies.”
Dr. Pariser agreed, saying that with proper training, non-physician clinicians can prove invaluable in providing dermatologic care to a practice’s patients in a more efficient manner that increases patient satisfaction.
“If the PAs are properly trained and properly supervised, they can do medical dermatology to some degree. The trick is to teach them to recognize what they don’t know and let them appreciate that they aren’t going to be as capable at diagnosing medical conditions. Their value isn’t in diagnosing, but in managing patients once diagnoses have been made,” he said. “PAs and NPs have become a fact of life in dermatology, and it’s vital to fold these people into our practice to play the right role in the future of our specialty.” [pagebreak]
Non-physician clinicians in dermatology
While the appropriate use of non-physician clinicians remains a controversial and evolving issue, what’s clear is that dermatologists are increasingly turning to PAs and NPs to provide help with the patient workload. The specialty has seen a marked increase in practices employing a non-physician clinician as the number of practices actively seeking to hire one or more has remained largely steady.
Source: 2007, 2009, and 2012 AAD Dermatology Practice Profile Surveys
AAD statement addresses supervision issues
The American Academy of Dermatology’s position statement on the practice of dermatology includes language on the appropriate supervision of non-physician clinicians and allied health professionals. The Board of Directors approved an amendment to the statement, which was originally crafted and approved in 2010, at its Aug. 3, 2013 meeting.
“Any procedure using any approved device that can alter or cause biologic change or damage, should be performed only by an appropriately trained physician or nonphysician under the direct, on-site supervision of an appropriately trained physician ”
“When practicing in a dermatological setting, non-dermatologist physicians and non-physician clinicians such as nurse practitioners and physician assistants, consistent with their appropriate training and experience should be directly supervised by an on-site dermatologist and have timely review of their medical records. For those rare instances, under extenuating circumstances, when a dermatologist is not available on site, there should be written protocols outlining how a patient is to be seen by a non-physician clinician ”
“Licensed allied health professionals, including but not limited to registered nurses and licensed practical nurses, when practicing in a dermatological setting, should only provide care after a patient receives an initial evaluation, diagnosis, and treatment plan from a dermatologist. Allied health professionals should be directly supervised by an on-site dermatologist when providing care or performing specific procedures/techniques.”
For the full statement, go to www.aad.org/forms/policies/Uploads/PS/PS-Practice%20of%20Dermatology%20Protecting%20and%20Preserving.pdf.