Letter to the Editor

Dear Editor,

I read with great interest the recently published article by Ms. Barras et al, “Patient awareness of differences in health care provider training,” from the March 2023 issue.1 I share the authors’ passion for educating others regarding the important differences in training standards of dermatology professionals, and have previously addressed this subject in Practical Dermatology.2 I am writing to share some errors and omissions I observed in the piece,1 so that it may be improved.

The authors’ stated purpose was to assess public awareness of how training requirements differ between clinician types.1 For unstated reasons, the average hours of clinical dermatology experience completed by dermatologists during residency (6,917 hours) was not incorporated into their methods.2,3 Instead, the authors claim without evidence that dermatologists complete 12,000 to 16,000 hours of clinical training.1 There is no primary data source to support this statement, as the Association of American Medical Colleges has no minimum hour requirement for medical students to graduate.2,4 The only peer-reviewed study I’m aware of that evaluated clinical hours accrued by medical students showed that they actually tend to overestimate their patient care experience in medical school.5

Barras et al correctly state that physician assistants (PAs) must complete a minimum of 2,000 hours of clinical experience before graduation.1 However, they omit that the average new graduate PA actually has 5,250 hours of medical experience upon initial certification.2,6 There is also no mention of the dermatology-specific qualifications available to PAs, ie, the Diplomate Fellowship (a comprehensive introductory course taught by dermatologists and senior PAs), and the Certificate of Added Qualifications in Dermatology, which requires 4,000 hours of dermatologist-supervised experience and passing a written examination.2,7 The authors incorrectly state that nurse practitioners (NPs) must complete 1,500 hours of supervised patient care to enter their profession1; the correct minimum hours of patient care to become certified by the American Academy of NPs is 500 hours.8 There is no mention of the dermatology certified NP credential available to these professionals, which requires 3,000 hours of clinical experience in dermatology and passing a standardized written test.2,9

These factors might have affected the accuracy of the results reported by Barras et al, as they are directly related to the survey instrument.1 Unfortunately the article offers no detailed methods section delineating what responses were considered correct, thus readers cannot evaluate for such effects. More information on methodology would improve the transparency of this work.

Barras et al cite no evidence to support their assertion that PA-delivered care results in different patient outcomes.1 Instead, two studies are referenced which the authors claim investigated the diagnostic accuracy of dermatology NPs and PAs.10,11 One of these evaluated four NPs and one PA;10 the other makes no mention of either NPs or PAs.11 There are over 4,580 dermatology PAs in the US,12 and this sample size of one might not be representative of the profession’s clinical aptitudes overall.

It appears that Barras et al1 erroneously combined the findings of Matsumoto et al11 with those of a different article sharing some co-authors, which suggested PAs have subpar diagnostic accuracy for melanoma based on number needed to biopsy (NNB).13 NNB has numerous limitations and is a poor proxy for diagnostic accuracy, which Dr. Marchetti and I have previously described in detail.14 World experts have criticized the quoted study in particular because it failed to control for confounding variables, including melanoma’s greatest risk factor—personal history of the malignancy.13,15 There is only one study I’m aware of that completely controlled for confounding variables while evaluating melanoma diagnostic accuracy of dermatologists alongside PAs. The results showed that PAs were 15.9% more sensitive than dermatologists for detection of melanoma, with a tradeoff of being less specific.16 This study was conducted at the same institution as the aforementioned article,13 and both were co-authored by the same senior researcher.

The survey instrument used by Barras et al initially abbreviates medical doctors as MDs, but in a subsequent question uses this same abbreviation for dermatologists.1 The American Medical Association (AMA) Manual of Style recommends that acronyms refer to one term only, and remain consistent throughout a written work.17 Deviating from AMA style in this way is confusing to readers and survey participants, as clearly not all MDs are dermatologists. The distinction is critical because many MDs receive no clinical dermatology training, for example it is possible for internists to complete all 8 years of medical school and residency without ever performing an observed skin examination.18 This unorthodox use of the MD acronym in the survey instrument may have caused some knowledgeable survey participants’ responses to be coded as incorrect, and vice-versa.

Barras et al make no mention of institutional review board approval,1 which is generally expected for scientific research involving human subjects. This omission raises questions about the study’s adherence to basic ethical principles, eg, informed participant consent.19,20 There is also no response rate disclosed, which is typically reported in survey-based manuscripts.

For an investigation into the accuracy of the public’s knowledge, this article by Barras et al contains a concerning number of critical errors and omissions.1 As a peer who appreciates their earnest intentions and dedication to this important topic, I recommend they revise this work and exercise greater attention to detail in a new iteration. A free mentorship service now exists for aspiring dermatology researchers: the Collaboratory for Interprofessional Authorship in Dermatology (CIAD). Our team of mentoring authors have been published in every major American dermatology journal, and we would happily assist these fellow scholars to produce more refined manuscripts in the future.

Very respectfully,

Peter A. Young, PA-C

Dermatology PA of the Year, 2022

Communications Committee, Society of Dermatology PAs

1. Barras A, Loehr C, Trettin K, Creel J, Haas C. Patient awareness of differences in health care provider training. Practical Dermatology. Published March 2023. Accessed April 21, 2023.https://practicaldermatology.com/articles/2023-mar/patient-awareness-of-differences-in-health-care-provider-training

2. Young PA, Davis KE, Bae GH. The elephant in the exam room: emerging dermatology qualifications of different types and stripes. Practical Dermatology. Published March 2023. Accessed April 21, 2023. https://practicaldermatology.com/articles/2022-mar/the-elephant-in-the-exam-room-emerging-dermatology-qualifications-of-different-stripes-and-types

3. American Medical Association, Fellowship and Residency Electronic Interactive Database Access. Published online 2021. Accessed April 21, 2023. https://freida.ama-assn.org/specialty/dermatology

4. American Medical Association, Fellowship and Residency Electronic Interactive Database Access. Accessed April 21, 2023. Available online at https://freida.ama-assn.org/

5. Casey C, Senapati S, White CB, Gruppen LD, Hammoud MM. Medical students self-reported work hours: perception versus reality. Am J Obstet Gynecol. 2005;193(5):1780-1784. doi:10.1016/j.ajog.2005.08.017

6. Physician Assistant Education Association, By the Numbers: Program Report 35: Data from the 2019 Program Survey, Washington, DC: PAEA; 2020. doi: 10.17538/PR35.2020

7. National Commission for Certification of Physician Assistants. Published online September 15, 2020; modified November 29, 2021. Accessed April 24, 2023. www.nccpa.net/specialty-certificates/#dermatology

8. American Academy of Nurse Practitioners. Statement on NP students and direct clinical hours. Published March 23, 2020. Accessed April 21, 2023. https://www.aanpcert.org/newsitem?id=105

9. Dermatology Nurse Practitioner Certification Board. Published online August, 2019. Accessed April 24, 2023. www.dnpcb.org/Eligibility

10. Nault A, Zhang C, Kim K, Saha S, Bennett DD, Xu YG. Biopsy use in skin cancer diagnosis: comparing dermatology physicians and advanced practice professionals. JAMA Dermatol. 2015;151(8):899-902. doi:10.1001/jamadermatol.2015.0173

11. Matsumoto M, Secrest A, Anderson A, et al. Estimating the cost of skin cancer detection by dermatology providers in a large health care system. J Am Acad Dermatol. 2018;78(4):701-709.e1. doi:10.1016/j.jaad.2017.11.033

12. Griffith CF, Young PA, Hooker RS, Puckett K, Kozikowski A. Characteristics of physician associates/assistants in dermatology. Arch Dermatol Res. 2023;10.1007/s00403-023-02593-7. doi:10.1007/s00403-023-02593-7

13. Anderson AM, Matsumoto M, Saul MI, Secrest AM, Ferris LK. Accuracy of skin cancer diagnosis by physician assistants compared with dermatologists in a large health care system. JAMA Dermatol. 2018;154(5):569-573. doi:10.1001/jamadermatol.2018.0212

14. Young PA, Marchetti MA. On the validity of biopsy cost analysis pertaining to nonphysician clinicians. Dermatol Online J. 2022;28(2):10.5070/D328257410. Published 2022 Mar 15. doi:10.5070/D328257410

15. Marghoob AA, Marchetti MA, Dusza SW. Performance of dermatology physician sssistants. JAMA Dermatol. 2018;154(10):1229. doi:10.1001/jamadermatol.2018.2693

16. Ferris LK, Harkes JA, Gilbert B, et al. Computer-aided classification of melanocytic lesions using dermoscopic images. J Am Acad Dermatol. 2015;73(5):769-76. doi:10.1016/j.jaad.2015.07.028

17. Gregoline B. Abbreviations. In: Christiansen S, Iverson C, Flanagin A, et al. AMA Manual of Style: A Guide for Authors and Editors. 11th ed. Oxford University Press; 2020:555-640.

18. McCleskey PE. Commentary: To improve melanoma detection, help teach our colleagues. J Am Acad Dermatol. 2015;73(6):966-967. doi:10.1016/j.jaad.2015.09.035

19. Barrow JM, Brannan GD, Khandhar PB. Research Ethics. In: StatPearls. Treasure Island (FL): StatPearls Publishing; September 18, 2022.

20. US Department of Health and Human Services, Office for Human Research Protections. The Belmont Report: Ethical Principles and Guidelines for the Protection of Human Subjects of Research. Published April 18, 1979. Accessed April 22, 2023. https://www.hhs.gov/ohrp/regulations-and-policy/belmont-report/read-the-belmont-report/index.html