Physician Assistants in Dermatology: A Look at the Ethical Considerations

Dr. Greenberg:
Welcome to DermConsult on ReachMD.  I'm Dr. Michael Greenberg.  And joining me to talk about the ethical use of physician assistants in dermatology practices is Dr. John Weiss, who’s the president and co-managing partner at Georgia Dermatology Partners.  Dr. Weiss, welcome to this program. 

Dr. Weiss:
Thanks, Michael.  It's great to be here.  I appreciate the opportunity to work with you on this. 

Dr. Greenberg:
I think it's a really interesting and important subject.  So just to start off, Dr. Weiss, can you give us a brief description of the physician assistant's role in dermatology practices and the services they're allowed to provide? 

Dr. Weiss:
Sure, it would be my pleasure.  We employ seven or eight advanced practice providers, one nurse practitioner, and the rest are physician assistants, or PAs for short, and in our practice, they have a role of primary patient care.  I think the key is excellent training, but we make sure all of our PAs and nurse practitioners are trained in dermatology by the managing partners of our practice.  They train for a minimum of three months up to six months, and we start them very slowly.  We also make sure that they run every patient by a physician until they are ready to practice somewhat independently. 

The other thing that's important is that they are able to access a physician at any time in our practice, and all of our physicians are board-certified dermatologists.  They see patients just like we do.  They start with basic issues, such as acne, psoriasis, and atopic dermatitis, and then expand.  The key is constant education and just knowing they have 100 percent access to keep them learning at all times.  We even have a dermatopathologist in our practice, and we have them sit with her, look at slides, and read slides, not that they learn all dermatopathology, but they get a feel for what it is and the importance of it in the practice. 

Dr. Greenberg:
Okay.  So what are the benefits of utilizing PAs in your practice? 

Dr. Weiss:
The biggest issue is for patients to have access to our practice.  The demand for dermatologic care is absolutely enormous, and there's no way that we could supply all of that demand for care with just dermatologists.  While that would be nice at times, it's just not possible, and so our PAs are truly extenders of our care.

Dr. Greenberg:
Okay.  Let's think back a little bit because I remember a past time when the derm literature was filled with editorials saying that only dermatologists should see every patient that came along.  But now we've got PAs doing that, and they're not even doctors, so how can you explain that paradigm shift, Dr. Weiss?  And has it really been for the benefit of our patients, or is it about making money? 

Dr. Weiss:
So I would say it is not just about making money.  It is honestly about quality of care.  The difference is that the general internist, family practitioner, or OB/GYN who is perhaps today trying to practice dermatology have CRY-ACs, which means to freeze lesions that they think are a case or subcase, are not fully trained in dermatology, whereas I would propose to you that the advanced practice providers in my practice are very well trained in dermatology and can function at the level of a third-year resident or better after years of practicing. So a lot of it has to do with training.  My PAs and nurse practitioners are far better trained in the nuances of dermatology than the average primary care physician. 

Dr. Greenberg:
For those just tuning in, you're listening to DermConsult on ReachMD.  I'm Dr. Michael Greenberg, and I'm speaking with Dr. John Weiss about the use of physician assistants in dermatology practice. 

So, Dr. Weiss, given everything we've discussed so far, what are some of the ethical questions that have been raised when it comes to PAs in the derm setting? 

Dr. Weiss:
So there are lots of ethical potholes in the use of advanced practice providers, PAs, and nurse practitioners in the dermatology setting.  I think they fall under at least two categories.  One would be medical and the practice of medicine; the other would be monetary.  Again, it does come down to making sure they're well-trained, but it's also making sure that if a PA, nurse practitioner, or other advanced practice provider is seeing a dermatology patient or Medicare patient, and they are not truly practicing incident-to care, that the physicians are not managing the care of the patient and that you are not billing the care as incident-to the physician. So that is one very important ethical standard by which we practice.  We bill all of our PA and nurse practitioner charges as they are being provided by them on their own Medicare numbers.   That to me is essential.  The other is to make sure that they are not practicing outside of the scope of which they are trained.  We do not use PAs in our practice to do Mohs surgery or to do closures for Mohs surgery, and I think it's absolutely key that everyone practices in their lane, and that's a standard to keep it ethical in that regard. 

Dr. Greenberg:
So what are some of the strategies that we can use in collaborating with our advanced practice providers to ensure we're providing quality and ethical care? 

Dr. Weiss:
I think communication is key.  Whenever I see an article in an online newsletter or in a journal, I think sending it to them to let them know it's important in case they didn't see it is absolutely key.  I think continuing and monitoring education is very important; monitoring and advancing in their skillsets and knowledge, while constantly and continuing to grow throughout their careers.  We have some PAs who have now been with us 15 years, and they are some of our best teachers of the other PAs, and they often teach me something.  If they see a case and how they can work it up, it can be a fantastic experience for everybody. 

Dr. Greenberg:
I know.  Throughout my long career, I have learned more from physician assistants and nurses sometimes than I've learned from physicians.  As a matter of fact, if I go way back, it was a nurse in a dermatologist's office who told me the right way of taking verruca off, which I hadn't learned in my residency yet.  

Dr. Weiss:
Right, absolutely. 

Dr. Greenberg:
You know, Dr. Weiss, there's still some bigotry in our profession about PAs because they have PA and not MD, Doctor of Medicine, after their name.  Do you want to comment about that and how the letters after a name really don't matter? 

Dr. Weiss:
Well, I think that says it best.  The letters after a name don't matter.  Let's think back a couple dozen years to when there was the whole debate about MDs and DOs, Doctor of Osteopathic Medicine, in dermatology, and how DOs were not given a full fellow membership in the Academy. And what we saw over time is that some of our most valued, smartest, and politically active members are DOs.  Some of the members on our board are DOs.  And there is no difference in the quality of care or knowledge that those individuals have.  I would suggest that the same thing applies to PAs and advanced practice providers in general.  The letters after the name don't matter.  It's the drive of the individual to learn, to get better, to provide quality of care, and to be a part of the team of dermatology providers in a practice that serves to be outstanding. 

Dr. Greenberg:
Well this has been a great discussion looking at the utilization of PAs in dermatology practice.  I want to thank my guest, Dr. John Weiss, for sharing his brilliant insights on this important topic.  Dr. Weiss, it was great speaking with you today. 

Dr. Weiss:
Great to speak with you too, Michael.  Thank you very much. 

Dr. Greenberg:
For ReachMD, I'm Dr. Michael Greenberg.  To access this episode and others from the series, visit ReachMD.com/DermConsult where you can Be Part of the Knowledge.  We thank you for listening.