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The Society of Dermatology Physician Assistants (SDPA) would like to offer our view of the issues described in the recent feature article, “Guideposts for the Future of Dermatology,” by Neal Bhatia, MD and a few of his colleagues. (July 2019, available here) Dr. Bhatia is correct: The specialty of medical dermatology is under fire. SDPA members face the same difficulties in the clinic, and we share many of the same concerns that dermatologists have.

Physician assistants (PAs) are committed to collaborative team practice and work only in collaboration with physicians in every state in the union. PAs are bound by law to limit scope of practice to that of the physician with whom they work. No PA is legally able to work in a manner that is not agreed to by the collaborating physician. Like physicians, PAs train in general medicine, pass board exams, do CME, do MOC, and recertify every 10 years. PAs do not have the opportuniy for residencies in most cases. Those PA residencies that do exist are highly competitive and very expensive, as there is no government funding.

It is true that PAs can change specialties, but we are then bound to limit scope of practice to the new specialty and to undertake the expected learning curve to become proficient in that new area. Proficiency is obtained by an apprenticeship model analgous to that upon which medical residencies are built. An expert physician offers knowledge and experience to the PA who is seeking to learn. Together, they care for the patients who need help. The amount of oversight and help decreases over time as the PA’s proficiency rises to the point where the expert feels comfortable that the patients are safe in the care of the now well-trained PA. All medical professionals are lifelong learners. There will always be situations which call for ongoing collaboration, whether that is between a physician and a PA or between specialists and subspecialists. No one person has all the answers, and we must all work together for the benefit of the patients in our care.

Physician assistants are providers and we are proud to be PAs. We are not physicians and we respect the knowledge and expertise of the physicians with whom we work. We do not condone PAs with doctorate degrees using the title of doctor in the clinic. We agree that it is confusing to the patients. Additionally, there are state laws that prohibit PAs from representing themselves in any way that might mislead patients. Physicians and PAs have common ground in the way we are misrepresented in the media and handled by middle management of healthcare systems. Physicians should be proud of their hard-earned title and emphasize and defend that title. However, building up physicians and specialists in the eyes of the public should not demean the role of the PA on the patient care team. Dermatologists and PAs should work together to educate the public regarding the importance of seeing a properly trained specialist for the care of their skin issues. For many patients, that person may be a PA in the office of a dermatologist who oversaw his/her training and education and feels that patients are in good hands. To fail to recognize and acknowledge this important partnership does a disservice to those dermatologists who rely on PAs to be able to meet the needs of their community. Data provided by the AAD show that 46 percent of dermatologists employ a PA or nurse practitioner (NP) as of 2014 and that number is likely greater now. Doris Day, MD has a point when she notes that many dermatologists employ PAs or NPs without proper training or oversight. This is dangerous for the patient, the PA, and the dermatologist and is strongly discouraged by the SDPA.

Dr. Gold makes the point that dermatologists have made it difficult for PAs to attend educational meetings such as those put on by the AAD. As a result, long ago SDPA developed two excellent CME meetings per year intended for PAs and attended by NPs as well. These are well run meetings with expert speakers and medical directors, such as Ted Rosen, MD. Most dermatology PAs no longer attend the AAD meetings because the education specific to the PA profession is now available at events designed specifically for the Derm PA. If you employ PAs or NPs, you should encourage them to attend our meetings. Even better, consider speaking at one of our meetings. The SDPA is always looking for quality speakers. Every one of us has a story of making a diagnosis missed by many others, including physicians in all specialties. Diagnoses don’t get missed only by PAs. Diagnoses get missed because we are all human and our patients are also human. We all can continue to learn, and sometimes fresh eyes are exactly what is needed. It was Sir William Osler who said, “We miss more by not seeing than we do by not knowing”.

Pharmaceutical companies do support SDPA members well, both in our CME meetings and in the clinic. You will be happy to know that going forward PAs will be included in the reporting according to the Sunshine Act. We agree that ongoing relationships with pharma can help to encourage research in the treatment of some of the most devastating diseases we face.

Representing ourselves to the public without the AAD happens only because the AAD has declined offers to collaborate. Recently SDPA created a coalition of groups concerned about access to quality dermatologic care called the Greater Access for Patients Partnership (GAPP). The AAD leadership did not respond to offers to join the coalition. A report commissioned by the GAPP coalition found that access to care can be increased by the use of PAs and NPs, by increasing the diagnostic confidence of primary care clinicians and by increasing use of telemedicine.

There are only so many dermatologists in the US, and there are more than enough patients who need care. The SDPA and our members are willing to collaborate on many issues that face us both in the clinic. We would like to work together on research, access to care, appropriate representation in the clinic, and to the public, dealing with insurance companies and corporate environments, and so much more. We have the same goal: quality patient care. We can do so much more together than we can apart. When you help us up the hill, you get farther up the hill as well.

—Submitted by the SDPA Board of Directors

Editor’s Note: The editorial staff appreciates comments from the SDPA. Keep an eye out for additional coverage of issues related to dermatologic practice and collaborative care.

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