It may seem unusual for an employee to express a desire for more work. Yet a number of PAs in dermatology—as well as those in other areas of practice—seem to have just such a concern. In online forums, at conferences, and in general conversations, a proportion of PAs suggest that they could boost their productivity if only their employers would support it. At the same time, some physicians (hopefully a very small number) may feel that a PA is not meeting expectations for productivity. A mis-match in expected and actual productivity can stem from any of a number of factors, not the least of which can be simple miscommunication about the PA's role in the practice. The solution to productivity is open communication and the establishment of practice policies and incentives that are mutually beneficial to the PA, the practice, and, of course, the patients they serve.

Strategy 1: Assign a medical assistant/nurse to the PA.
The single most effective way to improve a PA's productivity is to assign a medical assistant or nurse to work exclusively with the PA. Some PAs (myself among them) have two MAs assigned to them, while the most prolific may have three. Some practices hesitate to assign an MA or nurse to the PA because they immediately identify a practice expense without recognizing the bottom-line benefit.

Consider this scenario. Suppose the MA receives $10 per hour to room patients, take histories/complete intake, help set up for procedures, retrieve samples, etc. This assistance can easily shave three minutes off of each patient encounter for the PA. If the PA sees just 20 patients a day, then the addition of an MA can add 60 minutes to the PA's day. In those 60 minutes, a PA should be able to see at least four more patients. At a collection rate of $85/patient (a low estimate) that would result in the PA generating an extra $340 per day—all for a cost of only $80 for the MA. Extrapolate those figures over the year, and the addition of a MA at $20,000 can result in your PA collecting an extra $81,600—four times your original investment in the MA! Try to get those percentages in the stock market right now!

The figures used above are probably low, so the reality is that providing your PA with an MA can provide an even greater benefit. Consider, too, the irrationality of paying a PA's salary, then forcing that professional to chase labwork, prep exam rooms, etc.

One essential element for success is that the MA be commissioned specifically to work with the PA. Ideally, the same MA or MAs will work with the PA consistently, so that the parties can learn to work well together and the MA can begin to anticipate the PA's needs. If the PA simply gets to borrow any "floating" MA when—and if—available, then there may be times the PA practices alone, thus hindering productivity. Or the floating MA may not feel "invested" in helping the PA work efficiently.

In addition to the direct financial benefits associated with assigning an MA(s) to the PA, it also sends an important message to patients and staff. Patients (particularly those who have never been seen by the PA) who consistently see the PA bringing patients back from the waiting room, doing their own surgical preps, and otherwise performing the duties of an MA may think of the PA as a lower-level assistant rather than as an advanced practitioner. As such, these patients may be reluctant to ever utilize the services of the PA in the future.

The PA should have some degree of involvement in the hiring and review process for any employee that works with or for him/her. The PA's involvement in selection of an MA reinforces that the MA will be working for the PA and helps ensure a good personality match. Of note, the screening process should include questions regarding the MA's knowledge of PAs. If the MA is unfamiliar with the role of PAs or seems to have an unfavorable view of PAs, this is obviously a concern.

Strategy 2: Provide proper financial incentive.
There are multiple methods for structuring a compensation package for the PA, the most common of which is for the PA to receive a percentage of collections or billings over a base pay. Regardless of the specifics of the plan structure it must be fair, explainable, and attainable (and not just barely). Explainable means that you must have a rationale for setting the threshold. It is reasonable to set a threshold at the PA's total direct cost to the practice (base salary for the PA and any assigned staff plus other direct expenses that would go away if the PA were no longer employed there). According to responses to the most recent salary survey by the Society of Dermatology Physician Assistants, this threshold on average to start receiving a bonus is $169,300. It is not reasonable to choose a threshold figure because it "sounds good" or is the figure used by a colleague. A commonly used and fair percentage of collections over this threshold is 20 percent to the PA, and the practice/physician keeps the remaining 80 percent majority.

So how should a practice set the PA's base pay? National and local trends and averages can offer some guidance but should not be the sole determinant of base pay, which must be determined on a case-by-case basis. Ultimately you and/or the practice decision makers must thoughtfully consider the question: What is this PA worth to me/us? How will he or she contribute financially to the practice and, as important, what intangible benefits will he/she bring? What are you willing to pay for these contributions?

Although most PAs are immensely profitable, your number one priority is improving patient access to care. So if your PA increases access to care, either by directly offering appointments, lightening up your schedule, or allowing you more time with complicated patients, he or she is already worth his/her weight in gold (which in the current economy is saying a lot!). If the practice stress level drops and patients feel more welcome and at ease, this can translate to improved word-of-mouth promotion.

If you're getting a "deal" on your PA, then he or she won't be your PA for long. It's easy for another physician to make a more attractive offer that your under-payed employee will surely entertain. Also, eliminate the mindset of paying a PA rates that are appropriate for physician residents. This is an uncommon practice based on the logic that there may be parallels in the practice level of the PA and resident. Not only is this logic incorrect, the rate also significantly underpays the PA over the long-term—unless, of course, the PA's salary will triple or quadruple in three years, as the resident's would.

It's impossible to overstate the need to openly and directly discuss expectations with the PA when establishing a compensation package. The PA must be aware of both the tangible and intangible benefits you seek to reap from their service and determine whether or not he or she can meet your goals. And while everyone cares about financial remuneration, it's important to remember that the PA may be looking for certain intangibles, too. You may be able to offer scheduling flexibility or other benefits that another practice cannot, even if your financial package is lower.

Strategy 3: Build it and they will come.
It seems logical to slowly transition the PA into a practice: Begin by offering services on one or two days and then add additional days as demand grows. Yet, the reality is that this may be one of the slowest ways to integrate a PA and generate demand for services. A far more successful approach is to introduce the PA at a full schedule, whatever that might be. Of course this is dependant on the PA's skill, training, and comfort level. In fact, the full "infrastructure" for the PA should be in place: support staff, exam rooms, supplies, etc. on day one. Patients and staff will find it easier to make appointments with the PA if there are more options than just one or two days a week.

It then becomes incumbent on staff to properly schedule patients for the PA. That starts with proper training on the skills and services of the PA and techniques for explaining the role of the PA to patients. The PA, supported by the practice physicians, plays an integral part in this training.

Of course, the success of the PA will depend on more than the staff's ability to "sell" him or her. External and internal marketing are important. Your website should include information about the PA. Consider running an announcement in the local paper. Encourage your PA go out in the community to build a referral network—particularly from general practice PAs and NPs. I lectured to a local NP dinner group several times on dermatologic issues and quickly found patients coming to me that were sent by attendees.

Avoid the temptation to have the PA always assist you. Certainly the PA should shadow you initially to learn your treatment style, become acclimated with the practice, and meet patients. The duration of this shadow period depends on your preferences and the PA's experience. It could be weeks or months depending on the parties involved. During that time period, you may find that the PA helps you to see patients more quickly and efficiently. You may get out of the office a bit earlier or feel less stressed at the end of the day. As such, you may be tempted to maintain the current arrangement indefinitely.

But if you keep the PA working directly with you, then you can't maximize profitability and increased patient access to care. After all, a well-trained nurse can provide similar side-by-side assistance at a lower salary. Furthermore, when the PA is constantly seen working alongside the physician, it sends the wrong message to staff and patients, who may come to view the PA as only a practitioner in training rather than as an autonomous advanced care provider.

The Ultimate Intangible
Salary matters. Perks and benefits matter. But in the end, the ultimate determination of a PA's productivity may depend on whether or not he or she likes you! In the end, they're working for you and your practice, so they better think you're worth it. This doesn't mean you must become best friends, but you must have a mutually respectful, cooperative, and communicative relationship. More importantly, the PA must feel that you care about him/her professionally and that you are invested in his/her success. Do you treat the PA like a valued colleague or as another employee? Are you willing to teach the PA and open to learning from him/her?

It can benefit the relationship tremendously if you take a personal interest (call the PA to check in when they have a medical or family emergency) and pat the PA on the back when they do a good job. Recognition of an accomplishment, even every few months, will be greatly appreciated. It lets the PA know that you are aware of his/her contributions.

The physician/PA relationship is unlike any other relationship in the office. It really is a partnership that depends on mutual trust, respect, and communication. A relationship built on the right foundations—both in terms of personal interactions and practical matters—will become longstanding cornerstone of your practice and care to the community.