PracticalDermatology

Mid-level providers, such as nurse practitioners (NP) and physician assistants (PA), are becoming increasingly prevalent in the health care field; however, little is known about what patients understand about the level of education and training requirements for NPs and PAs. Board-certified dermatologists are allopathic (MD) or osteopathic (DO) physicians who diagnose and treat more than 3,000 different diseases and conditions in patients of all ages, from newborn to the elderly.

A board-certified dermatologist undergoes a minimum of 8 years of medical education and training, which includes 4 years of medical school, 1 year of internship, and 3 years of residency training. During this time, they complete 12,000 to 16,000 hours of direct patient care before they can practice independently. Medical students who attend schools accredited by the Liaison Committee on Medical Education (LCME) are required to care for patients in both inpatient and outpatient settings in the following clinical rotations: family medicine, internal medicine, obstetrics and gynecology, pediatrics, psychiatry, and surgery.^1,2 Students at colleges of osteopathic medicine undergo similar medical education and training, with additional training in osteopathic medicine.³

PAs complete a 26-month program followed by 2,000 hours of clinical rotations that emphasize primary care in ambulatory clinics, outpatient physician offices, and acute or long-term care facilities.⁴ Rotations could also include family medicine, internal medicine, obstetrics and gynecology, pediatrics, general surgery, emergency medicine, and psychiatry.⁵

NPs must earn a Bachelor of Science Nursing degree (BSN), which traditionally takes 4 years. Many then go on to practice as a registered nurse before entering a nurse practitioner-focused graduate master’s or doctoral nursing program with completion of more than 1500 hours of supervised, hands-on clinical care varying between 2 and 4 years, respectively. PAs and NPs are not required to complete a residency program. Those who elect to practice in dermatology are often trained in the clinic by dermatologists unless they complete additional training in dermatology of which there are very few programs. As such, there are no uniform training requirements in such a setting. Training requirements, including length of time, vary from practice to practice.⁶

Studies demonstrate differences in patient outcomes and scopes of practice. New research shows that dermatologists are more effective than PAs in diagnosing skin cancer.^1,7,8 Researchers examined data from 33,647 skin cancer screenings in 20, 270 patients at University of Pittsburgh Medical Center-affiliated offices from January 2011 through December 2015. It was found that, compared to dermatologists, PAs needed to perform more biopsies to detect melanoma and nonmelanoma skin cancer. To diagnose 1 case of melanoma, the number needed to biopsy was 39.4 for PAs and 25.4 for dermatologists. To diagnose 1 case of skin cancer, the number needed to biopsy was 3.9 for PAs and 3.3 for dermatologists.⁷ A 2015 study from the University of Wisconsin comparing malignancy rate of biopsies performed by dermatologists versus non-physicians suggests that non-physicians perform more biopsies, thus increasing patient morbidity and the cost of care.⁸

The literature to date suggests public support of physician-led, team-based care. As members of the health care delivery system, it is a common goal of physicians and mid-level providers to ensure that patients receive the highest quality care in a cost-effective manner. According to four nationwide surveys, 84% of respondents prefer a physician to have primary responsibility for diagnosing and managing their health care and 91% of respondents said that a physician’s years of medical education and training are vital to optimal patient care, especially in the event of a complication or medical emergency.⁹ Additionally, nationwide surveys confirm increasing patient confusion regarding the many types of health care providers, including physicians, nurses, physician assistants, technicians, and other medical personnel.

Our goal, using a survey assessment, was to assess patient awareness of the differing training requirements amongst dermatology providers. Further, we are investigating different demographic factors that could be associated with the levels of such awareness. Finally, we are inquiring as to our patients’ opinions of each provider type, with regards to perceived level of expertise and quality of care delivered.

WHO CAN TELL THE DIFFERENCE?

A multifaceted survey was distributed to dermatology clinics in New Orleans, LA and surrounding areas via electronic or printed formats. The survey investigated patients’ perception of the amount of specialty training in dermatology, years of medical education plus clinical training, as well as their personal opinions and experiences regarding each type of provider. Demographics in Table 1 include age, race, and level of education. To assess confounding factors, patients were instructed to include past experiences, such as if they have received post-graduate training as a PA, NP, or MD, if they have a spouse or close relative in any of these professions, or if they have worked in the health care field; this is shown in Table 2.

The study accumulated more than 700 surveys as seen in Table 3, with 442 qualifying for the primary study population based on exclusion criteria. Among the participants, 99% reported that they assumed MDs are required to have specialty training in dermatology, spend time treating dermatology patients, and are required to pass a standardized written exam in dermatology. Approximately 75% of patients assumed the same for NPs and PAs. Results also demonstrated that 50% of patients underestimated the years of specialty training in dermatology for MDs, while 76% and 73% overestimated the years of specialty training for PAs and NPs, respectively. Board-certified dermatologists spend more than 4000 total clinical hours, while NPs and PAs spend 1000 and 2000 total clinical hours, respectively. Regarding dermatology focused clinical hours, MDs train more than 4000 hours versus NPs and PAs who spend less than 40 dermatology clinical hours. Also, 49% of respondents correctly identified the number of hours MD spend during their dermatology training.

PATIENT PERCEPTIONS OF CLINICIANS

The results of our survey found that patients perceived board-certified dermatologists to be the field’s leading source of expertise and health care delivery, but there was a lack of awareness regarding accurate comparison of the years of training and number of clinical hours of NPs and PAs to MDs. This is especially evident in the number of years and clinical hours spent in dermatology specialty training, as seen in Chart 1. According to our results, patients assumed that PAs and NPs are required to complete specialty training. In addition, the underestimation that was reported for MDs’ training further signifies patients’ lack of awareness of the training that each type of provider undergoes. This lack of awareness may be influenced by various geographic, socioeconomic, educational level, and/or intrinsic factors (sex/race).

Chart 1: Patient Accuracy/Correctness About Provider Training Requirements

Chart 2 quantifies survey respondents’ opinions and beliefs regarding NP and PA providers compared to board-certified dermatologists. Most disagreed that NPs/PAs had the same level of expertise, provided the same level of care, and had roles interchangeable to MDs. Most patients believed that the NP/PA should be required to have supervision by a board-certified dermatologist and that the NP/PA should not be allowed to practice dermatology independently. If given the choice, most responded that they would prefer to be treated by a board-certified dermatologist rather than NP/PA.

Chart 2: Patient Opinions of NP/PA Compared to MD

COMPARE AND COUNSEL

The aim of our study was to identify knowledge gaps of the public about health care provider types and their respective credentialing and training. Most of the patient respondents considered board-certified dermatologists to have more educational requirements and training hours than mid-level providers, although patients lacked consensus regarding the accurate number of specialty training years and hours that are required for each provider. Patients preferred board-certified dermatologists over mid-level providers; however, most patients did not research which level of provider was taking care of them. As mid-level providers are increasingly being integrated into the healthcare system overall and in specialty fields such as dermatology, it is important to make patients aware of the differences in healthcare provider training.

To our knowledge, this is the first study of its kind, as we could find little-to-no evidence of such data in the literature. As such, our findings could prove useful in a multitude of ways, and further studies should be conducted to help stratify these original findings.

The authors have no relevant financial or non-financial relationships to disclose.

1. Board of Directors. Position statement on the practice of dermatology. Published August 18, 2018. Accessed June 24, 2022. https://pdf4pro.com/view/position-statement-on-the-practice-of-dermatology-15df6c.html.

2. Liaison Committee on Medical Education. Standards, publications, & notification forms. LCME. Published July 19, 2016. Accessed June 24, 2022. https://lcme.org/publications/.

3. American Association of Colleges of Osteopathic Medicine. Osteopathic Medical College Information Book: Class entering 2018-2019. AACOM. Published 2018. Accessed June 24, 2022. https://www.aacom.org/docs/default-source/cib/aacom-cib-2019-all-web.pdf.

4. American Academy of PAs. What is a PA? AAPA. Published June 17, 2022. Accessed June 24, 2022. https://www.aapa.org/what-is-a-pa/#tabs-2-how-are-pas-educated-and-trained.

5. American Academy of PAs. PA Education Preparation for Excellence--AAPA. Published December 2019. Accessed June 24, 2022. https://www.aapa.org/wp-content/uploads/2017/01/Issue_brief_PA_Education_1216.pdf.

6. The Society of Dermatology Physician Assistants. Hire a Derm PA Career Center. Published 2022. Accessed June 24, 2022. https://hireadermpa.com/.

7. 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

8. 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

9. Kenneth J. Tomecki. Advocacy. American Academy of Dermatology. Published May 3, 2021. Accessed June 27, 2022. https://www.aad.org/advocacy.