The Elephant In The Exam Room: Emerging Dermatology Qualifications of Different Stripes and Types

The qualifications of nurse practitioners (NPs) and physician assistants (PAs) in dermatology, and descriptive terms thereof, have become controversial. Office staff understanding of nonphysician clinician (NPC) credentials may be poor, as revealed in a 2021 study by Creadore et. al., which showed that receptionists at 18 percent of dermatology clinics describe NPCs as “dermatologists,” “doctors,” “physicians,” and “board-certified.”¹ Multiple factors likely contribute to general confusion regarding the qualifications of NPCs, particularly recent events that warrant discussion.

In 2019, an organization called The American Board of Dermatology Physician Assistants was formed but quickly disappeared from public discussions following opposition from the American Board of Dermatology and American Academy of Dermatology (AAD). That group has re-emerged with the new name National Board of Dermatology Physician Assistants (NBDPA), whose website states their inaugural cohort became “board-certified dermatology PAs” (a phrase they have trademarked) in October 2021.2 Of similar controversy, the American Academy of PAs resolved in 2021 to replace “assistant” with “associate” in their profession’s title, which the AAD opposes, believing it is a misrepresentation that will confuse patients.

The Dermatology Nurse Practitioner Certification Board offers a credential called the dermatology-certified nurse practitioner (DCNP),3 which patients may equate to a physician’s board certification in dermatology. Some doctoral-educated NPs introduce themselves to patients as “doctor,” which is legal in certain states. The hypothetical statement “Dr. Smith is board-certified in dermatology” could be considered accurate by some in reference to an NP, depending on geography.

These linguistic divisions between NPCs and dermatologists may lead to conflicting instructions given to staff, reducing their ability to convey consistent messaging to patients. As most dermatologists in group practices employ NPCs,4 a substantial portion of dermatology offices will likely face these and similar nomenclature-related challenges.

In anticipation of progressive NPC presence in the specialty during a prolonged dermatologist shortage, these controversies should prompt interprofessional dialogue and objective evaluation of relevant NPC qualifications. Standardized credentials for dermatology NPCs are becoming more widespread, such as the Diplomate Fellowship (an online course offered through the Society of Dermatology Physician Assistants (SDPA) which is taught by dermatologists, dermatopathologists, and PAs), and the aforementioned DCNP and NBDPA exams. The National Commission for Certification of Physician Assistants (NCCPA) also recently announced the planned release of a standardized written exam, the dermatology certificate of added qualifications (CAQ), which will launch in 2023.5 We have summarized the requirements for these in Table 1, to promote accuracy and transparency.

Applicants to NP programs must first be registered nurses (RNs), and commonly accrue one to two years of clinical nursing experience prior to graduate study.^6,7 After completing a master’s or doctorate in nursing practice and passing a certification examination of 175 questions, the RN becomes a nationally certified NP. After earning state licensure and accruing 3,000 clinical hours in dermatology within a three-year period (a small portion of which may also come from dermatology clinical rotations during NP school), the NP may then sit for the 175-question DCNP written exam.3

Before their graduate schooling, PAs must satisfy direct patient care experience requirements through volunteerism at health care facilities and employment as medical assistants, paramedics, nurses, and similar roles. The specific patient care requirements vary between PA programs, but the national mean among matriculants is 3,240 hours.8 Accredited PA programs must have a medical director who is a licensed physician,⁹ and PA students must complete a minimum of 2,000 hours in supervised clinical rotations with preceptors who are licensed NPs, PAs, and physicians.¹⁰ After graduation, they are eligible to sit for the 300-question Physician Assistant National Certification Exam, apply for state licensure, and seek employment. To sit for the NCCPA’s dermatology CAQ exam, which is 120 questions long, licensed PAs must complete 75 hours of dermatology-specific continuing medical education and 4,000 hours of dermatology employment.5 To sit for the NBDPA’s exam of 125 questions, PAs must be in good standing with their state medical board and have three years of employment experience with the same dermatologist.

Open communication between health disciplines is essential to facilitate transparent, well-defined, consistently phrased qualifications. Whether as their assistants or colleagues, NPCs will share an interwoven future with dermatologists, therefore preservation of respectful relations is paramount. The pursuit of dermatology-specific training by NPCs should be encouraged but represented unambiguously: patients should be explicitly notified of the license type and dermatology credentials for their clinician and told where to find reliable information about said relevant qualifications if curious. Clinicians should be familiar with these distinct certificates and discourage staff from implying they are the same.

The question of who may legitimately advertise themselves as board-certified and the nuances of acceptable alternative terms will probably be debated intensely for the foreseeable future. But if we professionals of varying backgrounds can agree to mutually support evolving educational standards and promote each other’s unique faculties, we can—and should—maintain our primary focus on what’s most important: safe and effective patient-centered care.

The authors are indebted to Evelyn Kobayashi and Robert Johnson for their excellent assistance as medical librarians; Angela Blood of the American Association of Medical Colleges for fact-checking; and the clinicians who suggested edits to the manuscript: Alan Rockoff, MD, FAAD; Ian Troesoyer, DNP; and three board-certified dermatologists who wish to remain anonymous.

1. Creadore A, Desai S, Li SJ, et al. Prevalence of Misrepresentation of Nonphysician Clinicians at Dermatology Clinics. Cureus. 2021;13(10):e18793. Published 2021 Oct 14. doi:10.7759/cureus.18793. PMID: 34804659

2. National Board of Dermatology Physician Assistants. Published online March, 2021. https://www.paboardcertification.org/ Accessed January 20, 2022.

3. Dermatology Nurse Practitioner Certification Board. Published online August, 2019. https://www.dnpcb.org/Eligibility Accessed November 30, 2021.

4. Ehrlich A, Kostecki J, Olkaba H. Trends in dermatology practices and the implications for the workforce. J Am Acad Dermatol. 2017;77(4):746-752. doi:10.1016/j.jaad.2017.06.030. PMID: 28784330

5. National Commission for Certification of Physician Assistants. Published online September 15, 2020; modified November 29, 2021. https://www.nccpa.net/specialty-certificates/#dermatology Accessed December 6, 2021.

6. Jividen S. Nurse Practitioner School Requirements - Admission & Prerequisites. Published online 2020. https://www.nursingprocess.org/nurse-practitioner-school-requirements.html Accessed February 8, 2022.

7. Top Masters in Healthcare. What Experience is Needed To Become a Nurse Practitioner? https://www.topmastersinhealthcare.com/faq/what-experience-is-needed-to-become-a-nurse-practitioner/ Accessed February 8, 2022.

8. 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

9. ARC-PA. Accreditation Standards for Physician Assistant Education, Fifth Edition. Published September, 2019. http://www.arc-pa.org/wp-content/uploads/2021/03/Standards-5th-Ed-March-2021.pdf Accessed January 10, 2022

10. American Academy of PAs. Published online March 27, 2018; modified November 17, 2021. https://www.aapa.org/what-is-a-pa/#accordion Accessed December 6, 2021

11. American Medical Association, Fellowship and Residency Electronic Interactive Database Access. Published online 2021. https://freida.ama-assn.org/specialty/dermatology Accessed February 8, 2022.

12. American Nurses Credentialing Center. Test content outline, family nurse practitioner board certification examination. Published online May 22, 2019. https://www.nursingworld.org/~48f9cc/globalassets/certification/certification-specialty-pages/resources/test-content-outlines/familynp-tco-may-222.pdf Accessed January 31, 2022.