Inside the Mind of NP and PA Candidates: What Employers Often Miss

I own a high-volume dermatology clinic and a full-service medical spa. That means my days are split between patient care and running a business: I write offer letters, build compensation models, manage overhead, and make hiring decisions. In addition, I consult nationally on employment contracts for MDs, PAs, and NPs—more than 500 to date. In this role, I help providers determine whether the contract in front of them is a genuine career opportunity or a costly mistake.

I’ve drafted noncompete clauses and been subject to them. I’ve signed the front of the paycheck and cashed it. That dual perspective—both employer and provider—is increasingly rare in private practice today. It gives me an unusually objective view of the patterns I see on both sides of the hiring process, patterns that are remarkably consistent from one practice to the next.

One of those patterns is worth naming up front, because it underpins everything that follows: practices frequently approach NP/PA candidates differently than physicians, and these candidates notice. Offer structures differ, negotiation leans toward the physician, and transparency in discussions is often uneven. Whether intentional or habitual, this disparity shapes how providers evaluate not just the offer but the practice itself.

Most of this friction is avoidable, and the solutions are often simpler than either side assumes. The following 5 patterns recur in my consulting work: they represent what seasoned NP/PA candidates weigh most heavily when evaluating offers, and what many practices undervalue, overlook, or dismiss as “we know better.”

1. Revenue Transparency Is Not Optional

An experienced dermatology NP/PA seeing 25 to 35 patients per day in a properly staffed clinic can generate $575,000 to $850,000—or more—in annual collections. The SDPA’s 2024 Practice Survey, which included 994 dermatology PAs nationwide, documented a profession that has nearly doubled in size since 2013, growing from 2,323 to over 4,580 and still expanding.¹ Mid-career and senior providers understand their production value with precision, even if they don’t say so outright in the first meeting.

Candidates want specifics: historical production data for comparable providers, achievable bonus thresholds, and compensation models tied to auditable, transparent math. If the model relies on a practice-defined Net Revenue figure with annual unilateral adjustments and no visibility, it won’t withstand scrutiny from an experienced candidate.

Ask yourself: if a compensation structure cannot withstand the question, “May I review the production data?” the issue isn’t the candidate—it’s the model.

2. Clinical Infrastructure Determines Real Compensation

The strongest production percentage won’t matter if the clinic cannot support the volume the model assumes. A provider arriving to a single medical assistant shared across 3 clinicians, scheduling that leaves no room for documentation or procedures, and a front office struggling to acquire new patients will fall short. Both sides end up frustrated, blaming each other for a structural problem.

The SDPA 2024 survey lists staffing shortages and insufficient clinical support among top challenges, alongside insurance burdens and volume pressure. JCAD Workforce Survey data shows that among NP/PAs seeing 100–200 patients per week, 31% had only 1 clinical support staff member. At that ratio, infrastructure caps production regardless of skill or effort.

Infrastructure investment is not separate from compensation—it is the condition under which the compensation model succeeds or fails. Established candidates evaluate the clinical environment with the same scrutiny they give the offer letter. Early recognition of a resource deficit often informs their decision; those who miss it usually discover it within the first quarter—and start looking elsewhere.

One phrase I hear repeatedly post-interview: “The schedule will fill itself once you get established.” To employers, it signals market confidence; to candidates, it signals the practice has left the risk of building volume on someone with no guaranteed income.

3. Autonomy Belongs in the Contract, Not in a Conversation

Supervision requirements for PAs and NPs vary by state, but day-to-day clinical authority is often dictated more by internal policy than law. Internal policy often mirrors the supervising physician’s comfort level rather than a deliberate operational decision. Experienced candidates know this, making supervisory structure a key factor in evaluating offers.

I once consulted for a PA with 6 years of dermatology experience who accepted a position where every prescription and biopsy required physician co-signature—even routine acne prescriptions and standard eczema refills. The result: a 3 to 6 day delay on patient care. The bottleneck affected patients, not the practice or physician. Informal authority left her functioning like a scribe, not a provider.

When candidates hear, “We’ll figure out supervision as we go,” they hear, “Your clinical scope is undefined, and can be expanded or restricted at will.” Supervisory models should be explicit in the contract: baseline authority, conditions for expansion, and timelines. Ambiguity here is one of the fastest ways to lose a strong candidate.

4. The Evaluation Runs Both Directions

The dermatology NP/PA hiring market has shifted. Demand exceeds supply, and experienced providers with procedural skills and production history are highly selective. According to SDPA 2024, 43% of dermatology PAs have 11+ years of experience. These are professionals who quickly recognize operational dysfunction.

The phrase I hear most from applicants is, “We are like a family here.” And the phrase they view with the most skepticism. In their experience, “family” often means informal boundaries, undocumented expectations, and personal accountability. Intent doesn’t matter—experience does.

Critical questions include: How long has your longest-tenured PA/NP stayed? What led to the most recent departure? Can I speak with a current PA/NP before signing? Practices that answer confidently have little trouble recruiting; those that deflect confirm the candidate’s suspicions.

5. Exit Provisions Reveal More Than the Offer

Almost every practice presents well during recruitment. What candidates scrutinize most closely is not compensation but termination and post-employment provisions. These clauses reveal how a practice manages relationships under stress.

Examples include:

• 18-month noncompetes covering 6 practice locations
• Tail malpractice coverage assigned entirely to the provider
• Uncapped early-departure penalties
• Training repayment clauses triggered by voluntary departure
• Accounts receivable transfer on the termination date

Stacked together, these clauses can cost departing providers tens of thousands before they secure another role. Experienced candidates read exit provisions as a window into the practice’s values. Contracts that make leaving prohibitively expensive signal what the practice prioritizes—and it’s rarely what the employer intends.

The Offer That Wins

The most sought-after providers—those with procedural skills, documented production, and clinical maturity—also have the widest options. Dermatology PAs report higher job satisfaction and lower burnout than PAs in other specialties. They are committed to the work but intolerant of opaque compensation, under-resourced environments, and restrictive agreements.

The winning offer combines:

• Transparent compensation
• Properly resourced clinical operations
• Autonomy defined in the contract
• Honest answers about culture and turnover
• Fair exit terms

Do this, and you recruit someone who stays. Everything else is positioning.

Reference

SDPA 2024 practice survey. Accessed April 2, 2026. https://members.dermpa.org/page/2024PracticeSurvey