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Optimizing relationships with dermatology physician extenders requires active role


National report - Employing physician extenders (physician assistants and nurse practitioners) may help dermatologists meet the existing high demand for their specialty care.

But it also brings new responsibilities for supervising and training those non-physician personnel, as well as for preventing them from taking their skills to nondermatologist practices, Mary E. Maloney, M.D., says.

Dr. Maloney is professor of medicine and director of dermatologic surgery, University of Massachusetts Medical School, Worcester.

Recent data show that physician extenders have become an important part of dermatology practices.

According to American Academy of Dermatology (AAD) Association practice profile data, an estimated 22 percent of members employed physician extenders in 2002 while that proportion rose to 29 percent by 2005. Dr. Maloney herself contributed to that increase. After practicing dermatology for 22 years without a physician extender, she hired a nurse practitioner two years ago.

Reliance on physician extenders may be even higher in practices that are more surgically oriented. According to the results of a survey conducted by the American Society for Dermatologic Surgery, only 28 percent of 477 responders indicated using no physician extenders, while 28 percent employed physician assistants, 13 percent were using nurse practitioners, 29 percent had aestheticians, and 41 percent were using nurses in their practice that had no further training as extenders.

Driving factors

Several factors are driving the increasing employment of physician extenders in dermatology practices.

Regardless of geographic setting, wait times for new and follow-up patients may be excessively long, while dermatologists practicing in rural areas may have particular difficulty attracting partners. A shortage of medical dermatologists and an increased tendency for physicians to practice part-time, especially younger individuals, also contribute to the disparity between patient demand and provider supply.

Simultaneously, "pseudodermatologists" are emerging as a growing threat. Not only are more nondermatologists offering skincare and dermatologic surgery services, but those physicians are increasingly being sought out by patients who perceive them as more accessible.

Highlighting the latter issue are the findings of a recent British study in which patients with nonurgent skin problems judged suitable for care by a general practitioner with a special dermatology interest service were randomized to be seen by such a general practitioner or in the hospital outpatient dermatology clinic. The investigators reported the general practitioner was not only more accessible based on wait times, but was also preferred by patients.

"I think all dermatologists in this country would argue that latter point, but the fact is that primary care physicians in the U.K. and in the U.S. as well, have started to perceive their services as being as well received as ours," Dr. Maloney tells Dermatology Times.

The AAD has guidelines relating to care administered by nonphysician office personnel stating those individuals should work with direct physician supervision present onsite or immediately available and also that the physician see all new patients as well as existing patients with significant new problems. In addition, the AAD policy states it is the physician's obligation to ensure the physician extender is properly trained for the services they perform.

However, results of the ASDS survey show that not all dermatologists are adhering to that policy. While 77 percent reported their physician extenders always worked under direct supervision with a physician onsite, 19 percent indicated direct supervision was only sometimes available, and 5 percent noted they employed a physician extender who worked with no direct supervision.

"I would expect those latter situations represent physician extenders staffing off-site locations where there is no physician available. However, I believe we have accountability to adhere to the AAD guidelines that our colleagues have established." Dr. Maloney says.

Standards needed

The responsibility of physicians who employ physician extenders does not stop there.

Dr. Maloney believes it is imperative that dermatologists work to establish standards for the physician extenders, which may include some type of credentialing, in order to indicate the personnel who are serving in these roles are adequately trained.

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