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National report - When it comes to controversy regarding the role of physician extenders in dermatology practice, the relevant question is not if they should be used but rather how, Mark S. Nestor, M.D., Ph.D., says.
"I strongly believe that physician extenders can be a valuable part of a dermatologist's practice and can improve patient care, but proper utilization remains the bottom line. No matter how much training and education they receive, physician extenders cannot be a substitute for the dermatologist's knowledge and skills. However, they can still be a valuable part of the team for enhancing patient care," says Dr. Nestor, clinical associate professor, department of dermatology and cutaneous surgery, University of Miami School of Medicine, Miami.
Against that background, Dr. Nestor described the experience in Florida where members of the Florida Society of Dermatology and Dermatologic Surgery (FSDDS) undertook establishing new standards for use of physician extenders in dermatology practices.
"Most state laws require only indirect or general supervision and allow for virtual independent practice for many physician extenders. However, the model of physician extenders is different in primary care compared with specialty care. Therefore, I believe each specialty should adopt their own appropriate standards of care for the use of physician extenders, and I encourage dermatology societies in other states to consider Florida's lead in establishing a unified standard of care," notes Dr. Nestor, who is also in private practice in Aventura, Fla.
The standard of care in Florida for use of physician extenders in dermatology offices drew attention a few years ago as some dermatologists became concerned about a few situations where physician extenders working in satellite clinics appeared to be delivering inappropriate and unsupervised care.
"Some of the physician extenders in these offices had essentially no dermatology-specific training and were seeing new patients and new conditions. As a result, there were clinical errors, upset patients and unhappy referring physicians who were furious that their patients were never seeing a specialist," Dr. Nestor says.
After three membership votes over a period of two years, the FSDDS standard of care received majority approval. Those guidelines require a dermatologist to at least visually concur in a face-to-face manner with the clinical diagnosis and the treatment plan for new patients and new dermatologic problems as well as for skin cancer exams in existing patients. Then, the physician extender can perform the history, concurrent exam procedure, and treatment.
"The standards in Florida allow for indirect supervision for some services involving follow-up care," Dr. Nestor explains.
The FSDDS standards also state that established patients with chronic problems, patients with problems not responding as expected to therapy, and patients whose conditions are worsening should be re-evaluated by the dermatologist at regular intervals. In addition, dermatologists should at least directly supervise (ie., be present in the same office suite) significant cutaneous surgeries.
Dr. Nestor notes the FSDDS standards evoked protests from a small minority of dermatologists and from some physician extenders. However, the dissent has quieted after the introduction of the amended AAD guidelines on use of physician extenders that are even more stringent and call for direct physician supervision at all times.