Dermatologists, non-physician clinicians explore the roles of training and continued education in a developing area of medicine
By John Carruthers, staff writer, November 01, 2011
The demand for dermatologic services continues to increase while the physician workforce numbers remain static. As a result, more practices have begun taking on physician assistants (PAs) and nurse practitioners (NPs) to extend their practice’s ability to see a greater number of patients. Yet much of the training for these clinicians hasn’t yet been standardized or even formalized. Finding the proper training methods and continuing education opportunities, according to dermatologists and non-physician dermatology clinicians, is critical to a practice’s successful expansion of care.
PAs and NPs in 2011
Recent years have seen an increase in the number of PAs and NPs employed throughout medicine. The American Academy of Nurse Practitioners (AANP) estimates that approximately 140,000 are employed in practice as of 2011, while the American Academy of Physician Assistants reports 83,466 PAs are currently in clinical practice. The Dermatology Nurses’ Association estimates that between 500 and 600 NPs work in dermatology, a number that has remained consistent, while the number of dermatology PAs has grown considerably over the past year, according to Society of Dermatology Physician Assistants (SDPA) president Kari Holyoak. Much of the growth, she said, comes from an increasing number of dermatologists in underserved areas willing to hire a non-physician clinician in order to serve more members of their communities with team-based, patient-centered medical care.
Non-physician clinicians are a way to extend care to more patients, Holyoak said, “because our relationship with our supervising physicians is one of trust and open communication. That’s why dermatologists employ us, because our presence can really help extend care.”
David M. Pariser, MD, a past president of the American Academy of Dermatology (AAD), agreed, saying that when properly trained and supervised, PAs and NPs are the most efficient way available at present to extend dermatologic care to underserved populations. In addition, he said, PAs and NPs are often able to spend more time face-to-face with patients, answering their questions and offering additional information on their conditions.
“I employ non-physician clinicians, and I think it’s been a great addition to the practice,” Dr. Pariser said. “PAs and NPs, of course, can never substitute for a traditional physician, but by having them working under the appropriate supervision, I think it adds a significant dimension to care, and allows us to care for more people, which will be important as the health care reform legislation takes effect and we have more folks seeking dermatologic care.” [pagebreak]
The basic training required to become a PA or NP can vary by state, according to dermatologist Jeff Crowley, MD, who speaks on incorporating physician extenders into practice. The exact qualifications can be found through the board of health in a physician’s home state, or through the state’s official website.
“In California, you can have PAs that have an associate’s degree and 18 months of PA school. On the east coast, their experience is mostly masters-level courses. There’s this big spectrum of how well PAs are educated and trained,” Dr. Crowley said. “That needs to be addressed, but they’re all state-level regulations, so it’s difficult to get uniformity. Many PAs in California being minted don’t have a bachelor’s degree. You have to make sure that you hire and train someone who is knowledgeable and comfortable seeing patients.”
Certification adds a degree of uniformity, Holyoak said, through requirements for continuing education, and noted that today 80 percent of all PA programs award a masters degree. (More information about PA training requirements in different states is available in this PDF.) More uniformity is seen in the training of NPs. The Dermatology Nurses’ Association notes that NPs in dermatology hold either masters or doctoral degrees in nursing.
Initial dermatology training
After they complete their training to become a PA or NP, of course, non-physician clinicians who wish to work in dermatology need more specialized training. Due in part to the sudden growth of PAs and NPs in the specialty, dermatology training for these clinicians remains far from standardized. Only two dermatology-specific nurse practitioner programs exist and according to Holyoak, most PA training includes little to no formal dermatology education. This, according to Dr. Crowley, underscores the need for thorough, well-supervised training and continued work with the PAs and NPs in one’s practice.
“With the lack of training opportunities right now, I really think that you look at PA or NP training as sort of an apprenticeship type of training. You basically treat the PA as a resident is treated. You see all the patients with them, and it takes a couple of years of work for a PA to be up to basic levels where they can operate semi-autonomously,” Dr. Crowley said. “In my experience, it’s been around two years before I’ve been comfortable with their abilities and skills. It’s a big amount of time and effort that you have to put into it. I think a lot of dermatologists think they can hire a PA fresh out of their program and have them up and running in a short time. I believe that’s an unrealistic expectation.”[pagebreak]
Dr. Pariser, whose practice employs 10 dermatologists and seven non-physician clinicians, takes a formalized six-month approach to hiring and training PAs and NPs. In the first three months, he said, the clinician has little to no contact with the patients, instead attending dermatology teaching conferences like a resident, doing strictly observational shadowing of dermatologists, studying a training manual created by Dr. Pariser and his colleagues, and practicing procedures on pig’s feet.
After the first three-month period, he said, the trainees are allowed a limited schedule of patients in follow-up scenarios. For each of those visits, Dr. Pariser said, a dermatologist sees the patients after the PA or NP does, in order to confirm their findings. Should a PA or NP pass the entire six-month period, Dr. Pariser begins to assimilate them into the practice.
“At the end of the six-month period, I personally spend a little time with each of them — we spend some time with the pig’s foot and they demonstrate to me that they can do the procedures. I get a feel for their skills and knowledge, and if I feel that they’re ready, they get their own schedule. The doctor’s there to back them up for new patients and new problems in existing patients,” Dr. Pariser said.
Though Dr. Pariser’s system has worked well for his practice and become formalized over time, it’s by no means the standard for each practice or each non-physician clinician, according to Holyoak.
“The time to train a PA will vary depending on the clinical experience of the PA and how comfortable a physician is with the PA concept,” Holyoak said. “I trained side by side with my supervising physician, seeing and discussing each patient together for six months before I started seeing my first patients. My initial patients were those presenting with acne and warts and progressed as my clinical experience progressed.”
While many PAs receive the bulk of their dermatology training away from academic centers, Lakshi Aldredge, MSN, ANP-BC, a dermatology nurse practitioner in Virginia, said that her training through the Portland V.A., following six years as a primary care NP, allowed her a more traditional dermatology education experience. The training was informal, carried out with the help of a dermatologist mentor, but set up very much like the beginning of a residency program. Her six months of dermatology education featured both didactic lectures and rounds, as well as significant time with her mentor dermatologist.
“For me, my dermatology education was helped very much by the classroom didactic, by the clinical rotations, and the hands-on supervision that occurred as I started to come into my own with my critical thinking in dermatology,” Aldredge said. “I think it’s critical for PAs and NPs to have that oversight, so they can feel comfortable that they’re getting good training, and so that as they move forward, they feel like they have someone they can ask questions and present cases to. I think that all of us have to be able to identify those things that we don’t know and be able to go to the experts for.”[pagebreak]
In addition to the training they may receive on the job, PAs and NPs should also actively seek continuing education throughout their careers. Differing qualifications from state to state on PA licensure can increase the importance of continued quality medical education for clinical staff, according to Dr. Crowley. (The educational requirements for NPs are mostly standardized nationally.)
Most nurse practitioners, according to the AANP, are required to be board-certified and undertake continuing medical education to maintain certification. For dermatology NPs, according to Aldredge, the time is usually split between a majority of dermatology CME and correlated general medical education. This split, Dr. Crowley said, increases the value of the continuing education to his practice.
“There are CME days in my clinical staff’s employment contract. I also give them a stipend to pay for CME. I think that’s important. If you’re not reimbursing, they may not choose what makes the most sense for the practice in terms of CME,” Dr. Crowley said. “I require half of their CME be derm-related, because they have to take general medical board exams every six years. I like that they receive cross-training in general medicine.” According to Dr. Crowley, it’s also important to encourage a non-physician clinician’s interests and let them expand and reinforce that knowledge base. “Both of my PAs have developed their own interests, and we’ve tried to give them help pursuing those. One of my PAs does more women’s care, which she was doing previously, so she’s incorporated that into her practice,” Dr. Crowley said. “My other PA treats a lot more children, so she’s become kind of a pediatric specialist. We’ve tried to encourage them to become more educated in those fields, based on their personal interests and the needs of the practice.”
As the relationship between dermatologists and non-physician clinicians continues to develop, Aldredge said that successful partnership will continue to ensure better dermatologic care for a greater number of patients.
“I think that most NPs — and PAs for that matter — are really grateful to dermatologists for working with us and trusting us to help treat their patients,” Aldredge said. “An NP or PA who works with a board-certified dermatologist provides excellent dermatologic care, not only in clinical outcomes, but in patient satisfaction and in helping to promote the success of the practice, as well as academic or large medical institutions.”
Dermatology PA and NP organizations
Society of Dermatology Physician Assistants
Nurse Practitioner Society of the Dermatology Nurses Association
Continuing education opportunities for PAs and NPs
For all non-physician clinicians, the pursuit of continuing education is vital. As this developing area of medicine continues to grow and refine itself, the most capable PAs and NPs will be those who have received the best training and continuing education. While the American Academy of Dermatology’s annual and summer meetings feature a number of symposia open to PAs and NPs, associations for those clinicians have also begun to regularly host their own educational meetings and provide other educational programming.
According to Society of Dermatology Physician Assistants President Kari Holyoak, concern by the AAD about a dearth of training opportunities prompted the SDPA to create its Distance Learning Initiative, a distance learning module for PAs working under board-certified dermatologists.
“In response to the AAD’s concerns regarding the need for specific dermatology training for PAs, education is one of the things we chose to really focus on. The course is 10 online learning modules. The learning modules are cases that the PA works through, just as if they’re seeing a patient. The PA will do a history, a physical, can consult with a dermatopathologist, and come to a diagnosis and recommend treatment. The reason it’s so helpful to our members is it’s so derm-specific. It’s advanced, high-quality dermatology education,” Holyoak said. “If you request a pathology report, it will provide a description of the findings, so you have to fit the findings to your diagnosis and at the end find a way to offer patient education and a treatment plan, and make referrals as needed. It’s very true to what we do in the office. It’s one of the ways we addressed the concerns over derm-specific education. We want to increase credibility with the physicians who trust us to care for their patients.”
In addition to its Distance Learning Initiative, the SDPA hosts both fall and summer meetings. Its Summer Dermatology Conference will be held in Seattle from July 11-15, 2012, and it will hold its 10th annual Fall Conference Oct. 31-Nov. 3, 2012 in Las Vegas. The organization’s members, according to Holyoak, come largely for a specialized educational experience not replicated elsewhere.
“I think we’ve made great strides in our relationship with the AAD, and I do feel that many of our members enjoy going to the Annual Meeting. But we also see a large portion of our members coming to our two yearly SDPA meetings,” Holyoak said. “We bring in some of the best speakers from around the nation, and it’s a time for them to come away with great pearls and practical things they can take back to their office. That’s one of the biggest benefits to our membership.”
For NPs there are a number of continuing education choices through both the annual Dermatology Nurses Association meeting and the American Academy of Nurse Practitioners. DNA’s NP society will hold its next annual forum Feb. 16-19, 2012, in Denver.