Compared with dermatologists, physician assistants have lower diagnostic accuracy for melanoma.

[DubbiDoctor]

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Accuracy of Skin Cancer Diagnosis by Physician Assistants Compared With Dermatologists

Randomly saw this article, and figured I'd post it here. Research on primary care (methodological objections aside) consistently shows that midlevels provide similar outcomes to physicians, enabling independent practice in an increasing number of States. I've gotten worried that that trend would extend to other medical specialties, but this article makes that seem unlikely. Dermatologists, your jobs are safe.

 

[mk04447]

So let me get this straight, a skin specialist correctly diagnoses a skin problem more often than a PA? No wonder this country is in so much debt.

 

[doctalaughs]

If you actually read the article the study was drawn only from dermatology offices, so presumably this is comparing dermatologists to PAs specifically working in derm (not primary care PAs).

The result may seem obvious to any idiot but in a world where midlevels are increasingly making ridiculous claims that their minimal training provides equal quality care to a physician it’s smart we are doing studies like this to get ahead of the curve (see anesthesiologist vs CRNA debacle, milevel push to creake fake “doctorates,” PAs trying to rename themselves physician associates etc).

 

[Oussedik]

PAs are seeking more autonomy. They want to be able to practice independently. Here's a clip from the AAPA, courtesy of Ade Adamson's Twitter. Y'all should follow him, he posts cool stuff.

Twitter: AdeAdamson

 

[W19]

If you actually read the article the study was drawn only from dermatology offices, so presumably this is comparing dermatologists to PAs specifically working in derm (not primary care PAs).

The result may seem obvious to any idiot but in a world where midlevels are increasingly making ridiculous claims that their minimal training provides equal quality care to a physician it’s smart we are doing studies like this to get ahead of the curve (see anesthesiologist vs CRNA debacle, milevel push to creake fake “doctorates,” PAs trying to rename themselves physician associates etc).

But it is sad that physicians have to do studies like those... This should be self-evident.

 

[Mister Significant]

Most of my friends who want to become midlevels want to do so because its shorter schooling, and they have less responsibility. I guess I could see how this mindset while their young changes when they get older. They probably start regretting the short cut.

 

[Solodyn]

PAs are pushing for a Doctor of Medical Science so they can be called doctors....

DMS - Lincoln Memorial University

 

[asmallchild]

PAs are pushing for a Doctor of Medical Science so they can be called doctors....

DMS - Lincoln Memorial University

If the standards to get into PA school are as rigorous as med school,

If the schooling is as lengthy and as expensive as med school,

If there is a residency training period equivalent to doctors',

If the residency training period is as lengthy and as rigorous as doctors',

If they are willing to inherit the same legal liabilities doctors do,

Then sure, by all means, we'll call you doctor.




I think this is something we all need to keep an eye on and not allow it to progress unchecked.

But at least in my neck of the woods, patients are much smarter than we often give them credit for. They look up our bios. They know whether we are MDs / DOs and where we trained. They are willing to see midlevels for certain issues. They know which midlevels are good and which ones aren't good. They know when they want or need the MD / DO. They know which MDs / DOs in the community are good vs not good. It's not as large of a concern in my practice and community in terms of midlevel takeover and midlevels pushing for independent practice (n=1 of course)

Back to the original article, if you want to take a more cynical stance, some of these megapractices prefer it that way. They don't really care about diagnostic accuracy, they just care that you are biopsying everything under the sun.

 

[ranked2match]

[QUOTE="asmallchild, post: 19945634, member: 120014"

Back to the original article, if you want to take a more cynical stance, some of these megapractices prefer it that way. They don't really care about diagnostic accuracy, they just care that you are biopsying everything under the sun.[/QUOTE]

Agree with above - many PAs biopsy more because they are told to biopsy alot in order to bring in more revenue. Moreover, derms keep selling their practices to private equity firms who will, in turn, favor the employment of midlevels who cost much less. Many derms also allow their PAs to work pretty much autonomously, which further undercuts the argument against independence...

 

[Corpsman89]

Just wanted to point out to some of you that this article fails to mention one important point.

It compared PAs with 6.9 years of experience (avg) to Derms with 16.5 years of experience (avg) if you count residency.

Well, duh. If you compare Derms to Derms with the same 6.9 to 16.5 you're probably gonna get those same results. Otherwise, experience doesn't mean much.

Apparently I cannot provide a link because of SDN rules, but Dr. Zirwas (dermatologist) provided his analysis of this publication. Here is the expert from Dr. Zirwas:

"The article by Anderson et al that recently published in JAMA Dermatology shocked me. It has not been my experience that PAs are worse than dermatologists at diagnosing skin cancer. However, as I read the title and abstract, it seemed to show exactly that. When I read the actual article, however, it painted a far different picture. Let me explain.

In the results section, they note that the dermatologists had a statistically significantly greater amount of experience in dermatology (13.5 years) compared to the PAs (6.9 years). However, even this is misleading, as they state that they counted experience for the dermatologists as starting after they finished residency, but they counted experience for the PAs as starting on their first day in dermatology. That seems odd – if dermatologists aren’t gaining clinical experience during residency, then what exactly are they doing? Obviously residency should count, meaning the difference in experience between the two groups is actually close to 10 years (6.9 years for the PAs vs 16.5 years for the dermatologists).

Once I saw that difference, and knowing that it has already been proven that dermatologists with 10 years or more experience are better at diagnosing thin melanomas compared to dermatologists with less than 10 years experience, the interpretation of the actual results of the article changed dramatically.(1) In fact, what the title should be is: “Physician Assistants with Less than 7 Years Experience Diagnose NMSC as well as Dermatologists with Over 16 Years Experience”.

That made me start thinking more about the article and the intent behind it. That the dramatic difference in experience was the cause of the difference in diagnostic accuracy is an obvious hypothesis that already has data to back it up.(1) It is also extremely easy to confirm or disprove using the data the authors collected. I can imagine that it just didn’t occur to the authors to run this analysis, but that it didn’t occur to the authors, the reviewers, or the journal editors? Highly unlikely – if it didn’t occur to anybody, then they aren’t very smart. If it occurred to someone but they didn’t do it, they aren’t very ethical.

I’ve written and submitted a letter to the editor of JAMA Dermatology pointing the above out and asking to have the authors run the analysis to control for years of experience. I hope we all get to see the results – maybe we will be surprised and clinical experience won’t be the determining factor of diagnostic accuracy – maybe dermatologists are better or maybe PAs are better. Either way, it is important that we know the truth.”

 

[username456789]

The difference in years experience is definitely an issue, but why on earth would you include residency in this time? The whole premise of Dermatology physician vs midlevel is that both, after finishing their training, are out practicing and billing for their services.....but one of them has drastically more experience and presumed ability. That’s the reason people usually prefer to see a physician in the first place.

I’d be interested to see the comparison between a physician one year removed from residency and a PA after one year in derm, and then the same thing with each person five years removed, and ten, and so on. I’m sure the gap narrows with time. But if anyone is arguing that physicians might be better at diagnosing skin cancer, they absolutely should not be comparing a first year resident and a newly minted PA. THAT is equally disingenuous in my opinion.

 

[Corpsman89]

Fine then 6.9 (PA) to 13.5 (MD, not including residency)

Still pretty disingenuous, no?

The major problem: Even as medical scientists all of the above posters who posted before I did failed to actually read the article and methodology. They read the title, maybe the abstract and then boom, conclusions have been made.

 

[asmallchild]

Fine then 6.9 (PA) to 13.5 (MD, not including residency)

Still pretty disingenuous, no?

The major problem: Even as medical scientists all of the above posters who posted before I did failed to actually read the article and methodology. They read the title, maybe the abstract and then boom, conclusions have been made.

This thread is going to be a on short leash as I don't want this to devolve into a midlevel vs physician debate

In an ideal world, you would be comparing similarly experienced midlevels with dermatologists. This is going to be an imperfect study because honestly, who is going to dedicate that much time and money to this? This was a medical record review study of one major academic institution. I could be wrong and perhaps there's one brewing but I don't see a major scale collaboration amongst multiple academic institutions to pool data to answer the question of who is more accurate.

One group has significantly more training, one group is tasked with overseeing the other group, it seems pretty clear which side is going to win. The other question is what you are going to do with this information? Even if the study is conducted with perfect conditions, if a group is intent on hiring midlevels, it won't matter to them who is more accurate. If a group is intent on hiring dermatologists, it won't matter to them even if the midlevels are more accurate. What if the midlevels are more accurate? Are we going to scrap the current medical education system as we know it for dermatologists?

I do agree that as we review literature, a critical eye is necessary. It is easy to simply scan the title and abstract and come to a conclusion. I do agree that the entire article should be reviewed and critically assessed to see if the endpoint is supported by the methodology.

 

[Corpsman89]

My only concern is that troubling findings were indeed discovered, or the findings they wanted to discover were not found so they modified the methodology to get a title they wanted. I would hope they would publish the results of a PA with similar experience to a Dermatologist, but they didn't, so yes, I wonder why.

Regardless, I don't want to get in a PA vs MD argument either. Who does? MDs have far more training than PAs and definitely far better training than NPs. I can say PAs at least value our physician-PA relationship and for the most part enjoy collaborating together. I just find it incredibly troubling when an article with heavily flawed and disingenuous methodology comes out bashing PAs, and threatening the trust the public has with us.

 

[doctalaughs]

You (and Dr. Zirwas) are reading nefarious intent into this article when there is none. They clearly aren’t trying to hide the experience gap between the two groups.

Of course experience matters - thats the major point of the article and should be self-evident.

In general, if you randomly see a Dermatologist you likely are going to get someone with more experience, standardized training (and thus accuracy) than a PA practicing in derm. That’s the implication, so there is no reason to control for this variable. It would be nice to see a comparison with “equal” experience mainly to gague the effectiveness of residency, but thats a different and harder study to complete (and not the point of this article). The article isn’t saying that PAs are inherently bad clinicians and can’t learn....

So I see no inherent “troubling flaw” in the article. Now you may say again, that the conclusion is glaringly obvious (that someone with more training and experience is better than someone with less) but I will again refer you to the whole CRNA vs anesthesiologist debacle where suddenly many thousands of extra hours of experience “don’t matter” anymore ... and assert that these types of articles are, SADLY, necessary. If you want to read truly shockingly unethical propaganda “studies” look at some of those NP anesthesia “equivalence” ones. It actually makes me nauseous.

 

[Corpsman89]

Then why didn't they do a study comparing Derms with 6.9 yrs to Derms with 13.5 yrs? WHY do they need to throw in PAs? Wouldn't that be the ultimate comparison if you want to gauge experience?

 

[asmallchild]

Then why didn't they do a study comparing Derms with 6.9 yrs to Derms with 13.5 yrs? WHY do they need to throw in PAs? Wouldn't that be the ultimate comparison if you want to gauge experience?

That study has already been done.

 

[doctalaughs]

Because derms with 6.9 yrs of experience aren’t trying to remove themselves from the board of medicine, setup their own supervisory/independent body, rename their whole profession to look “better” in the piblic eye.... all in a slow “creep” that is strikingly similar although maybe 10 years behind the other midlevels (NPs, CRNAs).

 

[Corpsman89]

PAs have watched as NPs have been granted independence state after state. We watch seeing lesser trained providers have more autonomy than us. We have watched as hospitals have begun to preferentially hire NPs over PAs because of the supervision we require.

PAs are seeking changes because physicians have done nothing to help us or support us. Most physicians understand that at least PAs are trained in the medical model. PAs have standardized training unlike NPs, and PAs have, in general, better quality training. And with all of this we still get no support from physician groups.

PAs NEED parity with NPs. All we want is an equal footing. We DO NOT want independent practice, just a level playing field with NPs. Which means practice guidelines are to be determined AT THE PRACTICE LEVEL. If a practice hires a new grad, then they can make the new grad have a supervisory agreement for a certain time. If they hire a PA who has 30 years experience they can just let them do their thing with minimal supervision. It's up to the practice. It is good for PAs, physicians, and patients.

In a perfect world NPs would be in the same position as us, but they aren't, so we MUST adapt. In a perfect world physicians would have backed us up when NPs started to push for independence and could have emboldened the MD/PA relationship. They didn't and now we have poorly trained NPs about to completely wipe out the PA profession.

 

[asmallchild]

As promised, locked. If you want to debate about midlevel autonomy, do it on the midlevel forum. This is dermatology. You can debate the merits of the article stating that a dermatologist’s accuracy is > than that of a PA (and the associated flaws of the methodology) but this isn’t the forum for midlevel talk.