Dermatology PAs

[DermViser]

So I was looking through different Derm private practice websites to see how they arrange their websites and I happened to come upon this. Now I won't put the private practice website that put this, but put the direct link.



0:12 - 0:40 -- really burned me up esp. in comparing PAs to derm residents

I fully expected and I am not surprised that private practice dermatologists take part in this video. On the other hand, I can't believe someone like Paul Nghiem, a well-known academic dermatologist, would contribute his blurb to this propaganda.

To think we have tons of highly qualified dermatology applicants every year who put in 4 years of backbreaking work thru medical school and fail to match into derm. Meanwhile, we have no hesitation, whatsoever in propping up PAs in doing dermatology ---> Notice the PSA here doesn't delineate PAs as only limited to tackling "common" dermatology problems, as one of the PAs talks about treating pemphigus foliaceus, but all types of dermatological problems as well as cosmetic dermatology.

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[wjs010]

Wow ... Usually it a nurse encroaching on some specialty... Ouch. They have mid levels trying to encroach derm too? I'm pretty sure that makes , what... Every specialty now?

 

[asmallchild]

So I was looking through different Derm private practice websites to see how they arrange their websites and I happened to come upon this. Now I won't put the private practice website that put this, but put the direct link.



0:12 - 0:40 -- really burned me up esp. in comparing PAs to derm residents

I fully expected and I am not surprised that private practice dermatologists take part in this video. On the other hand, I can't believe someone like Paul Nghiem, a well-known academic dermatologist, would contribute his blurb to this propaganda.

To think we have tons of highly qualified dermatology applicants every year who put in 4 years of backbreaking work thru medical school and fail to match into derm. Meanwhile, we have no hesitation, whatsoever in propping up PAs in doing dermatology ---> Notice the PSA here doesn't delineate PAs as only limited to tackling "common" dermatology problems, as one of the PAs talks about treating pemphigus foliaceus, but all types of dermatological problems as well as cosmetic dermatology.

Unfortunately, it's all about money and I've seen numerous practices employ PAs to take on more of the "grunt" work so the physicians can take the more lucrative work/procedures. One practice I'm familiar with has PAs doing their own excisions and cosmetic procedures (usually lower risk laser procedures) but a lot of this is dependent on where you practice. Where I'm located, patients won't even allow the PAs to numb them let alone attempt the excision/cosmetic procedure.

 

[sonofva]

Dude in my town United just dropped all actually dermatologists and now has all patients see a plastic surgeon who doesn't actually see any of the patients but supervises 6 PAs. Way of the future my friend.

 

[Dral]

How is seeing a plastic surgeon more cost effective? Do they suddenly know how to manage PV, psoriasis, and MF?

Not being argumentative, just curious.

 

[asmallchild]

Dude in my town United just dropped all actually dermatologists and now has all patients see a plastic surgeon who doesn't actually see any of the patients but supervises 6 PAs. Way of the future my friend.

How is seeing a plastic surgeon more cost effective? Do they suddenly know how to manage PV, psoriasis, and MF?

Not being argumentative, just curious.

Probably a mill for skin cancer excisions and reconstructions and not actual dermatology.

Dermatologists are not going away anytime soon and certainly not because of a plastics + PA model to provide the full spectrum of dermatologic care.

 

[DermViser]

Unfortunately, it's all about money and I've seen numerous practices employ PAs to take on more of the "grunt" work so the physicians can take the more lucrative work/procedures. One practice I'm familiar with has PAs doing their own excisions and cosmetic procedures (usually lower risk laser procedures) but a lot of this is dependent on where you practice. Where I'm located, patients won't even allow the PAs to numb them let alone attempt the excision/cosmetic procedure.

I was just shocked that a prominent derm who works in academic medicine, who lectures at SID and AAD meetings to attendings and residents, would lend his hard earned credibility to a video that throughout makes it look as if PAs are just as well-versed in basic sciences/clinical sciences as their medical student to physician counterparts, as if the credentials are easily interchangeable. His clip by itself, and what he was getting at, is quite benign. Makes me wonder if he's even seen the entirety of the video and what he was contributing to.

On another note, I don't know of one MD school in U.S. in which medical students and PA students are taking all of their basic sciences together.

 

[sonofva]

How is seeing a plastic surgeon more cost effective? Do they suddenly know how to manage PV, psoriasis, and MF?

Not being argumentative, just curious.

I'm not saying I agreed with it, it's just what's happening here.

 

[Dral]

I never insinuated you did or should agree with it. As I stated, I'm curious and wanted you to elaborate (if you had any other information). For instance, do the med Derm cases get sent to a nearby academic center?

 

[Hoser]

Wow, that was frustrating to watch. The ONLY time I interacted with a PA student during medical was one throwaway class. We never shared a basic science course together. I'm not sure how that could possibly work since their entire (lecture + clinical) training is 2.5 years while med school basic science is 2 years... I have family and friends and co-workers who are PAs and whom I respect but our training programs are just factually different.

 

[DermViser]

Wow ... Usually it a nurse encroaching on some specialty... Ouch. They have mid levels trying to encroach derm too? I'm pretty sure that makes , what... Every specialty now?

To be fair, the only reason PAs can't encroach further in Derm, is bc they fall under the Board of Medicine. Unlike nurses, who fall under the Board of Nursing.

Hence why all they need is:

• Current NP State Licensure
• Master's degree in nursing
• National certification as a nurse practitioner
• 3,000 hours of general dermatology practice with a current practice in dermatology

and you too can call yourself a "board-certified dermatologist".

http://www.dnanurse.org/sites/default/files/downloads/2014/DCNP_Brochure-App_Combined_0.pdf

 

[wjs010]

To be fair, the only reason PAs can't encroach that much in Derm, is bc they fall under the Board of Medicine. Unlike nurses, who fall under the Board of Nursing.

Hence why all they need is: Current NP State Licensure, Master's degree in nursing, National certification as a nurse practitioner, and 3,000 hours of general dermatology practice with a current practice in dermatology and you too can be a "board-certified dermatologist".

http://www.dnanurse.org/sites/default/files/downloads/2014/DCNP_Brochure-App_Combined_0.pdf

That is dangerous.

 

[DermViser]

That is dangerous.

Quite appropriate they'd call it a pursuit of the "Piece of the Pie".

 

[Dral]

I love how there's a 'how did you hear about us? " Question. Haha

 

[DermViser]

I love how there's a 'how did you hear about us? " Question. Haha

I LOL'ed at that too. I wish I could pay the price for our Derm boards that they pay for theirs: $300/$400 vs. $2500. I could easily use the difference for a vacation getaway.

 

[DermMatch]

I'm in practice now and I will say that derm PAs.... suck.

They don't know how to treat acne.
They let an SCC progress to the point where the woman's left upper lip is now permanently notched upwards s/p Mohs.

But they make money for the MD. You can pay them $150K salary and take all the gravy home yourself, whereas an MD would need around $400K in private practice (all in, salary + production or whatever combination, depending on where you are located). I personally would **** bricks if I hired a derm PA. I'd be neurotically checking their work to the point where it wouldn't make sense for me to house and feed them.

And there's not enough derm MDs to go around.

Of course, it's not PC to criticize PAs or NPs.

 

[BestDoctorEver]

I guess if your specialty is not involved cutting flesh, you are not exempt from PA/NP encroachment. Radiology and Pathology are safe for a foreseeable future because most physicians would be terrified to treat patients based on PA/NP interpretations.

 

[BestDoctorEver]

But they make money for the MD. You can pay them $150K salary and take all the gravy home yourself, whereas an MD would need around $400K in private practice (all in, salary + production or whatever combination, depending on where you are located). I personally would **** bricks if I hired a derm PA. I'd be neurotically checking their work to the point where it wouldn't make sense for me to house and feed them..

I don't think physicians pay them that much... PA derm is the new stuff in South FL now and the few that I have talked to told me they make anywhere from 90k-120k... Heck! that is good for a 2-year professional degree with relatively low student debt.

 

[caide]

You'd have to question the PA's supervising dermatologist for their treatment of acne and skin cancer surveillance as well. I would be concerned with an NP with no supervision in dermatology.

I'm in practice now and I will say that derm PAs.... suck.

They don't know how to treat acne.
They let an SCC progress to the point where the woman's left upper lip is now permanently notched upwards s/p Mohs.

But they make money for the MD. You can pay them $150K salary and take all the gravy home yourself, whereas an MD would need around $400K in private practice (all in, salary + production or whatever combination, depending on where you are located). I personally would **** bricks if I hired a derm PA. I'd be neurotically checking their work to the point where it wouldn't make sense for me to house and feed them.

And there's not enough derm MDs to go around.

Of course, it's not PC to criticize PAs or NPs.

 

[DermMatch]

The sad truth about PAs and NPs is that many of them DON'T have direct MD supervision. MD supervision is often a myth. I know PAs and NPs who practice physically alone, with no MD on site. Think about it: How is the MD going to make money if they have to step into the room with the PA/NP every time, as though they were residents? Not happening. That'd slow you down and you'd take a hit in the pocketbook.

Another example today in clinic: NP stated to patient that her isolated area of hair breakage was solely due to mechanical trauma. Scalp WNL. However, the subtlety here: central centrifugal cicatricial alopecia can present first as hair breakage (possibly because hair shaft is weakened because of subclinical inflammation). NP missed the boat on that one (and this is a relatively good NP).

 

[DermMatch]

@BestDoctorEver you're probably right re: low pay in Florida -- I think it's geographically dependent.

 

[DermViser]

@BestDoctorEver you're probably right re: low pay in Florida -- I think it's geographically dependent.

There are some NPs that are even a part of some academic dermatology residency faculty. Haven't seen PAs (yet).

 

[deleted480308]

There are some NPs that are even a part of some academic dermatology residency faculty. Haven't seen PAs (yet).

?????????????

 

[Dermione Granger]

Indeed, there is at least one program that even allows NP students to do rotations with the department, and go to resident conferences

 

[reno911]

I'm probably as anti-NP/PA as possible (in the way they are most commonly used by derms; there is a good way to use them, but it is less common), but these anecdotes about how some PA or some NP mismanaged a pt in a certain way are not really the best way to fight the encroachment. The sad truth is that one could easily find legitimate board certified MD dermatologists that have made similar mistakes in the course of their practices.

I'm sure the rate of errors is higher with the NP/PA folks, but without any good studies (which I really think would be a great idea for someone to undertake), you're just doing to end up with both sides throwing anecdotes against each other and no one will convincingly win that argument.

 

[DermViser]

I'm probably as anti-NP/PA as possible (in the way they are most commonly used by derms; there is a good way to use them, but it is less common), but these anecdotes about how some PA or some NP mismanaged a pt in a certain way are not really the best way to fight the encroachment. The sad truth is that one could easily find legitimate board certified MD dermatologists that have made similar mistakes in the course of their practices.

I'm sure the rate of errors is higher with the NP/PA folks, but without any good studies (which I really think would be a great idea for someone to undertake), you're just doing to end up with both sides throwing anecdotes against each other and no one will convincingly win that argument.

I hardly doubt midlevels will fund a study which demonstrates poorer outcomes with midlevel vs. physician care. Even physicians will be reluctant to fund such a study due to the blowback it would cause when midlevels (NPs) have a much greater lobbying potential.

That being said, I also think a hearty embrace by academic dermatology residency programs of NPs is not smart either.

 

[Mad Jack]

I guess if your specialty is not involved cutting flesh, you are not exempt from PA/NP encroachment.

I eagerly await our Certified Nurse Surgeon overlords.

 

[BestDoctorEver]

There are some NPs that are even a part of some academic dermatology residency faculty. Haven't seen PAs (yet).

Are these NPs involved in teaching derm residents? Why physicians keep accommodating these people when their sole (hyperbole here) purpose is to replace physicians.

 

[secants]

I'm also having a hard time understanding the stringent cap on Derm resident positions but then specifically training NPs, who can practice independently in several areas, who will, as mentioned above, inevitably to go out and practice as a "dermatologist" and reap the monies. At least stick to PAs..

 

[DermViser]

I'm also having a hard time understanding the stringent cap on Derm resident positions but then specifically training NPs, who can practice independently in several areas, who will, as mentioned above, inevitably to go out and practice as a "dermatologist" and reap the monies. At least stick to PAs..

NPs aren't trained by academic dermatology faculty. NPs are regulated by the Board of Nursing, not the Board of Medicine. Bc their boards are so lax, all they have to do is work some hours with a private practice doc, and get a "certification" from their nursing board (and they probably don't even need that).

 

[secants]

NPs aren't trained by academic dermatology faculty. NPs are regulated by the Board of Nursing, not the Board of Medicine. Bc their boards are so lax, all they have to do is work some hours with a private practice doc, and get a "certification" from their nursing board (and they probably don't even need that).

So it's basically like doing a SubI in Derm and then after one month being able to essentially practice on your own? That's the impression I'm getting. I don't mean train directly by academic derms but from my experience, most PA students and some NPs essentially rotate at places with residencies and "Tag along" the team for whatever service they're on to get their watered down clinical experience. Are the PP docs getting paid to take students?

 

[DermViser]

So it's basically like doing a SubI in Derm and then after one month being able to essentially practice on your own? That's the impression I'm getting. I don't mean train directly by academic derms but from my experience, most PA students and some NPs essentially rotate at places with residencies and "Tag along" the team for whatever service they're on to get their watered down clinical experience. Are the PP docs getting paid to take students?

According to their "brochure": http://www.dnanurse.org/sites/default/files/downloads/2014/DCNP_Brochure-App_Combined_0.pdf

They only need 3,000 hours of practice in any general dermatology practice, which they likely get from private derms by working under them. The Derm NP certification is more just a "gold star" credential (for now), not a requirement to practice dermatology, after which they can then say they're a "board-certified" dermatologist.

 

[llort1337]

This is unfortunate. It seems PAs can do the work of a dermatologist. It's similar to primary care where you have DNPs taking over physician jobs. Many states allow them to work independently and recently I saw one state pays them equal to the physician. Let's hope derm doesn't run into this problem with PAs. If it can happen to primary care, you would think it'd happen even faster in derm considering it takes less comprehensive knowledge than primary care.

 

[asmallchild]

This is unfortunate. It seems PAs can do the work of a dermatologist. It's similar to primary care where you have DNPs taking over physician jobs. Many states allow them to work independently and recently I saw one state pays them equal to the physician. Let's hope derm doesn't run into this problem with PAs. If it can happen to primary care, you would think it'd happen even faster in derm considering it takes less comprehensive knowledge than primary care.

Your recent string of posts, and this one in particular, really highlights how little you know about dermatology.

 

[oracle2]

My derm used to employ another derm, now she has two PA's basically doing the scripts, acne, more basic and routine stuff. She does all the cosmetic stuff, not sure why future derms are complaining about this since clearly she is making more monev off of this model.

 

[asmallchild]

My derm used to employ another derm, now she has two PA's basically doing the scripts, acne, more basic and routine stuff. She does all the cosmetic stuff, not sure why future derms are complaining about this since clearly she is making more monev off of this model.

Making more money doesn't necessarily mean that model is best for patient care, or the future of the specialty.

 

[MOHS_01]

My derm used to employ another derm, now she has two PA's basically doing the scripts, acne, more basic and routine stuff. She does all the cosmetic stuff, not sure why future derms are complaining about this since clearly she is making more monev off of this model.

p.s. There is nothing "clear" about this situation. You make a presumption, one that I cannot agree with in fact.

 

[KanyeWes]

I really wished more people would realize how NP/PA are encroaching on derm, so that the field gets less competitive.

Wishful thinking. On my part.

I am really interested in derm, but I don't have the connections to land this residency.

 

[DermViser]

I really wished more people would realize how NP/PA are encroaching on derm, so that the field gets less competitive.

Wishful thinking. On my part.

I am really interested in derm, but I don't have the connections to land this residency.

Try trolling harder, Kanye West, considering you just got off the waitlist to get into medical school.

 

[KanyeWes]

Try trolling harder, Kanye West, considering you just got off the waitlist to get into medical school.

how am I trolling?

I would like people to realize this encroachment so that this field to be less competitive, so that I can enter it in 3 years when I apply.

The competitiveness has dropped for rads. It happened to gas. I hope it happens to derm in time for me to apply.

again, how am I trolling?

 

[DermViser]

how am I trolling?

I would like people to realize this encroachment so that this field to be less competitive, so that I can enter it in 3 years when I apply.

The competitiveness has dropped for rads. It happened to gas. I hope it happens to derm in time for me to apply.

again, how am I trolling?

"I am really interested in derm, but I don't have the connections to land this residency."

Again, try harder next time in a better attempt at trolling.

 

[KanyeWes]

"I am really interested in derm, but I don't have the connections to land this residency."

Again, try harder next time in a better attempt at trolling.

lol, if that is trolling, then I give up.

I don't have to explain why having access and connections to program directors and faculty who know program directors will be an advantage when getting letters of rec.

lol, I am being trolled by someone calling me a troll. the irony.

 

[DermViser]

lol, if that is trolling, then I give up.

I don't have to explain why having access to program directors and faculty who know program directors will be an advantage when getting letters of rec.

lol, I am being trolled by someone calling me a troll. the irony.

There are people who have matched into dermatology without having a home dermatology residency. You saying, "I am really interested in derm, but I don't have the connections to land this residency," makes it sound like you believe that having "connections" by themselves lands you a derm residency. It doesn't.

 

[KanyeWes]

There are people who have matched into dermatology without having a home dermatology residency. You saying, "I am really interested in derm, but I don't have the connections to land this residency," makes it sound like you believe that having "connections" by themselves lands you a derm residency. It doesn't.

DUH! step scores. research. amazing dean's letters. grades. No one said connections are solely the only thing people need to get into a derm residency. you assumed that, and I never implied that.

but not having a home derm residency program, that puts me at a significant and real disadvantage. if you cannot concede to that, then we have nothing else to discuss.

i have no one to get help or mentorship for that residency, which is essentially almost as hard to land as plastics. how can I seriously land derm when I don't have any meaningful resources at my home school? And they literally specialize in something else.

Geez. haterz everywhere stirring stuff up even when you done nothing.

 

[KanyeWes]

There are people who have matched into dermatology without having a home dermatology residency. You saying, "I am really interested in derm, but I don't have the connections to land this residency," makes it sound like you believe that having "connections" by themselves lands you a derm residency. It doesn't.

What is the proportion of people land derm who don't have a home derm residency program?

My assumption, not many.

 

[asmallchild]

how am I trolling?

I would like people to realize this encroachment so that this field to be less competitive, so that I can enter it in 3 years when I apply.

The competitiveness has dropped for rads. It happened to gas. I hope it happens to derm in time for me to apply.

again, how am I trolling?

Don't hold your breath. The correct mindset is to say you'll work hard for a position. A bit defeatist (and frankly, sad) to wish something becomes less attractive so that you would qualify for it. Not having a home program puts you at a disadvantage, it by no means is a death blow and plenty of students have matched without the benefit of a home program.

 

[Dermione Granger]

I myself came from a smaller school with no home program for derm, neurosurgery etc, and year after year we match students into these fields. Not only were they outstanding, top of the class type student, they also work hard to make connections happen by doing away rotations, research project etc at another school. Many of the derm departments around our area actually know that we dont' have a derm department and they happily take our students for research fellowships or projects. Sure there are some people who have special connections (e.g. father-in-law is a dean or chair somewhere) but almost everyone I know from previous years who matched derm worked hard for it. They did research during M2 to M3 year, did 2-3 aways rotations, and without personality disorder (in most cases they are people you like to hang out with). I sure felt very fortunate to have met many amazing mentors in dermatology who were very willing to take me under their wings for case reports, career advice, and LORs once they know I am serious about derm and I don't have a department or connections. If you look at the derm match list, year after year there are MD students w/o home department who match.

 

[sore eye asses]

I myself came from a smaller school with no home program for derm, neurosurgery etc, and year after year we match students into these fields. Not only were they outstanding, top of the class type student, they also work hard to make connections happen by doing away rotations, research project etc at another school. Many of the derm departments around our area actually know that we dont' have a derm department and they happily take our students for research fellowships or projects. Sure there are some people who have special connections (e.g. father-in-law is a dean or chair somewhere) but almost everyone I know from previous years who matched derm worked hard for it. They did research during M2 to M3 year, did 2-3 aways rotations, and without personality disorder (in most cases they are people you like to hang out with). I sure felt very fortunate to have met many amazing mentors in dermatology who were very willing to take me under their wings for case reports, career advice, and LORs once they know I am serious about derm and I don't have a department or connections. If you look at the derm match list, year after year there are MD students w/o home department who match.

fantastic post. dead-on. btw, great name.

 

[KanyeWes]

I understand it might be a defeatist attitude, but I have to be realistic about my abilities. Not all of us can be derm material in terms of grades, board scores, # research pubs, and etc.

people have their limitations in terms of aptitude, available opportunities, and circumstance.

 

[Medicine123abc]

I mean, I agree with Kanye having matched in Derm this year, went on 15+ interviews and learned about how my home program works with other programs in the selection process. Connections and who vouches for you > everything else. It takes time and access to impress a big wig.

Derm residencies are small so they have a huge impetus to make sure they 'know' who they are getting. Lots of calls behind the scenes. Plenty of double checks. And if you're an unknown with great stats/recs, you're viewed as suspect in regards to 'really' wanting to attend to that program. There are plenty of students that look like you that they 'know' or someone they know knows you.

Yes, you can do all the things Dermione suggests...but what MS1 can confidently say "yes I want to do Derm" on day 1. It shouldn't be that hard. I have nothing against research fellowship, though I didn't do one, but it's like writing a $300,000 check to the world for the privilege of doing someone else's research for a year. Is it truly formative or is it to ensure a spot in Derm? Last time I checked medical school is 4 years, medical training is long enough already and expensive enough already.

I think the process needs to de-emphasize the letters of rec and who you know. It should be more fair in regards to a more rigorous on-site interviewing to really assess a candidate's problem solving ability (as elite companies do) and understanding of their research (whether in cards, derm, health policy). The pitfall of not evolving the selection process is that every Derm applicant is going to follow the same formula..