jplkl

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Annually I make an appointment to have my Dermatologist examine me for potential skin problems. At the last appointment the office called and said the PA would be doing these screenings going forward. I'm wordering what Dermatologists think of this practice? Why should I settle for a PA screening me for skin problems over a Board Certified Dermatologist?
 

doctalaughs

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Annually I make an appointment to have my Dermatologist examine me for potential skin problems. At the last appointment the office called and said the PA would be doing these screenings going forward. I'm wordering what Dermatologists think of this practice? Why should I settle for a PA screening me for skin problems over a Board Certified Dermatologist?

Go to a different practice. While it’s common to employ PAs — at the very least you should be given a choice who does your screen, even in a practice that utilizes them.

Only practices I see that have the mid levels do ALL the screens are those that are telling them “you need to do 3 biopsies per patient” and then just feed all the minor stuff into a Mohs mill, or excise every mildly atypical nevus.
I personally only use em for acne and warts.
 
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deleted480308

Annually I make an appointment to have my Dermatologist examine me for potential skin problems. At the last appointment the office called and said the PA would be doing these screenings going forward. I'm wordering what Dermatologists think of this practice? Why should I settle for a PA screening me for skin problems over a Board Certified Dermatologist?
If I care enough to go to a specialist I want to see a specialist
 
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Dr. Doctor MD

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Annually I make an appointment to have my Dermatologist examine me for potential skin problems. At the last appointment the office called and said the PA would be doing these screenings going forward. I'm wordering what Dermatologists think of this practice? Why should I settle for a PA screening me for skin problems over a Board Certified Dermatologist?
In my (unrealistic) personal opinion, midlevels in dermatology should never be allowed to perform a total body skin exam that isn't 100% re-checked by a board certified dermatologist. (I acknowledge that this is purely wishful thinking and will never happen, but I'll explain my reasoning).

A total body skin exam could theoretically reveal one or more of hundreds to thousands of different dermatology diagnoses, the majority of which a midlevel probably hasn't even heard of. Sure they can play "guess the atypical nevus" or find the "pink bump" or "brown bump" and biopsy every single one, but that is garbage medicine, and they are just playing guess and check. They will consistently miss important findings and scar patients with their shotgun biopsy method. The more and more dermatology patients that midlevels see for skin checks, the worse they disfigure and scar the general public and the number of missed or delayed diagnoses increases.

When a board certified dermatologist examines you head to toe during a skin check, they are evaluating your skin in its totality. They have studied pure dermatology for 3 years, passed some of the most rigorous board exams, and are aware of the vast majority of cutaneous pathologies.

When a dermatolgoist looks at your skin they aren't just looking for pink or brown bumps: Are there any spots suspicious for cutaneous neoplasms? What pigmentation changes are present and what could they represent? Are there areas where the skin is xerotic, scaly, or excoriated? Is that subtle thin pink papule an amelanotic melanoma, an inflammatory papule, or a funny looking SK? Could an underlying systemic disease be responsible for an increased number of benign skin findings that otherwise wouldn't be worrisome (Leser-Trelat, Stigmata of Liver Disease)? Are nail changes present, and if so what do they represent? For numerous uncommon benign findings that can be found on skin exams, is there any further exploration that needs to be done or other diseases to search for? Has the literature shown that benign finding to be associated with a systemic or underlying disease, and if so what additional questions should you ask the patient? Based on their medical history are there additional areas that should be checked or other specific ROS questions to be asked during the exam?

The list goes on and on... but the point is that a midlevel could never do this, not with even with 30+ years of experience? So no I would never ever go to a midlevel for a skin check.

At least for a dermatology visit with a specific complaint, the midlevel knows what the chief complaint is and can take a stab at it even if they are completely wrong. Hopefully they call in their supervising physician if they are confused or if there is any uncertainty, or eventually after several round of mismanagement a physician will finally get involved. But how could a midlevel involve a physician in your care when they didn't even pick up the problem to begin with on a routine skin exam? They can't

TLDR; Don't go to a midlevel for a skin check
 
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jplkl

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Thank you all for your responses. I thought having PAs doing the screen was bad medicine. I’ll try to convince my Dermatologist to change this practice or find a new one.
 
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deleted480308

Thank you all for your responses. I thought having PAs doing the screen was bad medicine. I’ll try to convince my Dermatologist to change this practice or find a new one.
I would be shocked if every doc with midlevels doesn’t have some portion demand to only see the doc
 
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naijacardriodoc

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dermatologist for sure...PA I saw kept undervaluing my need for accutane until the dermatologist came in and said yes I need it. It was very frustrating. I will never do that again.
 
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I called up a private derm practice in my town to have an "age spot" looked at on my cheek that had grown larger and darker over a period of about 5 years.

It was a cosmetic-heavy practice where the board-certified derm was busy all day doing procedures. I was asked by the secretary on the phone if it was the kind of lesion that needed a dermatologist to look at or would a PA suffice? Very odd question, since I didnt inform her I had any medical training that would qualify me to make this kind of decision. I can sort of understand a really busy practice where PA's would see 90% of all first visits and then refer appropriate cases to the derm, but when did it become normal for a front desk person to ask patients to screen themselves for what kind of provider they need?
 
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chocomorsel

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This country is all about money. There is so much greed in medicine and plenty of doctors who are in this straight up to make as much money as possible without regard to actually doing work to help people.
But such is this country. All about me me me and money money money. Look at it now.

And no, it’s not OK to expect PAs to see 90% of first visits. What if they miss something and don’t refer? They should maybe do the follow ups.
 
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reno911

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dermatologist for sure...PA I saw kept undervaluing my need for accutane until the dermatologist came in and said yes I need it. It was very frustrating. I will never do that again.

It's hard to read a lot into this experience.

You could take one acne patient, have two different dermatologists look at them, and come up with two different opinions on whether accutane is indicated.

I'm not sure that would imply that one of them was incompetent.
 
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chocomorsel

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It's hard to read a lot into this experience.

You could take one acne patient, have two different dermatologists look at them, and come up with two different opinions on whether accutane is indicated.

I'm not sure that would imply that one of them was incompetent.
Either way, it's better that it comes from the dermatologist. Yeah, there is more that one way to skin a cat.
But why is it a four year residency if a PA with 1/4 the education can do it?
Are we over educated and unneeded?
 
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doctalaughs

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Can midlevels do simple dermatology like accutane/acne, Botox, warts etc. Sure- just like CRNAs do simple anesthesia. Should they? Probably not (just like they shouldn’t be practicing any sort of medicine with essentially no direct oversight).

The ironic thing is that most many MDs (not just Derm) no longer even make money off their midlevels, as PE firms take it all.
 
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reno911

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Spoken like someone who loves using mid levels at “top of their license”.

I disagree and clearly the person who wrote that felt the same way too.

I'm not sure what alternate reality you've got in your head, but I'm sure it's fascinating.

I've never had a mid level and never will. I'm about as anti-midlevel as can be.

But I'm even more against bad logic.

So feel free to disagree all you want, it's still illogical. Anyone who thinks that anecdote above somehow proves midlevels are bad, is terrible at logic, dermatology or both.

There are plenty of legitimate reasons to be wary of midlevels, there is no reason not to stick to those.

Throwing poorly-reasoned criticisms at midlevels hurts your agenda much more than saying nothing at all.
 
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chocomorsel

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I'm not sure what alternate reality you've got in your head, but I'm sure it's fascinating.

I've never had a mid level and never will. I'm about as anti-midlevel as can be.

But I'm even more against bad logic.

So feel free to disagree all you want, it's still illogical. Anyone who thinks that anecdote above somehow proves midlevels are bad, is terrible at logic, dermatology or both.

There are plenty of legitimate reasons to be wary of midlevels, there is no reason not to stick to those.

Throwing poorly-reasoned criticisms at midlevels hurts your agenda much more than saying nothing at all.
If a patient is the one who feels undervalued by a mid level then it doesn’t hurt our agenda to listen to their concerns and gladly treat them. I hope you aren’t telling your patients they are being illogical by wanting to see you instead of a PA or NP.
 

reno911

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If a patient is the one who feels undervalued by a mid level then it doesn’t hurt our agenda to listen to their concerns and gladly treat them. I hope you aren’t telling your patients they are being illogical by wanting to see you instead of a PA or NP.

You seem to make a lot of baseless assumptions about what I think.

There are plenty of logical reasons to desire to see an MD instead of a midlevel. Tons of them.

So, if that's all a patient said (i.e., "I'd prefer to see an MD"), then I would just assume they had a logical reason, and act accordingly.

In the unlikely event that they stated that preference and gave only some sort of illogical reason, then I would actually address the bad logic. First of all, to make sure I'm understanding them correctly and secondly, to hopefully improve their health care decision-making processes. I have actually done this in several contexts, but never in regard to a mid-level vs doc discussion. It never really comes up since there are no midlevels in my practice.
 

chocomorsel

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You seem to make a lot of baseless assumptions about what I think.

There are plenty of logical reasons to desire to see an MD instead of a midlevel. Tons of them.

So, if that's all a patient said (i.e., "I'd prefer to see an MD"), then I would just assume they had a logical reason, and act accordingly.

In the unlikely event that they stated that preference and gave only some sort of illogical reason, then I would actually address the bad logic. First of all, to make sure I'm understanding them correctly and secondly, to hopefully improve their health care decision-making processes. I have actually done this in several contexts, but never in regard to a mid-level vs doc discussion. It never really comes up since there are no midlevels in my practice.
Not making assumptions this time. Maybe initially when it sounded like you were defending the midlevel and not listening to the poster. Glad I was wrong.
Now, I am Just repeating what the poster above said. You can think it illogical all you want, just hope you aren't telling the patients that. Because to the patient, their thought process makes perfect logic. And it makes sense to me to listen to the patient's concerns.

But Kudos to you for not working with midlevels.
 
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reno911

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Not making assumptions this time. Maybe initially when it sounded like you were defending the midlevel and not listening to the poster. Glad I was wrong.
Now, I am Just repeating what the poster above said. You can think it illogical all you want, just hope you aren't telling the patients that. Because to the patient, their thought process makes perfect logic. And it makes sense to me to listen to the patient's concerns.

But Kudos to you for not working with midlevels.

If a patient told me exactly that (i.e., the anecdote in the post above), then I would absolutely tell them it was illogical. That doesn't mean I'm not listening.

Patients have all sorts of misconceptions that we correct all the time.
 

doctalaughs

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If a patient told me exactly that (i.e., the anecdote in the post above), then I would absolutely tell them it was illogical. That doesn't mean I'm not listening.

Patients have all sorts of misconceptions that we correct all the time.

Patients say all sorts of illogical (and sometimes outright stupid) things.

I’ve learned over the last 20 years as a rule— unless it’s going to harm their health it’s best to say basically nothing.

Believe me- you’ll be happier, they will be happier and actually they are probably more likely to listen to you when it really matters (health wise).

But just my 2 cents; you can obviously practice how you want!!
 

reno911

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Patients say all sorts of illogical (and sometimes outright stupid) things.

I’ve learned over the last 20 years as a rule— unless it’s going to harm their health it’s best to say basically nothing.

Believe me- you’ll be happier, they will be happier and actually they are probably more likely to listen to you when it really matters (health wise).

But just my 2 cents; you can obviously practice how you want!!

Sure they say all sorts of stupid stuff, and most is ignored. But if a patient has had an issue with a relationship with another doc or provider and it comes up, it's worth exploring as it may inform your relationship with the patient going forward.
 
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doctalaughs

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Sure they say all sorts of stupid stuff, and most is ignored. But if a patient has had an issue with a relationship with another doc or provider and it comes up, it's worth exploring as it may inform your relationship with the patient going forward.

I suppose. Although in a prior lifetime I used to be in charge of my group in a multi-specialty practice and had to review/investigate patient complaints about their doctors. Over the years (and many thousands of complaints) I found the complaints that needed “further exploring” were maybe 1 in 1000. The rest you could nod your head and know everything you needed to know (and there was ZERO chance to “correct” their views).
 
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reno911

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I suppose. Although in a prior lifetime I used to be in charge of my group in a multi-specialty practice and had to review/investigate patient complaints about their doctors. Over the years (and many thousands of complaints) I found the complaints that needed “further exploring” were maybe 1 in 1000. The rest you could nod your head and know everything you needed to know (and there was ZERO chance to “correct” their views).

I suppose I could have been clearer about that. The scenario we're talking about is hypothetical, so it's not of much value.

But in the general case, when I say "correct" their views, what I mean is "try to correct" by just pointing out obvious stuff. I'm not going spend a lot of time on it (for something like this it would be extremely minimal), and as you say, more often than not you're not changing any minds. But I probably won't just let it pass and make it seem like I agree (assuming it's something that is relevant to our relationship -- if they're just making small talk, I can smile and nod with the best of them).
 
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