What is a Physician Assistant? 

A certified physician assistant (PA-C) is a licensed health care professional who practices medicine under the supervision of a physician, has completed a rigorous curriculum (Table 1), and has successfully completed the certification board administered by the National Commission on Certification of Physician Assistants (NCCPA). The NCCPA is an independent organization and its commissioners represent numerous medical professions. The certification for PAs is time-limited with recertification required every 6 years. PAs are also required to complete 100 hours of continuing medical education (CME) every 2 years with at least 50 of these hours in Category I. Physician assistants are formally trained in primary care and have graduated from one of 104 accredited academic medical model training programs in the United States. These programs are affiliated with medical schools and medical school faculty are responsible for a majority of the teaching. The matriculation requirement (Table 2) for PA programs is a bachelor's degree or substantial experience in an allied health field such as medical technology, radiological technology, nursing, pharmacy, or emergency medical technology. While most PA's enter training with the expectation of working in primary care, significant numbers of graduates seek positions in specialty care (Table 3). While there are a number of specialty-based physician assistant postgraduate training programs most PAs receive their specialty experience through on-the-job training. 

Who Establishes the Scope of Practice of the Physician Assistants? 

A PA provides a broad range of health care services that are traditionally performed by a doctor. PAs are trained to perform physical exams, diagnose illness, develop and implement treatment plans, order and interpret lab results, suture wounds, assist in surgery, provide preventative health care counseling, and, in 41 states, write prescriptions. A PA's role in a medical practice is determined by statute and by the supervising physician. 

What Does a PA Do in Dermatologic Surgery? 

In our practice the PA has her own patient-schedule and dedicated space. Both new and follow-up patient visits are scheduled for the PA. New patient encounters typically include skin cancer screening and preoperative consultation. Patients are also scheduled with the PA for consultation regarding cosmetic procedures such as laser resurfacing, pulse dye laser, tattoo removal, chemical peels, and dermabrasion. Follow-up visits include interval examination of skin cancer-prone patients and postoperative visits. Performance of skin surveillance for skin cancer by the PA is a valuable time saver for the physician. Clinical findings are discussed with the physician prior to the physician-patient encounter. The PA implements the biopsies, discusses wound care, writes prescriptions, and schedules appropriate follow-up appointments. Additional procedures such as cryotherapy, intralesional injection, preoperative photography, and office note dictation are also responsibilities of the PA. These time-consuming activities maximize physician efficiency while leaving patient care uncompromised and in most instances enhanced. Phone inquiries from existing and prospective patients and referring physicians are also effectively fielded by the PA (Table 4). A dexterous and motivated physician assistant can be trained to expertly perform numerous procedures. In our practice, the PA performs most of the laser therapy for vascular lesions, tatoos, and pigmented lesions. Patients are seen with the physician prior to each treatment session and the laser parameters are reviewed. The PA performs simple fusiform. excisional biopsies after discussion of the margins and orientation of the ellipse. Patinet-specific issues such as suture material, anesthesia, anatomy, and postoperative care are addressed as necessary. The physician is immediately available at all times during procedures. Following Mohs micrographic surgery, the PA is involved in wound management, such as undermining, side-to-side closure with dog-ear repair, and wound closure after tissue rearrangement (flap) surgery. While the physician designs, incises, undermines the flap, and places key sutures, the remaining portion of the procedure is performed by the PA. The PA performs full thickness grafting in selected patients after the physician's selection of the donor site. The PA also implements split-thickness grafting after the graft is harvested by the physician. 

How Do Patients Feel About a PA? 

Even in a referral-based quaternary care dermatologic surgery unit, patients have been extremely receptive to the involvement of a PA in their care. We feel that there are several essential elements that facilitate this: the professionalism of the PA; the level of professional interaction and respect shown to the PA by the supervising physician in the presence of the patient; the high level of confidence exhibited by the supervising physician toward the PA; and the actual demonstration of superb, meticulous, and methodical care by a well-trained PA. A frequently encountered comment from colleagues practicing in a more urban environment is that "my patients would never accept a PA." While we practice in bucolic North Carolina, our patients span the socioeconomic spectrum and we have never encountered this sentiment. 

What Role Does a PA Play in Academic Medicine? 

In addition to their ability to provide an extraordinary dimension to patient care, physician assistants play an important role in our academic mission. Our department employs three full-time physician assistants. Each of the PAS are appointed to our faculty and are highly integrated into the department's teaching mission. They are highly respected by PA students, medical students, and dermatology residents for their expertise and professionalism and have served as primary authors on peer-reviewed publications. 

What Formal Education is Available for PAs in Dermatology? 

The PAS in our department regularly participate in a variety of intradepartmental conferences including Kodachrome sessions with the residents and students, journal club, and clinical conferences. They perform in both student and teacher roles. In the absence of their supervising physicians the PAS can provide a reliable, well-educated perspective of his/her subspecialty area to conference attendees. In addition to local and regional specialty meetings, our PAS regularly attend the annual meeting of the American Academy of Dermatology as well as other national meetings. 

Are We Training Our Future Competitors? 

A frequent concern expressed about training PAs in specialty care is that a dermatologically-trained PA will become part of a gatekeeper's system and create an impediment to patient access to dermatologists. If we believe that we as dermatologists are the only specialists in diseases of the skin and that 3 years of postgraduate training are necessary to obtain this expertise, we can also confidently believe that specialty-trained PAS would not supplant the level of care that we provide. Moreover, all physician assistants are legally and ethically bound to practice under the supervision of a physician and never in competition with them. 

Conclusion 

Currently in the United States there are approximately 31,300 PAS in clinical practice. More than 7,500 students are enrolled in PA programs in 1998. The role that these physician extenders can play in dermatologic surgery is vast as is the resulting enhancement of patient care and physician efficiency. 

References 

1. I. Hughes N. American Academy of Physician Assistants News, 1997; 18:1. 
2. Davis A. American Academy of Physician Assistants News, 1998; 19:1. 
3. Clark AR, Jorizzo JL, Fleischer AB. Papular Dermatitis (subacute prurigo, "itchy red bump" disease: Pilot study of phototherapy). J Am Acad Dermatol 1998;38:929-33. 
4. Vonseggen W, Hinds A. Physician Assistants in North Carolina. N C Med J 1993;54:276-80.