ARTICLE FROM DERMATOLOGY WORLD PUBLISHED BY AAD FEBRUARY 1996 ISSUE, Page 13 "Physician Assistants Following Managed Care Into Dermatology Practices." For physician assistants, their time has come. The economics of managed care and the current emphasis on cost reduction are making PA's common participants in the provision of medical care, including dermatologic services, as the demand grows for quality care at affordable prices. "These mid-level providers are ideally suited to this cost- containment era," said Donald Scott, M.D., a Palm Springs, Calif., dermatologist, who has used a physician assistant in his practice for five years. "Having him with me helps open the practice to more patients." PA's fit well in a busy dermatology practice that is taking care of more patients under managed care, Dr. Scott said. They can help keep patients who need dermatologic care within the specialty since many of those patients are in health plans and might otherwise be seen by another physician who doesn't understand dermatologic care as well as his PA, he noted. "If PA's were allowed to do more work they would be able to take care of more of the large number of patients dermatologists see," Dr. Scott said. As nonphysician practitioners, PA's are trained to understand their limitations, so they don't work on cases that are beyond their education, experience, skill level, or what the state law allows them to do, he added. PA Background PA's began treating patients nearly 30 years ago. They work in every type of medical and surgical specialty, clinics, operating rooms, the military, physicians' offices and HMO's. PA's can provide a broad range of medical services, as long as they do so under a physician's supervision. Depending on state requirements and the arrangement between the physician and the PA, they perform physical exams, diagnose, treat illnesses, order and interpret tests, assist in surgical treatment of a variety of clinical pathology, and sometimes write prescriptions. Many states allow the physician assistant to practice in a satellite clinic. According to American Medical Association Guidelines for Physician/Physician Assistant Practice, the supervising physician must also identify the PA's scope of practice, exactly what services he or she is responsible for and how each service should be handled. Several dermatologists who use a PA said they often see a patient with the PA, help the PA decide the course of treatment and review and sign all medical charts. More than 25,000 PA's now practice in the United States, nearly one-quarter of them in large cities. Many assist in medically-underserved communities, prisons, rural clinics and in HIV medicine. About half practice primary care medicine. In some rural areas, a PA is the only health care provider and confers with the supervising physician at a distance. Overall, PA's account for more than 150 million patient visits last year and wrote nearly 170 million prescriptions, according to the American Academy of Physician Assistants. PA's are often trained in some other area of health care before they enter a two-year medical physician assistant training program. Most held four-year undergraduate degrees, some have master's degrees and many had professional credentials such as R.N. or M.T. PA's must be certified by the National Commission on Verification of Physician Assistants, complete state licensing requirements and attend continuing education courses. To maintain certification, PA's must complete 100 hours of CME every two years and pass a recertification exam every six years. Currently, 68 accredited PA training programs in the country each graduate 25 to 100 assistants per year. PA's learn dermatology through on-the-job training with dermatologists, the completion of 50 hours of required CME per year, AAD and other dermatology-related CME conferences, lectures, tumor boards, dermatology grand rounds and home-study courses. Some PA programs offer lectures on dermatology and elective clinical dermatology rounds to PA students. Fitting In Doctors who are seeing more patients, spending less time with each one and watching costs rise could benefit from hiring a PA, said an AAPA spokesperson. Many dermatologists already perceive a need for PA's in their offices, according to Marie- Louise Johnson, M.D., chair of AAD's Allied Health Care and Patient Advocate Liaison Committee. The number of dermatology PA's is expected to grow as managed care proliferates and as more dermatologists accept capitated payments. The day-to-day activities of a physician assistant in dermatology vary depending on the practice setting. They often free up physicians to concentrate on more complicated dermatologic conditions. Besides handling routine patient care and education, they can assist with Mohs surgery, laser treatments, plastic and cosmetic surgery, chemical peels, tatoo removals, collagen replacement, sclerotherapy, and AIDS and acne treatment. Other PA's in dermatology work in university and teaching hospitals. Kurtis Opp, a PA who works for Marcus Conant, M.D., a San Francisco dermatologist, sees between 15 and 20 patients per day. Dr. Conant said he is pleased with how the arrangement affects his practice. Having an assistant to provide routine dermatologic care helps him practice state-of-the-art science in dermatology and HIV medicine, he noted. "A lot of doctors don't realize PA's can do minor surgical procedures and treat skin conditions associated with HIV disease," said Opp, a certified physician assistant and president-elect of the Society of Dermatology Physician Assistants. He also conducts research for Dr. Conant. In California, there are 2,600 PA's, who along with their supervising physician, are responsible for 50,000 patient visits per day, Opp said. PA's make good partners because they are trained to handle most common medical problems and complement a dermatologist's skills, said Joe Monroe, a certified physician assistant and SDPA's president and founder. Consequently, they can help dermatologists increase productivity and patient access to care. The society has about 125 members and strives to increase awareness of the role of dermatology PA's. Initially, some patients might have misgivings that the PA isn't a physician, but as they get to know the PA, those misgivings disappear, Dr. Scott said. A possible reduction in the number of slots in dermatology residency training programs and the subsequent drop in graduates could further expand demand for PA's, he added. PA's don't compete the physicians, dermatology nurses or nurse practitioners, Monroe said. He invited physicians to become acquainted with the PA's functions and capabilities so the two groups can work together as teams. "We won't reshape the face of dermatology, but we will be a player," he said. For more information on PA's, contact SDPA, 5705 N.E. 116th St., Vancouver, WA 98686; phone (360) 574-6919; fax (360) 253- 1446, or e-mail: jomonroe@pacifier.com, or visit the PA home page on Internet's World Wide Web at http://www.halcyon.com/physasst/. end SDPA updated Note: The URL for the web site for the PA Home Page has changed to: http://www.papage.com/papage/ Also...PA's are well suited to HMO's, but the majority of our members (95%) work in private dermatology practices. There are now 78 accredited Physician Assistant Programs.