IF YOU ARE LIKE MOST DERMATOLOGISTS, THE demands of treating multiple patients daily, responding to patient prescription calls, making practice management decisions, and otherwise maintaining a quality personal and professional life probably leave you harried. Although it may seem that you have not had a break in weeks and that your office has become your home, there may be a way to regain your life:  hire a [Certified] Physician Assistant.
 
Physician Assistants, or PAs, are DEpendent practitioners of medicine and  surgery, trained in one of 106 accredited medical school-model programs  across the country. Licensed or certified to practice by Boards of Medical  Examiners or the equivalent, PAs are found in virtually every specialty and  subspecialty of medicine and surgery in every sector of health care-private  practice, governmental and military, academic, and inpatient as well as outpatient settings. They currently number about 40,000, with about 55 percent of them practicing primary care.
 
 In 1972, a small number of PAs began practicing with dermatologists. With  the advent of managed care and falling reimbursement in the early 1990s,  fundamental changes in the profession gathered momentum which caused the  numbers of derm PAs to grow from six in 1993 to over 250 at present, with  weekly additions of PAs filling some of the 300 [derm] job openings nationwide.
At  this rate, the total number of derm PAs should reach 500 late in 2000.  In 1993, the Society of Dermatology Physician Assistants (SDPA) formed to further the employment and education of PAs in that specialty. The SDPA, a constituent organization of the American Academy of Physician Assistants, functions as a resource for dermatologists seeking information about PAs.
 
In that regard, SDPA has run an exhibit booth at the annual AAD conference  for the past three years, where we have spoken with hundreds of  dermatologists, answering their questions, as we do for the many who call  our organization. From those conversations, we have compiled some of the  most commonly asked questions that elucidate the facts about dermatology PAs.  Actual practicing derm PAs significantly contributed to the answers,  based on their own experiences.

1.  Where do PAs get their dermatologic training. Will I have to provide it?

PA programs are modeled after primary care medical curricula and include about the same amount of didactic and clinical dermatology training as medical school does. All students receive instruction in suturing, a valuable asset in a dermatology practice. Some PAs going into dermatology complete a surgical residency, and many come from surgical backgrounds. All experienced primary care PAs see the routine dermatologic problems that typically present to such practices. The typical PA student today has four years of health care experience as RNs, EMTs, [NPs] corpsmen or paramedics before entering PA school, and most have an undergraduate degree in science. So even PAs inexperienced in dermatology have had considerable exposure to it.
 
With only about 250 experienced derm PAs in the U.S., chances are you'll  need to train the person you hire. The good news is that if you hire the  right person and wisely invest some of your time, it won't be long at all  before the PA starts seeing selected patients on their own.  

To maintain certification, PAs must acquire 100 CME hours every two years.  Dermatology PAs seek this education at dermatology conferences. The SDPA  provides dermatology PAs with many educational resources: free dermatology magazines, a list of recommended books and CDs, a home-study course, a  website for derm instruction, and rotations with members.
 
A PA can obtain an MPAS degree with concentration in dermatology from the  University of Nebraska's Distant Learning Option. Some MDs arrange for their  new PA to attend a dermatology residency program for 2-3 months. The SDPA hopes  to develop a standard certification exam for dermatology PAs.

2.  What can a derm PA do, legally; What is his or her function 
in the office?  

The short answer: anything the supervising physician wishes to delegate, is allowed by state law, and the PA is competent to do. In most cases, PAs simply become another provider in the office.
 
The same state Board of Medical Examiners that oversees physicians also  governs most PAs. You can obtain a summary of your state's laws, showing  scope of practice, supervision required, prescribing authorities, regulating  authorities, etc., from AAPA within 60 seconds via fax. Phone (800)  286-2272, and key in document number 230.
 
Members of the Society of Dermatology Physician Assistants possess a wide  variety of clinical and surgical dermatology skills. They diagnose, treat,  and prescribe for various dermatologic conditions. They do biopsies, excisions, cryotherapy, phototherapy, patch testing, in-patient consults,  plastic surgery, laser resurfacing, assist at and close Mohs surgery,  perform chemical peels, collagen replacement therapy, intralesional injections, assist at liposuction, harvest skin grafts, and hair transplants. Some may specialize in such areas as: industrial derm, psoriasis, HIV, acne, tattoos, and advanced sclerotherapy. Many also teach in PA programs and some are preceptors in dermatology to farnily-practice residents.

3.  What is the average salary for dermatology physician assistants?

Asking this question is like asking what the average dermatologist earns. It all depends on experience and work performed.

Is the PA doing warts and acne, or lasers and Mohs assisting? Does he or she  have a medical assistant or an RN? PA's doing a good amount of surgery and  laser procedures, or seeing many patients in high cosmeticcontent jobs are at the high end of a $50K to well over $100K total income that includes  production bonuses plus base salary. Survey results show the average PA sees  28 patients daily.

Physician Assistants are licensed medical practitioners making a tremendous impact on the practice of medicine and patent care.  Today, an estimated 40,000 PAs work in the United States. The American Academy of Physician Assistants is headquartered in Alexandria, Virginia, which has official liaison status to most national medical oganizations such as the AMA, AAFP, as well as   the various other specialty organizations, represents their interests nationally.  The profession began in 1967 at Duke University as an effort to impact physician shortages by giving additional training and credentials to former military corpsmen.  But in the ensuing 30 years there was a development that almost no one would have predicted.

Experience showed that PAs could perform a surprisingly large percentage of the tasks traditionally reserved for physicians.  Along with improvements and standardization of their educational process, the result has been nothing less than the evolution from assistant to cost effective, true practioners of medicine and surgery.  Through it all, PAs have steadfastly maintained their dependent, non-competitive relationship with physicians, considering themselves to be team players, always subordinate to the physician as team captain.

The bottom line: According to an ongoing salary survey, a PA with about two  to three years derm experience will likely generate a conservatively  estimated revenue of three to four times [his/]her salary and would likely be "paying [his/]her own way" within six months, even if she is a new graduate. So  by the end of the year, you should easily recover the salary paid to the PA  during the training period. Some experienced PAs who see all comers and do  multiple procedures generate five to seven times their income, according to the same survey. Obviously, in your own situation, a great deal will depend  on the efforts of the PA you hire and on how comfortable you are teaching  and delegating.

4.  How do I bill for a PAs services? 

Depending on the insurance carriers you deal with, your PA will either get a provider number or bill under your name. Either way, you can bill for his/her services using the same codes you use now. The best way to find out about billing in your area is to talk to dermatologists in your state who also have a PA or call the American Academy of Physician Assistants (see below). The SDPA can help you locate such a practice.

5.  What about the acceptance of the PA by staff, patients, and referral base? 

The key is communication. Discuss your intention to hire a PA with your staff at the outset, giving them an opportunity to offer input, including interviewing the applicant. Carefully explain the applicant's qualifications as a provider to lessen the chance of misunderstanding. If staffers understand that you (and your partners) enthusiastically support the decision to hire a PA, they too will be enthused. If they understand that having a PA will make their lives less hectic, get them home earlier at night, and ensure the financial stability of the practice, the move will likely have their support.

In the same vein, patients will take their cue from physicians and support  staff, and will accept the PA to the extent they see acceptance  demonstrated. To avoid surprising your patients, consider having a brochure  printed up to introduce the new provider and his or her qualifications. Mail  it to selected patients, and leave copies in the waiting room and with the receptionist. Make sure your patients know that having the PA around will  mean they get their problems taken care sooner. If you do this right and if  you pick the right PA, you may overhear some of your patients asking to see  the PA!
 
You would do well to send this same brochure to your key referring physicians along with a letter introducing the PA to them. Let them know  their patients may be offered an appointment with the PA who can see them sooner, but that they always have the choice of seeing you instead. Consider holding a reception (or a luncheon, perhaps) for the PA so these physicians can come meet the PA personally. If they hear that the patient they sent to the dermatologist was seen by a PA they've never heard of, they may be upset. Things will go much better if they know who the PA is, and they hear their patient is pleased about getting an appointment so quickly.

6.  What does hiring a dermatology physician assistant do for me, personally?

Let's look at this typical scenario: The PA sees 30 patients (10 of them same-day appointments), does two hours worth of surgery, sees two drug reps, and covers five patient phone calls for refills, generating $1,500 revenue or about four times what you pay him[/her].   During the same day, you see 30 patients, in a timely fashion (down from  your usual 50) and get an hour for lunch instead of the usual 15 minutes.  You and your staff get home an hour earlier than usual. Your family is  pleased, the administrator is happy, your income goes up, your hours go down, and your patients get in quicker. They, your staff, and you are more relaxed.

7.  Are there any dermatologists I can talk to who already have PAs in their office? 

Yes, upon request by a dermatologist, we provide a list of 25 dermatologists who have volunteered to personally answer your questions.

8.  How do I find a qualified physician assistant? Where do I advertise? 

SDPA is not a recruiting firm but can help you find a PA through:

•    SDPA's Member Newsletter (place a free ad).
•    The Internet, where you can post your contact information to 150 online  SDPA members.
•    A list of PA magazines in which to advertise.
•    Very abbreviated resumes of many PAs who are seeking jobs in dermatology in your state.