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Editorial |

Mid-Level Practitioners in Dermatology:  A Need for Further Study and Oversight

H. Ray Jalian, MD1; Mathew M. Avram, MD, JD2,3
[+] Author Affiliations
1Division of Dermatology, University of California, Los Angeles
2Wellman Center for Photomedicine, Massachusetts General Hospital, Boston
3Department of Dermatology, Massachusetts General Hospital, Boston
JAMA Dermatol. 2014;150(11):1149-1151. doi:10.1001/jamadermatol.2014.1922.
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Since the passing of the Congressional Balanced Budget Act in 1997,1 the scope of practice of mid-level health care providers, namely nurse practitioners and physician assistants (hereinafter “mid-level providers”), has rapidly expanded. While originally envisioned to improve access to primary care in underserved areas under the supervision of a physician, mid-level providers have expanded their scope of practice and are now able to bill independently for the procedures they perform.

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The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
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Comment of Mid-Level Practitioners in Dermatology
Posted on September 18, 2014
Binh Ngo, M.D.
Keck U.S.C. School of Medicine
Conflict of Interest: None Declared
The article: Scope of Physician Procedures Independently Billed by Mid-Level Providers in the Office Setting by Coldiron and Ratnarathorn in the August edition of JAMA Dermatology (1) raises awareness of an alarming trend to substitute physician extenders for trained and qualified physicians in the diagnosis and treatment of complex conditions. Dermatology is a specialty requiring four years of training. Board certification requires documentation of adequate performance on a large number of procedures and success on a difficult examination and subsequent recertification at ten year intervals. Physician assistants and nurse practitioners do not have this training, nor proof of adequate performance. The original intent to expand primary care was to allow physician extenders to deal with common conditions with simple treatments. That intent has been grossly perverted. The Medicare payment data cited by the authors confirms the reality that physician extenders are now independently evaluating complex conditions and performing surgical procedures without physician overview. I have seen many cases where improper care was delivered by such unsupervised staff. For example, an electrodesiccation and curettage was performed on an invasive squamous cell carcinoma on the scalp, a lupus rash misdiagnosed as contact dermatitis, and mastitis misdiagnosed as contact dermatitis and improperly treated with prednisone. In some practices, these staff members perform Mohs surgery on difficult to eradicate skin cancers, procedures wherein dermatologists typically receive an additional year of Fellowship training. The role of a physician extender should be to supplement the work of a physician, not to practice medicine autonomously. Patients are often shunted to physician extenders when they arrive for appointments with the physician. They should be informed beforehand whether the doctor or physician extenders will be seeing them in the office and who will be doing a procedure on them. If given the choice, patients overwhelmingly want their care to be provided by qualified professionals (2). The current trend to degrade qualifications of those providing needed care is fueled by the desire of government and insurers to lower the cost of health care, abetted by the greed of physicians who want to bill for care they do not perform. Foreign medical graduates who have been trained in their country of origin are obligated to pursue a full course of post graduate residency in the United States before they can carry out a specialty. Physician extenders should likewise have a full course of specialty training prior to being allowed to function in complex activities..REFERENCES:1) Coldiron B, Ratnarathorn M. Scope of Physician Procedures Independently Billed by Mid-Level Providers in the Office Setting. JAMA Dermatol. 2014 Aug 11. doi: 10.1001/jamadermatol.2014.1773. [Epub ahead of print]2) Bangash HK, Ibrahimi OA, Green LJ, Alam M, Eisen DB, Armstrong AW.Who do you prefer? A study of public preferences for health care provider type in performing cutaneous surgery and cosmetic procedures in the United States. Dermatol Surg. 2014 Jun;40(6):671-8. doi: 10.1111/dsu.0000000000000016.
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