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Breaking News: Response to "Elephant in the room"

In Response to “Elephant in the room of dermatology”

Physician assistants (PAs) will soon be celebrating 50 years of working alongside physicians. Unfortunately, there continue to be some physicians who are misinformed about the training and capabilities of PAs. After a review of a recent article “Elephant in the room of dermatology” by Dr. Brett Coldiron, we can agree on two things: we hope that this article stimulates a little self-examination among dermatologists and that any PA who finds themselves in the position of being expected to see a full range of dermatologic conditions without adequate training and back up should be uncomfortable and seek to get out of that situation. It is in the best interests of the patient that all those involved in their care are properly trained and practice with appropriate access to consultation. All PAs are formally trained in primary care as suggested, similar to the medical school model. Physicians then go on to residency and PAs go to work in physician offices to receive additional training while seeing patients with a physician. Regardless of training or ability, current legislation requires PAs in all states to work with a collaborating physician. So we work together in the care of our patients, who might just argue that access to dermatology is as important as access to primary care.

It is important to remember that Dr. Coldiron’s letter is an opinion piece and should be treated as such. He is careful to use terms such as “may be subject to” since there are no data to support his claims. Where there is current information that does not support his opinion, such as malpractice claims data, he resorts to future predictions of dire events. (In fact, PAs experience a very low ratio of paid claims—much lower than physicians. Data from the National Practitioner Data Bank show that from 2005 through 2014, the average was 1 paid claim for every 550 PAs. During the same period, the average for physicians was one paid claim for every 85 physicians.) He uses these dismal forecasts to suggest that PAs should be limited to reimbursement for evaluation and management codes – cognitive services in the office. This limitation would require patients who need basic procedures such as skin tag removal or wart destruction to wait for an appointment with the physician rather than be appropriately treated, more efficiently, by a well-trained PA. While that would be a simple nuisance, the delay of a biopsy of a melanoma while waiting for the physician could result in real harm to the patient.

Dr. Coldiron suggests checking Medicare claims data to see if PAs are billing for procedures as a surrogate measure of independent practice. According to, these services have their own statutory benefit categories and are subject to the rules applicable to their specific category. They are not “incident-to” services and “incident-to” rules do not apply. With respect to evaluation and management services, having a physician on site is only one of several specific criteria to meet in order to use “incident-to” billing. So a PA must bill an office visit under their own provider number, even when a physician is on site and involved in the care of the patient, if the other criteria are not met. Because of this, no assumptions can be made based on claims data, regarding the presence or absence of a physician in the office suite at the time of performance of a procedure or patient visit.

Any PA who works in dermatology or wants to would be well advised to be sure they adequately research the practice and physician before accepting an offer of employment. It is important to be sure the physician is interested in either verifying your previous training and experience or providing adequate training themselves. Be sure they plan to be available for consultation when needed. This is not only the law in all states, it is simply good practice. No one medical practitioner can know it all. That is why we have subspecialists, and even experienced dermatologists consult each other on complicated cases. Ensure that your front desk staff is properly notifying patients that they will be seeing a PA. If the patient prefers to see a physician then you should ensure that they are able to do so. If you find yourself already in a situation with inadequate training or support, consider getting out. No one benefits from that situation.

The Society of Dermatology PAs continues to offer a robust dermatology curriculum to support the education of our fellow members, who all work with a BC/BE dermatologist, but this will never be a substitute for the training they will receive in the clinic. We support a team effort while at the same time encouraging our members to practice to the full extent of their training. To the dermatologists out there, please be a part of the solution and share your knowledge and expand your impact through the proper training of the PAs you work with. Our patients will be most grateful.


The Society of Dermatology Physician Assistants

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