The physician assistant (PA) workforce is undergoing substantial growth in the United States, particularly in dermatology practice.
A cross-sectional study was conducted in 2022 among more than 98,000 certified PAs in the US.1 According to the study results, the mean number of dermatology PAs increased by 11.6% annually from 2013 to 2018, compared with a mean annual increase of 7.8% in PAs across other specialties.
These study results further demonstrated that only 1.6% of dermatology PAs identified as Black or African American, compared with 3.7% of PAs in other specialties. Similar rates were noted for PAs identifying as Hispanic (approximately 6.0%) across specialties.1
In regard to location of practice, 94.7% of dermatology PAs practice in metropolitan areas. This rate is similar to the rate observed in 2022 among nonphysician clinicians (NPCs), a combination of both PAs and nurse practitioners (NPs) in dermatology.1 Further analysis showed that most dermatology NPCs were employed at private group practices, and the Southern US showed the greatest concentration of NPCs.2
With some variation in restrictions, PAs are permitted to practice with prescribing privileges in all 50 US states and territories, with the exception of Puerto Rico.3 For dermatology PAs to play an even more significant role in reducing health disparities, multiple barriers must first be addressed.
For additional insight into PAs in dermatology, including ongoing challenges and opportunities associated with the profession, we spoke with Cynthia F. Griffith, MPAS, PA-C; University of Texas Southwestern Medical Center in Dallas; and Peter A. Young, MPAS, PA-C; Permanente Medical Group in Sacramento, California, and Stanford University School of Medicine in Redwood City, California.* Drs Griffith and Young co-authored a commentary on the study by Arnold et al.4,5
*Editor’s note: The opinions expressed herein are their own and do not represent any institution or organization.
What are some examples of the benefits that PAs bring to dermatology practices and patients?
Ms Griffith: Dermatology PAs allow patients faster access to care.6 The availability of more well-trained professionals, such as dermatology PAs, can decrease wait times for appointments, which can not only increase access but also improve care. When a patient has a dermatology appointment, they often do not get seen or are evaluated by a nondermatology clinician, who may or may not have the recognition skills to identify and treat the patient’s condition. This delay in treatment can often increase morbidity and mortality.4
Mr Young: In addition to decreased wait times for appointments and a greater volume of patients served, benefits to practices and patients include cost-effective employees and financial savings to the health care system relative to physician services.7 PAs accomplish this while achieving equal patient satisfaction scores compared with physicians.8
This aligns with prior research showing that PAs are highly trainable. A comparison of dermatology knowledge acquisition between PA students and primary care residents showed no difference between these groups.9 Time spent studying, not degree or license type, was most predictive of examination scores.
What are some of the challenges dermatology PAs may face?
Mr Young: As individuals, dermatology PAs may be challenged to find employers with the right intentions — those who place patient care above all, with diagnostic excellence being the metric.10 Private equity investment firms have rapidly acquired a substantial portion of the dermatology clinics in the US.11 The ultimate responsibility of administration in these organizations lies with their investors.
Dermatology clinicians are highly reimbursed by insurance companies for therapeutic procedures such as biopsies and skin surgeries, for example. This incentivizes clinicians — PAs and supervising physicians included — toward performing more in-office procedures, the necessity of which may be unclear. It also incentivizes managers and administrators who are not medically trained to pressure clinicians into performing more procedures. Anecdotally, some clinicians are given written or verbal production quotas that dictate a minimum volume of skin biopsies to remain in good standing as an employee.
As a profession, PAs must overcome the apprehension of other stakeholders, such as some dermatologists and patients, which can result from misinformation about the profession. Reversing widespread misperception is exceptionally difficult, particularly for groups whose credibility was damaged by the information in question. For PAs, this credibility is inherently an uphill battle due to the profession’s novelty and a somewhat self-defeating job title.
One example of an article contributing to negative perception of PAs was published in JAMA Dermatology, which suggested their diagnostic accuracy for melanoma is subpar.12 Global experts on melanoma immediately wrote a reply that was also published in JAMA Dermatology, which refuted the study’s validity on grounds that are generally accepted by the research community.13 For example, the study did not control for confounding variables including the greatest risk factor for melanoma: personal history of prior melanoma. However, the article was not retracted, and it continues to be cited in both lay and scientific writings. Assertions that PAs are less accurate in diagnosing skin cancer usually refer to the ratio of skin biopsies performed vs cancers diagnosed, but omit the many limitations of this metric, which experts say is a poor proxy for diagnostic accuracy.14
There is only 1 published study that completely controlled for confounding variables while evaluating melanoma diagnostic accuracy of dermatologists alongside PAs. The results showed that PAs were 15.9% more sensitive than dermatologists for detection of melanoma, with a tradeoff of being less specific.15 This study was conducted at the same institution as the aforementioned JAMA Dermatology article, and both were co-authored by the same senior researcher. Despite providing higher-quality evidence on the question of melanoma diagnostic accuracy and being published in the Journal of the American Academy of Dermatology, which is the world’s most cited dermatology journal, these particular findings have received little public attention. Therefore, PAs must collaborate with dermatologists and employers to bring this type of information to the public, so patients can feel confident in the care they receive from PAs.
Recent study findings have highlighted the lack of racial diversity among dermatology PAs and a declining number of Black graduates from PA schools.1 What measures are needed to address these issues?
Ms Griffith: Almost every step in the process to being a PA is harder for Black students. The increasing cost of graduate education disproportionately affects Black students who often have fewer financial resources. Increasing support for historically Black colleges and universities (HBCUs) will immediately and measurably increase the number of Black PAs and physicians. Offering mentoring programs, increasing access to preceptors and shadowing opportunities, and increasing outreach programs to college fairs and community events can also increase awareness of the profession.
Black and Hispanic clinicians tend to practice in geographic areas that are underserved.16 They can make a huge impact as they practice serving patients who were previously without care.
Mr Young: The raw number of Black graduates from PA schools is actually increasing because the number of PA programs and PA students has increased so much in the past 4 decades, but their percentage per cohort is declining.17 The declining percent of Black PA students and graduates has occurred during the profession’s transition from associate degree-level education to a master’s degree standard. This has prolonged the educational path and dramatically increased financial costs. The average total PA school tuition in 1985 was just over $6000 and was well over $100,000 in 2019.17 Black Americans have, on average, lower household income than other racial and ethnic groups.18
In 1985, no PA schools required the GRE in order to matriculate. In 2019, 57.7% of programs required it.17 The GRE is more predictive of examinee race and ethnicity than of their success in graduate programs. Required GRE scores for PA school matriculation are negatively associated with percentages of underrepresented minority students.4 Similar declines in the percent of Black students have been observed in occupational therapy and physical therapy during those professions’ transitions to master’s and doctorate degrees, respectively.19
Medical schools have similarly struggled to matriculate Black students, and there appears to be a strong protective effect from HBCUs.20 Historically there have been fewer HBCUs with PA programs than medical schools, and these have experienced prolonged closures due to changing professional standards, such the shift to a master’s degree standard.
National PA professional organizations must halt rising program tuition, eliminate the use of GRE scores in evaluating PA school applicants, and expand and support PA programs at HBCUs. These actions would help, but not completely resolve the issue, which is complex and multifactorial.
What can be done to increase the presence of dermatology PAs in underserved regions, including rural areas?
Ms Griffith: Dermatology PAs are in urban areas in large part because they are following the American Academy of Dermatology recommendations to be in the same location with our collaborating dermatologists, and dermatologists are largely in urban areas.5,21 As legislation improves PA practice flexibility, this will allow PAs to serve in more rural communities, bringing them closer to where patients reside and improving access for the primary stakeholder in medicine — the patient.
During the beginning of the COVID-19 pandemic, we learned that telemedicine can make it easier for patients to get care without driving very long distances. Where state law allows, dermatology PAs can utilize technology to allow patients access to care in rural areas.
Mr Young: A multipronged approach is needed to improve rural access to dermatologic care, and PAs should aid this undertaking. A recent article in JAMA Dermatology described the establishment of the Dermatology Rural Education and Access Model (DREAM) clinics.22 Considerable financial challenges exist to starting and maintaining these clinics, which are designed to improve rural access to dermatologists. Incorporating PAs into these offices could support their feasibility and sustainability, as PAs are cost-beneficial to employers.
Although PAs were originally meant to fill care gaps during a prolonged physician shortage, the maldistribution of dermatologists represents a barrier to serving this purpose. Nearly all dermatology PAs are concentrated in well-resourced metropolitan areas, where dermatologists can provide on-site supervision.1 If additional academic rural satellite clinics were created with permanent dermatologist staff, PAs could increase patient access to them. Like physicians, there are PAs originally from rural communities, who might practice long-term in these settings if given the chance.
The Accreditation Review Commission on Education for PAs (ARC-PA) is the profession’s accrediting organization for clinical training programs after degree completion and certification. Of the 10 specialties employing the most PAs, only dermatology, which ranks 5th, lacks any ARC-PA accredited postgraduate training opportunities. Simultaneously, the dermatology PA workforce is growing faster than all other specialties.1 Academic rural dermatologists could mentor these incoming generations of PAs, some of whom would eagerly compete for the opportunity to undergo formal clinical training.
Employing PAs in DREAM-like clinics and guiding their study alongside residents could address the gap of in-person mentorship programs for dermatology PAs. This could enhance their aptitude for responsible provision of quality care, while maintaining on-site supervision as required by the American Academy of Dermatology and assisting with clinic overhead costs. Meaningful job opportunities would thus be created, which generate value for professional education and underserved populations.
Emerging clinic models which aim to improve rural access to dermatologic care and endure the inherent long-term challenges could find synergy in the dermatologist-PA relationship. Research should be undertaken to explore integration of PAs into these settings.
What do you see as the future of the profession? Are there any emerging trends, for example? What remaining needs exist?
Ms Griffith: The future of the profession is bright. Job growth and opportunities are strong. The number of people who need medical care is ever-increasing, and PAs are expanding their knowledge base into many different areas in pursuit of better serving patients and improving patient outcomes.
As a whole, PAs are becoming primary investigators and participating in research focused on patient-centered outcomes. Dermatology PAs are working with Mohs Surgeons to close Mohs cases, improving outcomes by allowing patients to have swift treatment for skin cancers.23 The goal is to have highly trained professionals with a strong educational foundation providing the best care for patients.
Mr Young: Dermatologists and PAs must collaborate to progressively enhance and standardize the training of incoming generations of dermatology PAs. The most promising avenues for this are cooperation between national professional organizations of both PAs and dermatologists, and research co-authorship by PAs with dermatologists. This research might explore core competencies considered essential by both parties, delineate the unmet dermatology-related needs of our population, and tailor the workforce preparation benchmarks for future dermatology PAs.
The American College of Cardiology recently made history by issuing the first competency statement for PAs and NP) in cardiology.24 These core competencies were developed in collaboration with PAs and NPs and represent exemplary leadership which all dermatology professional organizations should aspire to.24 The Society of Dermatology PAs is currently seeking accreditation from the Institute for Credentialing Excellence for their Diplomate Fellowship program, a comprehensive course on general dermatology, taught by dermatologists and PAs. The National Commission on Certification for PAs has announced the first standardized examination for PAs specializing in dermatology, the Dermatology Certificate of Added Qualifications (CAQ).
The dermatology PA of the future will possess both of the above credentials, which will gradually become expected by employers and the public. Including the more than 3000 hours of health care experience before PA school and 2000 hours of clinical experience during PA school, the average certified PA with added qualifications in dermatology will have over 9000 hours of medical experience, 40% of which is in dermatology.25
- Arnold JD, Puckett K, Jeffery C, Kozikowski A. Evaluation of the dermatology physician assistant workforce in the US. JAMA Dermatol. 2022;158(6):693-695. doi:10.1001/jamadermatol.2022.1026
- Lakdawala N, Gronbeck C, Feng H. Workforce characteristics of nonphysician clinicians in dermatology in the United States. J Am Acad Dermatol. 2022;87(5):1108-1110. doi:10.1016/j.jaad.2022.01.019
- American Academy of Physician Assistants. PA prescribing. Published April 2019. Accessed February 1, 2023.
- McElroy-Brooklyn J, Faires Griffith C. A decline in Black and dermatology physician assistants. J Physician Assist Educ. 2022;33(4):275-276. doi:10.1097/JPA.0000000000000469
- Young PA, Griffith CF, Vasquez R. Geographic distribution and workforce diversity of dermatology physician assistants. JAMA Dermatol. 2022;158(12):1460. doi:10.1001/jamadermatol.2022.4453
- O’Brien JC, Chong BF. Reducing outpatient dermatology clinic wait times in a safety net health system in Dallas, Texas. J Am Acad Dermatol. 2016;75(3):631-632. doi:10.1016/j.jaad.2016.04.043
- Thomas E, Coombs J, Kim J, Hyde M. A survey of fellow members of the Society of Dermatology Physician Assistants. JAAPA. 2013;26(2):56. doi:10.1097/01720610-201302000-00011
- Hooker RS, Moloney-Johns AJ, McFarland MM. Patient satisfaction with physician assistant/associate care: an international scoping review. Hum Resour Health. 2019;17(1):104. doi:10.1186/s12960-019-0428-7
- McCleskey PE. Clinic teaching made easy: a prospective study of the American Academy of Dermatology core curriculum in primary care learners. J Am Acad Dermatol. 2013;69(2):273-279. doi:10.1016/j.jaad.2012.12.955
- Yang D, Fineberg HV, Cosby K. Diagnostic excellence. JAMA. 2021;326(19):1905-1906. doi:10.1001/jama.2021.19493
- Matthews S, Roxas R. Private equity and its effect on patients: a window into the future. Published online May 23, 2022. Int J Health Econ Manag. doi:10.1007/s10754-022-09331-y
- Anderson AM, Matsumoto M, Saul MI, Secrest AM, Ferris LK. Accuracy of skin cancer diagnosis by physician assistants compared with dermatologists in a large health care system. JAMA Dermatol. 2018;154(5):569-573. doi:10.1001/jamadermatol.2018.0212
- Marghoob AA, Marchetti MA, Dusza SW. Performance of dermatology physician assistants. JAMA Dermatol. 2018;154(10):1229. doi:10.1001/jamadermatol.2018.2693
- Young PA, Marchetti MA. On the validity of biopsy cost analysis pertaining to nonphysician clinicians. Dermatol Online J. 2022;28(2). doi:10.5070/D328257410
- Ferris LK, Harkes JA, Gilbert B, et al. Computer-aided classification of melanocytic lesions using dermoscopic images. J Am Acad Dermatol. 2015;73(5):769-76. doi:10.1016/j.jaad.2015.07.028
- Komaromy M, Grumbach K, Drake M, et al. The role of Black and Hispanic physicians in providing health care for underserved populations. N Engl J Med. 1996;334(20):1305-1310. doi:10.1056/NEJM199605163342006
- Physician Assistant Education Association. By the numbers: program report 35: data from the 2019 program survey. Washington, DC: PAEA; 2020. doi:10.17538/PR35.2020
- Peter G. Peterson Foundation. Income and wealth in the United States: an overview of recent data. Published November 9, 2022. Accessed February 23, 2023.
- Coplan B, Bautista TG, Dehn RW. PA program characteristics and diversity in the profession. JAAPA. 2018;31(3):38-46. doi:10.1097/01.JAA.0000530295.15656.51
- Morris DB, Gruppuso PA, McGee HA, Murillo AL, Grover A, Adashi EY. Diversity of the national medical student body – four decades of inequities. N Engl J Med. 2021;384(17):1661-1668. doi:10.1056/NEJMsr2028487
- Adamson AS, Suarez EA, McDaniel P, Leiphart PA, Zeitany A, Kirby JS. Geographic distribution of nonphysician clinicians who independently billed Medicare for common dermatologic services in 2014. JAMA Dermatol. 2018;154(1):30-36. doi:10.1001/jamadermatol.2017.5039
- Pearlman RL, Brodell RT, Byrd AC. Enhancing access to rural dermatological care: the time to start is now. JAMA Dermatol. 2022;158(7):725-726. doi:10.1001/jamadermatol.2022.1470
- Hyde MA, Hadley ML, Roberson C, Jacobson A, Pappas L, Bowen GM. Use of physician assistants in Mohs micrographic surgery: a survey of fellowship-trained Mohs micrographic surgeons. Dermatol Surg. 2010;36(11):1700-1703. doi:10.1111/j.1524-4725.2010.01721.x
- American College of Cardiology. ACC issues clinical competencies for cardiovascular NPs, PAs. Published March 20, 2020. Accessed February 1, 2023.
- Young PA, Davis KE, Bae GH. The elephant in the exam room: emerging dermatology qualifications of different stripes and types. Practical Dermatology. Published March 2022. Accessed February 23, 2023.