Physician extenders fill a need, but ...

San Francisco - While physician extenders represent one potential solution for underserved patient populations, they must only be used in supervised settings, according to an American Academy of Dermatology (AAD) official.

Although the relationship between extenders and physicians remains fairly constant, "There are now more physician extenders than there used to be," says Mary E. Maloney, M.D., division chief of dermatology at the University of Massachusetts and assistant secretary-treasurer of the AAD.

National shortage

Dr. Maloney says she considers physician extenders, by and large, to be physician assistants (PAs) and nurse practitioners (NPs).

"Some people would also include things like teledermatology as an extender of physicians' capabilities. But that's a technology rather than people," Dr. Maloney says. Nor does she include cosmetologists among physician extenders.

As for the relationship between physicians and physician extenders, "(it) depends on who's working with them," Dr. Maloney says. "There are many areas where there's a physician shortage, and physician extenders have improved access for patients to appropriate dermatologic care when they work in a supervised setting," she says.

Appropriate use?

In other areas where physician extenders are used, Dr. Maloney says, "There may not be a shortage. So the question is: What is appropriate use? I don't have a position or an answer to that question, just a desire to open a discussion."

A survey by the AAD's workforce task force has shown that, based on parameters including wait times, use of physician extenders and experience of recent graduates entering the workforce, "It appears there is an inadequate supply of dermatologists to meet the demand for services (Resneck J Jr, Kimball AB. J Am Acad Dermatol. 2004;50:50-54).

Long wait times

In particular, new patients waited an average of 36 days for dermatology appointments nationally, although means ranged from nine to 120 days by state. The same survey found that 49 percent of practicing dermatologists said their communities need more dermatologists, while just 20 percent described local supply as too high.

Dr. Maloney says, "There are areas where there are felt to be physician excesses by the physicians who practice there.

"In such markets, physician extenders' roles within individual practices probably differ a little from those in underserved markets, but one may find that there are fewer extenders in those areas," she says.

According to the AAD, appropriate use of physician extenders requires a physician to be on site or available to see all new patients or patients with new, significant problems, and physicians have an obligation to ensure proper training.

However, Dr. Maloney points out that the AAD is "not a policeman. We don't go around (checking for) appropriate use. We put a policy out suggesting that this is the appropriate way to use them, and trust practices to act accordingly."

CME for extenders

No less important is continuing medical education (CME) for physician extenders.

"At the moment," Dr. Maloney says, "most extenders get their education from their parent society, such as the American Academy of Physician Assistants.

"The question is: Should the AAD be involved in CME for physician extenders? Or should we leave it to the parent organizations?"

She says there's no easy answer. One potential advantage of the AAD becoming involved in physician extenders' CME would be the opportunity to help build content for these practitioners, which Dr. Maloney says would probably be useful.