Overall, the most commonly discussed topic was provider reimbursement (22.6% of all comments)(Table 2). Physicians and medical students were more likely to discuss physician expertise compared to APPs (32.1% vs 4.5%; P<.001). They also were more likely to raise concerns that the executive order would discourage future generations of physicians from pursuing medicine (15.5% vs 0%; P=.01). Advanced practice providers were more likely than physicians/medical students to comment on the breadth of NP and/or PA training (38.6% vs 19.0%; P=.02). The eTable shows representative comments for each theme encountered.
A subgroup analysis of the comments written by physicians supporting the executive order (n=4) and APPs disapproving of the order (n=12) was performed to identify the dissenting opinions. Physicians who supported the order discussed the need for improved pay for equal work (n=3), the competency of NP and PA training (n=2), the ability of a practice to generate more profit from APPs (n=1), and possible benefits of APPs providing primary care while MDs perform more specialized care (n=1). Of the APPs who did not support the order, there were 4 PAs, 2 registered nurses, 2 NPs, 2 NP students, and 2 PA students. The most common themes discussed were the differences in APP education and training (n=6), lack of desire for further responsibilities (n=4), and the adequacy of the current scope of practice (n=3).
Comment
President Trump’s executive order follows a trend of decreasing required oversight of APPs; however, this study indicates that these policies would face pushback from many physicians. These results are consistent with a prior study that analyzed 309 comments on an article in The New York Times made by physicians, APPs, patients, and laypeople, in which 24.7% had mistrust of APPs and 14.9% had concerns over APP supervision compared to 9% who supported APP independent practice.7 It is clear that there is a serious divide in opinion that threatens to harm the existing collaborations between physicians and APPs.
Primary Care Coverage With APPs
In the comments analyzed in our study, supporters of the executive order argued that an increase in APPs practicing independently would provide much-needed primary care coverage to patients in underserved regions. However, APPs are instead well represented across most specialties, with a majority in dermatology. Of the 4 million procedures billed independently by APPs in 2012, 54.8% were in the field of dermatology.8 The employment of APPs by dermatologists has grown from 28% of practices in 2005 to 46% in 2014, making this issue of particular importance to our field.9,10
Education and Training of APPs
In our analysis, many physicians cited concerns about the education and training of APPs. Dermatologists receive approximately 10,000 hours of training over the course of residency. Per the American Academy of Physician Assistants, PAs spend more than 2000 hours over a 26-month period on various clinical rotations, “with an emphasis on primary care.”11 There are multiple routes to become an advanced practice RN with varying classroom and clinical requirements, with one pathway requiring a bachelor of science in nursing, followed by a master’s degree requiring 500 to 700 hours of supervised clinical work. Although the Dermatology Nurses’ Association and Society of Dermatology Physician Assistants (http://www.dermpa.org) provide online modules, annual conventions with training workshops, and short fellowship programs, neither have formal guidelines on minimum requirements to diagnose and treat dermatologic conditions.2 Despite the lack of formalized dermatologic training, APPs billed for 13.4% of all dermatology procedures submitted to Medicare in 2015.12
Quality of Patient Care
In our study, physicians also voiced concern over reduced quality of patient care. In a review of 33,647 skin cancer screening examinations, PAs biopsied an average of 39.4 skin lesions, while dermatologists biopsied an average of 25.4 skin lesions to diagnose 1 case of melanoma.13 In addition, nonphysician providers accounted for 37.9% of defendants in 174 legal cases related to injury from cutaneous laser surgery.14 Before further laws are enacted regarding the independent practice and billing by NPs and PAs in the field of dermatology, further research is needed to address patient outcomes and safety.
Limitations
This study was subject to several limitations. Because of a lack of other sources offering discussions on the topic, our sample size was limited. Self-identification of users presents a challenge, as an individual can pose as a physician or APP without validation of credentials. Although great care was taken to minimize bias, grouping comments into broad categories may misinterpret a poster’s intentions. Furthermore, the data collected represent only a small proportion of the medical community—readers of Medscape and Reddit who have the motivation to create a user profile and post a comment rather than put their efforts into lobbying or contacting legislators. Those posting may have stronger political opinions or more poignant experiences than the general public. Although selection bias impacts the generalizability of our findings, this analysis allows for deeper insight into the beliefs of a vocal subset of the medical community who may not have the opportunity to present their opinions elsewhere.
Conclusion
Our analysis of the response to President Trump’s executive order reveals that a rollout of these regulations would be met with strong opposition. On October 29, 2019, more than 100 professional organizations, including the American Medical Association and the American Academy of Dermatology, wrote a letter to the Secretary of Health and Human Services that eloquently echoed the sentiments of the physician commenters in this study: “Scope of practice of health care professionals should be based on standardized, adequate training and demonstrated competence in patient care, not politics. While all health care professionals share an important role in providing care to patients, their skillset is not interchangeable with that of a fully trained physician.”15 The executive order would lead to a major shift in the current medical landscape, and as such, it is prudent that these concerns are addressed.