By David J. Goldberg, M.D.
Should dermatologic surgeons teach nonphysicians to perform dermatologic surgery? I think the question is no longer relevant.
This question was debated at the 2008 annual meeting of the American Society for Dermatologic Surgery, with compelling arguments both for and against the practice.
The fact of the matter is that non-MDs are already doing dermatologic surgery, with or without our teaching. This is not something we can stop. This cat is out of the bag.
The least we can do is make sure these non-MDs are well trained. After all, we are the experts. We have the know-how and the skills, and it behooves us to pass this knowledge on to our high-level physician-supervised physician assistants and nurse practitioners so that we can provide the best and safest care for our patients.
According to the American Society for Aesthetic Plastic Surgery (ASAPS), Americans spent approximately $13.2 billion dollars on cosmetic procedures in plastic-surgery offices in 2007; $4.7 billion dollars were spent for nonsurgical procedures.
ASAPS also found that the top nonsurgical cosmetic procedures in 2007 were botulinum toxin injections (2,775,176 procedures), hyaluronic acid fillers (1,448,716 procedures), laser hair removal (1,412,657 procedures), microdermabrasion (829,658 procedures), and intense pulsed light (IPL) treatment (647,707 procedures).
It's no wonder that we rely more and more on physician extenders to help us keep up with the demand for cosmetic services. In 2002, the American Academy of Dermatology reported that 20% of dermatologists were using NPs and PAs in their practices. In 2007, it was 30%, and by 2010, it is estimated that 36% of dermatologists will be using NPs and PAs.
Physician assistants have developed a critical role in medical practices. Currently there are 68,000 PAs in the country, and it is projected that by the year 2016 the number will be 83,000. And patients are going to PAs in greater numbers.
According to the American Academy of Physician Assistants, there were 14 million more patient visits to PAs in 2007 than there were in 2006. That is not going to change. In fact, being a PA in a dermatologist's office is very lucrative. The mean salary is $103,000 per year in a dermatology practice, making derm PAs among the most highly paid in the field. It's a win-win situation for all—physicians in dermatology and plastic surgery are finding the physician-PA team helpful for maintaining a successful aesthetic practice.
The American Academy of Dermatology and American Society of Dermatologic Surgery guidelines state that PAs must work under the direct supervision of a physician. Nevertheless, according to an ASDS survey, 51% of dermatologists have seen complications from botched procedures performed by PAs who did not have physician supervision.
Among the most notable: A 22-year-old North Carolina State University biochemistry senior died from lidocaine toxicity after a potent topical anesthesia was applied for laser hair removal of the legs, and a 25-year-old Arizona woman died after languishing for 2 years on a respirator as a result of having her legs smeared with Photocaine (6% lidocaine, 6% tetracaine) ointment and then occluded with cellophane for several hours. Both of these cases involved nonmedical personnel.
There is a consensus among PAs that they are not being trained well by their supervising doctors. They are excluded from the ASDS meeting, and they certainly don't get to see approaches from any other physicians. But there are plenty of other meetings for nonphysicians where they can learn injectables, fillers, and lasers.
We can censure dermatologists who train their own PAs and NPs on how to inject botulinum toxin fillers and perform other cosmetic procedures. We can continue to cover our eyes and ears and pretend that we can stop this. Or we can consider training our PAs and NPs ourselves.
I say we should take the bull by the horns. We should train high-level physician extenders to meet our high standards. We should continue to push for legislation to encourage physician supervision, and we should promote the high quality of who we are and what we do as dermatologic surgeons.
Dr. David J. Goldberg is director of the Skin Laser and Surgery Specialists of NY/NJ, clinical professor of dermatology and director of laser research and Mohs surgery at Mount Sinai School of Medicine, New York, and an adjunct professor of law at Fordham Law School, New York.