NEW YORK (Reuters Health) – Compared with dermatologists, physician assistants (PAs) are less likely to diagnose melanoma and more likely to perform more biopsies for each case of diagnosed skin cancer, researchers say.
The role of PAs has expanded over time and now includes skin cancer screening and making independent decisions about which lesions to biopsy, said Dr. Laura Ferris of the University of Pittsburgh School of Medicine in Pennsylvania.
“The diagnosis of early melanoma at its most curable stages is one of the most important things that we do as dermatologists,” she told Reuters Health by email. “However, doing this accurately requires years of training and experience.”
“While PAs can learn to do this over time,” she added, “we find that they are less accurate in their diagnoses and that this may lead to more biopsies than necessary being performed and possibly in missed opportunities to identify melanoma at its earliest stages.”
“This is likely in part due to the fact that PAs enter the workforce with significantly fewer years of experience and having seen far fewer melanomas than do board-certified dermatologists,” she said.
Dr. Ferris and colleagues reviewed records of 33,647 skin cancer screening examinations conducted by dermatologists or PAs for 20,270 patients (mean age at visit, 53; 63% women; 96% white).
As reported online April 18 in JAMA Dermatology, to diagnose one case of skin cancer (nonmelanoma, invasive or in situ melanoma), the number needed to biopsy (NNB) was 3.9 for PAs and 3.3 for dermatologists (P < 0.001).
To diagnose one melanoma, PAs needed to biopsy 39.4 pigmented lesions, whereas dermatologists needed to biopsy 25.4 (P = 0.007).
Patients screened by a PA were significantly less likely than those screened by a dermatologist to be diagnosed with melanoma in situ (1.1% vs. 1.8% of visits); however, differences were not significant for invasive melanoma (0.7% vs. 0.8%) or nonmelanoma skin cancer (6.1% vs 6.1%).
“Although the availability of PAs may help increase access to care and reduce waiting times for appointments, these findings have important implications for the training, appropriate scope of practice, and supervision of PAs and other nonphysician practitioners in dermatology,” the authors state.
Dr. Ferris said PAs “should work as a team with and under the direct supervision of a board-certified dermatologist. Ideally this would mean that the dermatologist makes the decision about what should be biopsied and the PA helps in counseling the patient, answering questions, performing the biopsy, and documenting the visit.”
When patients are not cared for by a team, she said, “dermatologists (should) consider carefully how much autonomy (PAs) are given and should at a minimum put in place systems to measure their performance.”
“Public awareness is important,” Dr. Ferris said. “When a patient is offered an appointment with a PA, they need to be aware that they are not seeing someone who did a residency in or had to pass a board examination in dermatology. A PA can join a practice and shadow a dermatologist for a few weeks and start seeing patients on their own.”
“Patients (need to) understand that seeing a PA instead of a board-certified dermatologist may mean that they are less likely to have their early melanoma detected and more likely to have unnecessary skin biopsies performed,” she noted.
“The PAs in our study were all supervised by board-certified dermatologists, but there is legislation under consideration in several states to allow nurse practitioners and PAs to practice independently,” she added, “and we anticipate that the discrepancy in care would be amplified were this to occur.”
Dr. Desiree Ratner, director of the Comprehensive Skin Cancer Center, Mount Sinai Downtown, and professor of dermatology, Icahn School of Medicine at Mount Sinai in New York City told Reuters Health by email, “Dermatologists need to make certain that their PAs are closely supervised as well as properly trained to minimize the potential risks and maximize the benefits for those patients who are entrusted to their care.”
SOURCE: http://bit.ly/2HVie3N
JAMA Dermatol 2018.
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