PAs Do More Biopsies, Find Less Early Melanoma than Dermatologists Interview with:

Laura Korb Ferris, MD, PhD Associate Professor, University of Pittsburgh Clinical and Translational Science Institute Director of Clinical Trials, Department of Dermatology University of Pittsburgh Medical Center

Dr. Laura K. Ferris

Laura K. Ferris MD, PhD
Associate Professor, University of Pittsburgh Clinical and Translational Science Institute
Director of Clinical Trials, UPMC Department of Dermatology
University of Pittsburgh What is the background for this study? What are the main findings? 

Response: Dermatology is one of the greatest utilizers of physician extenders, including physician assistants (PAs) in medicine. The scope of practice of PAs has also expanded over time from a role in assisting the dermatologist to taking a more independent role and many PAs now do skin cancer screening examinations and make independent decisions about which lesions are suspicious for skin cancer and need to be biopsied.

Our main findings were that, overall, in comparison to board-certified dermatologists, PAs were more likely to perform biopsies of benign lesions. For every melanoma that they found, PAs biopsied 39 benign lesions whereas dermatologists biopsied 25.

In addition, PAs were less likely than dermatologists to diagnose melanoma in situ, the earliest and most curable, but also hardest to identify and diagnose, form of melanoma. However, PAs had a similar rate of diagnosing the more clinically-obvious forms of skin cancer, including invasive melanoma, basal cell carcinoma, and squamous cell carcinoma. What should readers take away from your report?

Response: The diagnosis of early melanoma at its most curable stages is one of the most important things that we do as dermatologists. However doing this accurately requires years of training and experience. While .Physician Assistants can learn to do this over time, 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. Also, there is no such thing as a “board-certified” PA in dermatology, thus there is not an objective way for a patient to ensure that a PA is appropriately knowledgeable about dermatology. It is important that dermatologists who choose to hire physician extenders such as PAs and nurse practitioners consider carefully how much autonomy they are given and should at a minimum put in place measures to measure their performance. It is also reasonable to have physician extenders work as a team with a board-certified dermatologist such that the dermatologist makes the decision about what should be biopsied and the Physician Assistant helps in counseling the patient, answering questions, performing the biopsy, and documenting the visit. What recommendations do you have for future research as a result of this work?

Response: I would like to see our study replicated in other settings. We feel that we likely have a best case scenario in which Physician Assistants are supervised by board-certified dermatologists and have an affiliation with an academic medical center and that the care delivered in settings where a physician supervisor may be present on site only once a week and may not be board-certified in dermatology may be significantly worse. We would also like to see if a formal training program can be developed that helps to improve the diagnostic accuracy of skin cancer by Physician Assistants / nurse practitioners. Is there anything else you would like to add?

Response: There is significant interest in hiring Physician Assistants and nurse practitioners to deliver care that has traditionally been provided only by physicians, in part in an effort to lower costs and expand access to care. However, one recent study show that PAs are primarily practicing dermatology in urban areas and not in areas we would consider underserved. Also, missing opportunities for early cancer diagnosis and performing unnecessary biopsies will significantly drive up health care costs and studies like ours are needed to help us to better understand the broader financial impact of the decision to use physician extenders. This is particularly important as 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 and we anticipate that the discrepancy in care would be amplified were this to occur.

Disclosures: I am a consultant for DermTech international. 



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. Published online April 18, 2018. doi:10.1001/jamadermatol.2018.0212

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Last Updated on April 18, 2018 by Marie Benz MD FAAD