ABSTRACT
Objectives: Dermatology is not heavily covered in the curricula of physician assistant (PA) programs or on the certification examination, even though patient visits to PAs for skin complaints are very common. If significant on-the-job training is thus required for dermatology care, then practice setting differences likely impact the quality of that informal training. This study sought to identify differences in the ability of rural and urban PAs to diagnose skin disorders.
Methods: An Internet-based survey of rural and urban primary care PAs (n = 295) was conducted. The survey collected demographic information and provided case scenarios with questions related to diagnosis of a skin disease or complication.
Results: Average quiz score was higher for rural PAs than for urban PAs (61.6% versus 55.4%, P = .024). Rural PAs more commonly treated the majority of their patients seen for skin complaints. Rural PAs reported a greater comfort level in diagnosing and treating skin disease than did urban PAs (91% versus 80%, P < .05). Both groups referred a comparable percentage of patients to skin specialists. Regression analysis identified several factors that accounted for the ability to predict success scores for both the rural (P < .05) and urban (P < .05) groups.
Conclusions: The stronger overall ability of rural PAs to diagnose a variety of skin diseases is likely impacted by the higher number of dermatologic cases they see. PA educators should re-evaluate the curricula devoted to skin conditions and consider elective opportunities for students with an interest in a dermatology career.
OBJECTIVES
Dermatology is not well-covered in the curricula of physician assistant (PA) programs across the nation, when compared to topics like cardiology or pulmonology.1 Nor is it emphasized on the certification or recertification examinations: dermatologic conditions make up approximately 5% of the content of National Commission on Certification for Physician Assistants (NCCPA) exams, placing the skin among the three least commonly tested organ systems.2 These are interesting findings that warrant further study, given that dermatologic conditions are common reasons for patients to visit a PA.
In a 2008 survey conducted by the American Academy of Physician Assistants (AAPA), a convenience sample of about 2,200 PAs was asked to estimate the number of visits made to them in a typical week by patients for each of 28 common disorders, conditions, and services.3 Dermatitis and skin conditions were ranked as the seventh most common reason for patient visits.3 Satyaprakash and colleagues reported that primary care PAs are often responsible for diagnosis and treatment of dermatologic conditions.4 Clark and colleagues identified skin complaints as the third most common reason for visits to a PA.5
Discussions about the quality of dermatology training that PAs receive has also been fueled by a steady increase in the number of jobs for PAs in dermatology practices.6 Clark and colleagues reported that for PAs in this specialty, “the bulk of dermatology training … is received on the job from their dermatologist employer….”5 This finding may indicate poor coverage of dermatology in PA training programs, especially for graduates who want to practice in dermatology. If Clark's assertion about on the job training is correct, the quality of this experiential training is likely to depend on multiple variables, such as the frequency with which dermatology cases present to a practice and the availability of a supervising physician or a dermatologist for consultation and feedback.
In most urban areas, PAs can easily refer their patients to a dermatologist when necessary. In many rural settings, however, the limited availability of dermatologists can make referral difficult. Rural patients are also more commonly uninsured, which also creates barriers to care.7 Thus, rural providers often must manage conditions themselves that they might prefer to send to a specialist if referral was possible. This situation raises the question of how well rural PAs perform in the care of skin disorders. This study sought to identify whether differences exist in the ability to diagnose dermatologic disorders among PAs practicing in rural versus urban settings and to determine whether these PAs felt that their clinical training in dermatology was adequate.