DISCUSSION
The survey results reveal that a large majority of the respondents (42%) possess 5 years or less of clinical experience, indicating a large cohort of recent graduates. The survey pool did include more experienced PAs, however, with 22% reporting 6 to 10 years of experience and 35% reporting 11 or more years of experience.
More rural PAs (78%) than urban PAs (62%) reported diagnosing and treating 50% to 100% of patients seen for skin complaints, which represents a statistically significant finding (P < .01). Rural PAs also reported a greater comfort level in diagnosing and treating skin disease; 91% of rural PAs versus 80% of urban PAs say they are “somewhat comfortable” to “very comfortable,” which represents a statistically significant finding (P < .05). Good correlations were also seen between comfort level in diagnosing and treating dermatologic conditions and the type of practice setting (rural or urban). Despite differences in comfort level and percentage of patients diagnosed and treated for skin disease, both groups reported nearly the same percentage of patients referred to a skin specialist per week, which generally represented less than one-fourth of all visits for skin complaints. And as expected, a greater exposure to dermatologic conditions, which could be reproduced in a training program, is correlated with higher performance in diagnostic abilities. Finally, whether the PAs practiced in urban or rural areas, their perception of training in dermatology did not have any connection to their knowledge and diagnostic skills with dermatology cases.
LIMITATIONS
Several limitations exist within the survey instrument and population studied. For the survey instrument, respondents were asked to self-identify their primary practice location as rural or urban, and no additional steps were taken to validate respondent self-reports. Respondents were asked to estimate several study variables, including average number of patients seen for skin complaints, percentage of patients with skin conditions the PA was able to diagnose and treat independently, and percentage of patients referred to a skin specialist. Choice of a Web-based survey tool may have contributed to the relatively higher percentage of respondents who reported 5 years or less of experience, consistent with prior research identifying age bias in responses to Internet-based surveys.9,10 Characteristics of the respondents' computers, such as display quality or screen size, may have influenced the quality of images used in the case scenarios. Additionally, the case scenarios and questions represent, at best, only a small sampling of the many conditions that PAs encounter in practice. A larger series of case scenarios would likely enhance the external validity of results, but the researchers were concerned about the effects that an overly long survey would have on the quantity of responses. Finally, the sample was not large enough to allow for adequate subgroup analyses by type of primary care discipline.
CONCLUSION
The results of this survey suggest that rural PAs have developed stronger overall diagnostic ability for the identification of a variety of skin diseases. The results presented in Table 1 support the assertion that PAs practicing in rural areas diagnose and treat a higher frequency of dermatologic cases than their urban counterparts.
It is likely that rural patients more often see a primary care provider for skin complaints, allowing rural PAs to increase their experience with dermatologic conditions. Additional differences in diagnostic abilities between rural and urban PAs may be explained by patient population characteristics, access to continuing education, availability of a dermatologist for consultation, and level of physician supervision.
Fewer specialty practices are located in rural areas compared to urban areas; and, according to Donald Kollisch of the Rural Health Scholars Program at Dartmouth College, the ratio of patients to providers in rural areas is about twice as high as in urban areas.11 Thus, rural providers end up working longer hours to perform a greater variety of health services and are less able to refer difficult cases to specialists.
Interestingly, rural and urban PAs in our survey reported a comparable percentage of referrals to skin specialists. Prior reports have demonstrated that rural patients are less likely than urban patients to pursue referrals, and this would be a topic worthy of further study. U.S. News and World Report recently reported that 1 out of 5 patients ignores a referral.12 Barriers that likely contribute to failure to pursue a referral may include lack of education, lower socioeconomic status, lack of health insurance, poor understanding of the rationale for referral, fear of a serious diagnosis, failure to complete preauthorization procedures, and transportation issues. These barriers are likely more common among rural than urban patient populations.
As PAs are engaged in treating an aging population and our awareness of environmental and workplace exposures that promote skin disease increases, it seems appropriate that PA educational programs re-evaluate the quantity and quality of instruction and supervised clinical training offered to students in dermatology. The frequency of patient visits to PAs for dermatologic conditions and the increase in market demand for PAs in dermatology practices would seem to support greater educational attention to this organ system. Alternatively, programs could consider offering elective experiences in dermatology settings to students with interest. A greater availability of postgraduate educational activities focused on the successful diagnosis and management of skin disease could also enable PAs to better serve their communities in both rural and urban areas. JAAPA
Bryon Brown was a student in the PA program at the Medical University of South Carolina (MUSC), Charleston, when this article was written and is the principal investigator and primary author. Co-investigator Reamer Bushardt is Associate Professor and Director, and co-investigator Kevin Harmon is Assistant Professor, both in the Division of Physician Assistant Studies, MUSC. Research mentor Shaun Nguyen is a physician, biostatistician, and Assistant Professor, Department of Otolaryngology, Head and Neck Surgery, MUSC. The authors have indicated no relationships to disclose relating to the content of this article.
REFERENCES
1. Nestor MS. The use of mid-level providers in dermatology: a liability risk? Semin Cutan Med Surg. 2005;24(3):148-151.
2. National Commission on Certification of Physician Assistants. NCCPA examination content blueprint. http://www.nccpa.net/pdfs/Content%20Blueprint%20Booklet.pdf. Accessed November 11, 2009.
3. American Academy of Physician Assistants. Information update: number of visits to physician assistants for select disorders in 2008. http://www.nccpa.net/pdfs/Content%20Blueprint%20Booklet.pdf. November 2008. Accessed November 11, 2009.
4. Satyaprakash A, Balkrishnan R, Camacho F, et al. Quality of dermatologic care delivered by physician assistants: an analysis of prescribing behavior for the combination antifungal agent clotrimazole-betamethasone [letter]. Arch Dermatol. 2007;143(12):1591-1592.
5. Clark A, Monroe J, Feldman S, et al. The emerging role of physician assistants in the delivery of dermatologic health care. Dermatologic Clinics. 2000;18(2):297-302.
6. National Ambulatory Medical Care Survey: 1993-2006. National Center for Health Statistics, Centers for Disease Control and Prevention. Data available at http://www.cdc.gov/nchs/ahcd.htm. Accessed November 4, 2009.
7. Zillner E, Coburn A, Anderson N. Uninsured rural families. J Rural Health. 2008;24(1):1-11.
8. American Academy of Physician Assistants. 2008 AAPA physician assistant census report. http://www.aapa.org/images/stories/2008aapacensusnationalreport.pdf. September 25, 2008. Accessed November 11, 2009.
9. Smith CB. Casting the net: surveying an Internet population. JCMC. 1997;3(1). http://jcmc.indiana.edu/vol3/issue1/smith.html. Accessed November 4, 2009.
10. Kaplowitz MD, Hadlock TD, Levine R. A comparison of Web and mail survey response rates. Public Opinion Quarterly. 2004;68(1):94-101.
11. Associated Press. UA programs aim to recruit, train, and retain rural doctors. Diverse Issues in Higher Education. http://www.diverseeducation.com/artman/publish/article_8840.shtml. July 23, 2007. Accessed November 11, 2009.
12. Reinberg S. Many patients don't pursue referrals. US News & World Report Web site. http://health.usnews.com/usnews/health/healthday/070803/many-patients-dont-pursuereferrals_print.htm. August 3, 2007. Accessed November 11, 2009.