AMA Journal of Ethics^®

Nestor MS. The use of mid-level providers in dermatology: a liability risk? Semin Cutan Med Surg. 2005;24(3):148-151.

Medicine is a rapidly changing discipline. Practices common 20 or 30 years ago are obsolete today. Complex tasks formerly performed by physicians are now delegated to other members of the medical team. For this reason, medical students and residents must learn about the medical liabilities of practicing in today's high volume, cost-conscious, health team-dependent environment.

In his article on the use of mid-level professionals in the field of dermatology, Mark S. Nestor, MD, a professor from the University of Miami's Miller School of Medicine in Florida, outlines the roles of ancillary practitioners in dermatology and the degree to which the physician for whom they work is accountable for their actions [1]. Both nurse practitioners and physician assistants are becoming an integral part of the specialty. A shortage of dermatologists, ever-increasing patient volumes and changes in the number and types of in-office procedures are some of the reasons for this pattern [2].

Supporting Roles

The duties of these nonphysician clinicians go beyond such rudimentary tasks as taking histories or conducting basic exams; they may extend to prescribing medication and even participating in some office surgical procedures [3]. Much of their training is the responsibility of the physician, and the critical point Nestor makes is that "the dermatologist in most cases can be held legally responsible for the acts of their physician assistant or nurse practitioner" [2].

Dermatologists are entrusting more and more clinical tasks to physician assistants and nurse practitioners as revealed by the huge number of patient visits these staff members handle annually—39 million in a typical year during the 1990s according to statistics compiled by Adele R. Clark (a physician assistant herself) and her colleagues in "The Emerging Role of Physician Assistants in the Delivery of Dermatologic Health Care" [4]. During these visits ancillary staff perform biopsies and surgeries and prescribe narcotics.

As with all surgeries and prescriptions, things can go seriously wrong and create liability. Nestor shows that problems can occur if a physician assistant or nurse practitioner provides services that don't meet the standard of care because of the staff member's inadequate experience or supervision [5]. It is the physician's responsibility to guard against lapses and provide for clinical and ethical best practices.

Physicians Shoulder the Ultimate Responsibility

Despite the potential for problems, a good team working together can serve patients better and faster than a physician on his or her own, so mid-level care providers are likely to become and remain a valuable feature of almost all dermatology practices. Given these practice changes, it is important that the medical doctor demonstrate continual oversight and responsibility for ancillary staff. Nestor makes clear again and again that, as long as mid-level assistants continue to provide care for patients, the physician is liable for their actions and any allegations of malpractice that may arise due to their lack of adequate training. He goes on to highlight ways in which physicians can attempt to reduce their liability risk. They can, and should, for example,

• Seek better ways to instruct and train the nurse practitioner or physician assistant in methods of biopsy, excision or even some cosmetic procedures.
• Insure that community standards for care are met or exceeded.
• Teach procedures carefully and make sure they are mastered by assistants.
• See all new patients or new problems before deciding whether to delegate the treatment plan to an assistant.
• Make sure patients feel they are getting better care because of assistants—not being screened out from seeing a "real doctor" [6].

Of course, no matter how well the physician trains his or her staff, it is virtually impossible to duplicate the three intensive years of highly specialized post-graduate residency that are required for board certification in dermatology [3], so the dermatologist must remain the responsible party.

The American Academy of Dermatology and other state and specialty societies emphasize that the role of ancillary professionals in caring for patients with dermatologic disease should always be undertaken with the highest ethical, moral and safety standards [5]. Again, no matter whom patients see during a clinic visit, or to whom they speak when calling the dermatologist's office, the responsibility to ensure the highest medical and ethical standards in the patient's best interest remains with the physician.

A Resident's Perspective

As a new resident in dermatology, I read Nestor's article with particular interest, not only because of challenges I may face once I complete residency, but also and more importantly because of the way the practice changes Nestor describes will affect my patients. It is clear that increasing numbers of patients and the requirements of managed care are placing greater demands on dermatologists. It is critical that residents be made aware of these changes during their training, a time when young physicians gain the knowledge to practice safe, sensitive and ethical medicine. Though the majority of a resident's learning comes through interactions with attending physicians and their patients, nurse practitioners provide valuable insight and experience. In many cases, a nurse practitioner or physician assistant has more years of service with the practice or academic institution than the physicians. They may have well-established patient bases within the dermatology office setting, and with that patient base often comes a wealth of useful experience with academically challenging and valuable diagnoses. For me, these are just a few of the tangible benefits of learning from all members of the care delivery team.

Readers of Dr. Nestor's article may have questions—as I did—about this growing practice trend in the field of dermatology. As a resident, I wonder whether patients will continue to receive the highest level of care with the utmost attention to safe medical practices. How will the fact that so many of our nation's states are in medical liability crisis and fighting for tort reform affect the ability of dermatologists to continue incorporating assistants into their clinics?

Through my clinical encounters with mid-level professionals as a medical student and resident, I have discovered that they provide vital and important services to dermatology medical teams and, more importantly, to our patients. Dr. Nestor does an excellent job of outlining the challenges facing our specialty and the role of the nurse practitioners and physician assistants. Reading his article gives one a better understanding of the role, liability and obligations of dermatologists and their nurse practitioners and physician assistants. I believe that through the synergistic work of the physician and mid-level professional and nursing staff our patients will continue to receive better care than they otherwise would.