Cold Iron Truth

‘We have met the enemy and he is us’


In a recent article, the New York Times publicly exposed behavior that can only be described as appalling: Some dermatologists have been using unsupervised physician assistants (PAs) and nurse practitioners (NPs) to perform dermatology services on patients, including frail nursing home patients, many with dementia or other similar cognitive impairments, to increase their profits.

Dr. Brett M. Coldiron is a dermatologist and Mohs surgeon in Cincinnati.

Dr. Brett M. Coldiron

The article, published in November, is titled “Skin cancers rise, along with questionable treatments.” The New York Times analyzed recent Medicare dermatology billing data that found that independent billing by PAs and NPs accounted for more than 15% of the skin biopsies billed to Medicare in 2015. This was compared with almost none in 2005, as I pointed out in a comment in the article, for which I was interviewed.

The dermatologic organizations responding to the article included the American Academy of Dermatology, which, in a letter to the editor, stated that a board-certified dermatologist should “provide direct supervision of any nonphysician (PA/ARNP) for optimum dermatologic care,” a statement that was affirmed by the American College of Mohs Surgery. The American Society for Dermatologic Surgery and the Women’s Dermatologic Society sent similar, even more strongly worded letters.

Well, talk is cheap, and it is time for societies to step up and enforce their bylaws or amend them in order to remove members who practice in such an unethical fashion.

Also in November, an important paper by Adewole S. Adamson, MD, and his colleagues was published in JAMA Dermatology concerning the geographic distribution of physician extenders who billed Medicare independently for common dermatologic procedures in 2014 (doi: 10.1001/jamadermatol.2017.5039). The study found that they are geographically distributed in the same areas – suburbs and cities – where dermatologists already are located. In fact, 92% of those who were independently billing were employed by a dermatologist. The majority (71%) were in counties with high dermatologist density, while only 3% were in counties without dermatologists.

The argument that paraprofessionals provide care for the neglected in underserved areas of the country is unfounded. Physician extenders practice mostly in the same areas in which physicians practice, predominantly in the suburbs. This has been previously demonstrated by the American Medical Association and other surveys (N Engl J Med. 2013;368:1935-41).

In addition, as noted in the past, there are midlevel professionals who bill independently (that is, without direct supervision) for destruction of premalignant lesions, biopsies of skin lesions, excisions of skin cancer, surgical repairs, and flaps/grafts (JAMA Dermatol. 2014 Nov;150[11]:1153-9). But – based on a new finding in the Adamson study, and perhaps the most concerning – this list now includes the interpretation of pathology.

It must be noted that NPs and PAs are trained in primary care, even if up to a master’s degree or PhD level. This does not qualify them to practice specialty medicine independently. Neither does working for, or shadowing, a dermatologist, even if it is a near equivalent to completing a dermatology residency after medical school. PAs and NPs are qualified to practice primary care (PAs with a physician, NPs sometimes without) but not specialty medicine. They can work in a specialty medicine setting if they are directly supervised by a specialty physician.

In summary, “we have met the enemy and he is us,” to quote the comic strip character Pogo. As pointed out in the New York Times article, a few dermatologists are enabling and financially benefiting from paraprofessionals who practice dermatology, without any formal training.

The malpractice risk is huge. The insurance industry will surely realize that this costs them more, not less, because of additional biopsies, pathology interpretations, and missed diagnoses. Now the lay press has caught on to this abuse, and the exposure will not stop here. They will flip over every dermatologist using midlevel professionals in this fashion, starting with the biggest and working their way down

Fair warning has been given to those who use this practice model for their personal gain by the New York Times exposure and the hard lines drawn by the dermatology specialty societies. This technique of boosting profits is unsustainable. Dermatologists must supervise midlevel professionals or face public embarrassment, ethics probes from professional societies, audits, and possibly worse.

Our specialty should take this opportunity to distance itself from these profiteers. The patients hopefully will learn that they are being shortchanged, and demand to see a “real” dermatologist instead of a dermatology “provider.”

Dr. Coldiron is in private practice but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics. He is a past president of the American Academy of Dermatology. Write to him at

Next Article: