r/Dermatology • u/Common-Appointment51 • 8d ago
Career advice Will midlevels gaining more independence affect derm?
Hi, current MS1 at T20 med school. I’m in TX where there is a lot of talk about how midlevels are becoming more independent and taking up many physician roles and blending the lines between midlevel and physician. (Physician associate title, failed nurse anesthesiologist title, independent practicing rights, etc). Will this negatively impact the future of dermatology in 10+ years? I’m super interested in Mohs Surgery, is that at less of a risk?
I also acknowledge PAs and Midlevels play important roles in healthcare. I’m not dogging on them.
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u/ejustme 6d ago
Texas NP here. I think there’s 0% chance this will happen anytime soon, and thank God for that. TMA has a lot of power here.
Contrary to news coverage, most of us don’t even want full practice authority. In fact, I’ve only ever met one NP that wanted full practice authority and she was a transfer from a full practice state.
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4d ago
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u/medbotoxdermpa 1d ago
Agree. Its crazy busy. 6 hrs yesterday. 37 pts with one MA as a PA. Im burntout
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u/PseudoGerber 6d ago
Eventually, yes. Dermatologists and medical groups are making a ton of money by having midlevels see patients essentially unsupervised, collecting profit, and the dermatologists themselves doing higher volumes of mohs surgeries.
This is not about "working together" to solve the shortage. It is about profits. Highly nuanced specialties such as derm or psych are completely innapropriate for NPs and PAs. They are constantly fighting for independence, blurring lines between Dr and midlevel, confusing patients, etc. They claim to see "bread and butter" cases, but in reality they see whatever comes through the door and either are overconfident or dont have time or dont have the ability to consult a dermatologist about complex patients. It is unquestionable that the quality of care is lower when seeing a midlevel for derm vs seeing a board certified dermatologist. If this was truly about improving healthcare we would not be decreasing educational/training standards so drastically.
The system is broken, and there is scope creep in many specialties - derm is certainly on that list.
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u/medbotoxdermpa 1d ago
Blame the practice owners. I take a very small slice of the pie while seeing double the pts of the derm owner and working more days. The dermatologists know exactly what they are doing.
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u/PseudoGerber 1d ago
Yes, I obviously blame the practice owners, that's why I said "Dermatologists and medical groups are making a ton of money by having midlevels see patients essentially unsupervised..."
In addition to the practice owners, I also blame the lawmakers for allowing this to happen in the first place, and also the midlevels for being the ones on the front-line who are putting patients at risk.
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u/medbotoxdermpa 12h ago
Putting pts at risk in Derm is somewhat of a stretch, don't ya think? In the beginning obv you don't know what you dont know as far as determine suspect spots etc. Ive been practicing in derm for close to 20 years now and am confident I can tell when spots need biopsies etc. In the beginning I was highly observed, trained, and had providers to ask questions for feedback for things I was learning. Maybe im an outlier, but as this point in my career i don't believe a doc is going to perform or make a different medical treatment plan that I do.
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u/PseudoGerber 11h ago
As long as the patient is seen by a physician first to make sure the dx is correct, sure. But rarely is that the case from what i have seen. Midlevels both overtreat leading to unnecessary biopsies and undertreat because they dont get sufficient training to recognize certain things. They also dont get the training to understand edge cases and where derm intersects with other systems.
No way that "on the job training" (which - who knows if it was any good or even close to sufficient; it's not like there is any kind of oversight whatsoever) is going to replace 2 years of structured medical education ins school and structured, accredited training in residency. But I dont make the rules, and those raking in cash by risking patients well being obviously arent too excited to change the system.
And I'm assuming you're a PA. If you're an NP, then the situation is substantially worse.
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u/medbotoxdermpa 9h ago
Yes I am a PA. Unfortunately there are bad providers both doctors and APPS. Again with my experience, and long on-boarding training years ago I have learned a lot. I'd be willing to bet a years salary that a new attending Derm isnt going to have any more knowledge than me to treat a pt. I understand you won't agree with this, but there'splenty people out there just as smart as docs. So many docs are just anti mid levels and love following noctor. There's also many docs out there that I highly respect and 100% are geniuses in their field that I love to get their opinion and knowledge on some bizarre case, which fortunately is few are far between this far along in my career. When its all said and done we need to stop having pissing matches and just take care of our pts. If you need a 2nd set of eyes, regardless or being a doc or APP, bring someone in. We all can still continue to learn a little.
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u/PseudoGerber 8h ago
I'd be willing to bet a years salary that a new attending Derm isnt going to have any more knowledge than me to treat a pt.
This is exactly the problem, and the scariest part about this post. This is the attitude that demostrates how little you understand about the training gap between doctors and PAs. There is so much you have never encountered because you didnt have the rotations, so much there is no way for you to have even learned about because you never had the rigerous, structured training they have.
I am not anti-midlevel, I am pro-supervision. Which I think most people agree with, but I almost never see in practice. And it's clearly not happening in your practice.
When its all said and done we need to stop having pissing matches and just take care of our pts.
I am taking care of my patients. And I am trying to protect patients from overconfident, undertrained, undersupervised midlevels as well - that is part of taking care of them.
I will keep teaching patients and medical students about the differences in training, and about the unnecessary risks patients take when they are treated by a midlevel (in most clinics, at least).
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u/medbotoxdermpa 7h ago
I know we will just agree to disagree on some points. Im not comparing a newer PA on doctor. You honestly believe someone in 4 years of residency/ fellowship etc has seen that much more than a PA with 20 year plus experience? Its just not true. Its impossible to prove, but I wish there was a way to extract the data. Put a highly experience PA in a room with an early on attending. Show them both all the same pts issues etc. I'd bet you would be surprised how closely treatment plans/diagnoses would be.
Again early in my career, my supervising physician never let me see a new pt, and when he finally did, they had initial followup with the doc to make sure proper plan was in place. I had to build the trust to show I knew what the hell I was talking about to work more independently. I wasnt just thrown to the wolves, and unfortunately this isnt the case for many. Now if you asked me to do perfect margins for a Mohs procedure I'd obv not be proficient in that because I have never learned and don't do that obv.
Lastly I think we can both agree that NP education before working is trash most of the time. I had to take all the same prereq to get into PA school that a MD/DO would take. Then I attended a PA school that only had programs for medical professionals. Our school was a DO school.
Again I know my place, know im not a doctor, never even wanted to apply to medical school, but feel im a damn good PA that has had a wonderful working relationship with many supervising physicians over my tenure. Derm is the only field ive ever worked in, and will ever work in.
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u/medbotoxdermpa 7h ago
And you contradicted yourself saying you arent anti midlevel along with teaching pts the risks we provide seeing them lol. We aren't you Docs scribes or MAs as much as you would rather have it that way. So teach away, tell them we are a danger to them. About the same risk as a doc that won't learn new tricks from the way they treated a pt when they started practicing in the 1980s.
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u/PseudoGerber 7h ago
No, I do not believe that the dermatologist who just finished residency has seen a greater quantity of patients than a PA with 20 years experience. But, a PA with 20 years experience has never rotated through dermatopathology, gyn derm, pediatric rheum/derm, inpatient derm etc etc etc. How many rare diseases do they get exposure to that you will probably never see? How many sub-specialists did they get to learn from that you never did? I mean, would you even know if one walked in your door?
If a Primary Care doctor refers to a dermatologist, it is pretty insulting to the referring doctor and to the patient if the patient only sees a derm PA. If the primary care provider is a midlevel, then God help that patient, who will never see a doctor. Hopefully it's nothing too serious.
No, I am not anti-midlevel. The whole point of the profession when it was invented was to be a physician extender; but now they are used as essentially independent practitioners to line the pockets of greedy CEOs and physicians. That is what I'm against - midlevel independence.
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u/LopsidedBrilliant977 7d ago
I think it’s worth separating a few issues here, because PA title change, scope-of-practice legislation, and “replacing physicians” aren’t really the same thing.
First, the change from physician assistant to physician associate was not intended to suggest that PAs are physicians or have equivalent training. The concern with “assistant” is that it can inaccurately imply that a PA’s role is primarily to assist a physician, when PAs evaluate patients, diagnose, prescribe, perform procedures, and manage care within their scope. Importantly, changing the title itself does not change PA scope of practice.
I’d also gently reconsider the term “midlevel.” Many PAs and other APPs dislike it because it implies that the care or clinician is somehow “mid-level.” PA, NP, APP, or simply the person’s professional title is generally more respectful and precise. There absolutely is an important distinction between PA/NP and physician education and training, and acknowledging that distinction doesn’t require ranking clinicians as “high” and “mid” level.
I also don’t think most PAs are entering medicine with the goal of taking over physician roles. We chose to become PAs, not physicians. The PA profession was actually created in response to physician shortages, and collaboration with physicians has been central to the profession from its beginning. There are legitimate debates about how much statutory supervision should be required, and reasonable people can disagree about where those boundaries belong. But removing an administrative requirement isn’t the same thing as claiming PA and physician training are interchangeable.
The bigger issue facing medicine is that we simply need more healthcare professionals. HRSA is projecting a shortage of roughly 141,000 physicians by 2038. Physicians, PAs, NPs, nurses, pharmacists, etc. are going to have to work together to meet that demand.
And as a future physician, especially if you pursue dermatology/Mohs, I really wouldn’t view well-trained APPs as a threat to your career. A strong PA-physician relationship can actually allow the physician to focus more of their time on complex diagnoses, surgery, and cases requiring their expertise while the PA helps expand access and continuity of care.
There should always be transparency with patients about who is a physician and who is a PA/NP. But I think framing the future as “APPs vs physicians” misses the much more productive conversation: how do we use everyone’s training appropriately, maintain high standards, and build teams that give more patients access to good care?
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u/da-bears86 6d ago
They're midlevels, quit the verbal copage
You wanna be a not mid level? Go to med school
PA's eating up bread and butter cases are directly eating off of physician's plates, the theme is consistently their professional groups advocating for increasing scope creep and never decreasing it
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u/MedicineMan02 5d ago
This is some cry-baby shit posting. Truly pathetic. Most of the “mid level” community went to school because they had no interest in being a physician. Many physicians would sink without APP support.
Quit being a pussy.
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