To the Editor,
I greatly enjoyed reading the recent analysis by Dr. Laughter et al., “Advanced Practice Providers and the Dermatology Literature.” This letter intends to add to, not criticize, that article. Readers should be mindful that the article is a summary of peer-reviewed literature but not a comprehensive summary of dermatologist beliefs about nurse practitioners (NPs) and physician assistants (PAs); the study reviewed 88 published articles, but there are over 10,000 dermatologists in the United States (Glazer, 2017). We should listen thoughtfully to research and learn from it, but also rest assured that most dermatologists are weighing in via their actions rather than public writing; although only a fraction of dermatologists have published work related to NPs and PAs, the majority of those in group practices employ NPs and PAs (54% in 2014), a trend that is steadily increasing (Ehrlich, 2017). There are also some important limitations of the study’s design that I wish to point out.
Some research has generated favorable information about NPs and PAs as mere coincidence, without drawing attention if not specifically related to the study objectives. In an image reader study of eight PAs and 12 dermatologists, the PAs were 15.9% more sensitive than dermatologists for melanoma detection (p = .015; Ferris et al., 2015). However, because the study's purpose was to evaluate performance of a computer program that classifies skin lesions, the high diagnostic sensitivity for melanoma of these PAs went undiscussed in the article's conclusions. A later study from the same institution and corresponding author (which likely included the same, previously studied PAs) concluded that “the diagnostic accuracy of PAs may be lower than that of dermatologists” for melanoma in situ (Anderson et al., 2018). The second article was published despite lacking analysis of confounders, including the malignancy's primary risk factor—history of melanoma (Marghoob et al., 2018). Related to this, readers should note that the article by Laughter et al. did not evaluate validity of methods for the included studies, which may be a significant limitation considering the potential for editor bias on a controversial subject area.
An editorial board of physicians is unlikely to accept a manuscript titled “PAs Receive More Dermatology Training Than Primary Care Physicians,” although data exist to make that argument: internal medicine residencies require no dermatology exposure, and internists represent the highest number of primary care physicians (McCleskey, 2015). PA students, on average, receive more didactic dermatology instruction than medical students (20 vs. 10 hours, respectively; McCleskey, 2013). Similarly, a manuscript concluding “NPs and PAs can become as proficient as physicians in the diagnosis and management of common skin diseases” seems unlikely to be accepted by a high-impact editorial board, but the only study to compare dermatology knowledge acquisition of PA students and resident physicians showed no significant difference in test performance between the two groups. Time spent studying, not professional credential, was predictive of examination scores (McCleskey, 2013). Again, data like these were not relevant to their authors' conclusions and thus were not captured in the recent bibliometric analysis of NP- and PA-related dermatology literature.
There are articles in dermatology journals coauthored by NPs and PAs that deal strictly with medical content, rather than questions about their profession per se (DeWane et al., 2019; Grubb et al., 2011; Young et al., 2021). That these contributions were accepted by dermatologist editorial teams may be taken as a form of implicit positive sentiment toward the authors, or at least their work. It would be difficult to comprehensively capture instances like these in a literature search, so it is understandable that similar articles were not included in the bibliometric analysis.
It is worth noting that PAs produce less research compared with other health professionals (Miller & Dehn, 2014), and scholarship among PA educators has unfortunately dropped over the last decade (50.6% report having no publications; Kayingo et al., 2021). In a primarily physician-authored body of research, there may be relative overrepresentation of perspectives that tend to paint NPs and PAs in unfavorable light.
It may be impracticable to fully account for stakeholder biases, inattentional blind spots, limitations of available methods, and varying levels of research authorship. Regardless, this work by Laughter et. al. certainly adds insight and perspective that is highly valuable to all dermatology professionals. Authors from all camps should encourage and welcome interprofessional collaboration and co-authorship in dermatology journals to address the complexities of this subject. After all, even Robert Willan (the founder of modern dermatology) kept close acquaintance with a nonphysician medical practitioner: his father (Booth, 1999).
Peter A. Young, MPAS
Department of Dermatology
The Permanente Medical Group
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