“Beware the Aggressive Dermatologist”...

[VagabondMD]

was the title of the link for this article in Abnormal Returns:

https://www.nytimes.com/2017/11/20/health/dermatology-skin-cancer.html?utm_source=Daily+AR&utm_campaign=12f21 3da25-RSS_EMAIL_CAMPAIGN&utm_medium=email&utm_term=0_c08 a59015d-12f213da25-143451145&_r=0

Click bait, for sure, but certainly eye opening and reveals some of the scumbaggery that exists in lots of fields, hardly unique to Derm. I see more and more “patient mining”, blatant overcoding, fear mongering (“it COULD be cancer, so we better...”), and other unsavory practices with each passing year.

When the VC backed national Radiology firm was talking with us, they all but promised us more thyroid biopsies if we adopted their standards, as if it were a good thing.

[Hatton]

Really a frightening business model.

[VagabondMD]

Rex wrote:

I didn’t read the entire article but I don’t agree at all with the idea that you shouldn’t treat or under treat non melanoma skin cancers in elderly unless they are fairly unhealthy and thus likely to die soon especially SCC.

Click to expand...

I am not sure that was the argument. It was more along the lines of not scouring nursing homes for Alzheimer’s patients with skin lesions so that you could have more cases to examine/biopsy/treat/bill.

I remember the days early on in my career when older, frail, debilitated people would be treated with a reasonable level of restraint, not medically flogged to within an inch of their lives, like I now witness daily.

Sometimes I wonder if it’s not a doctor shortage, but an excess of doctoring, that plagues our system.

[Hatton]

I am not going to consent to a biopsy being done by a PA or np without even seeing the doctor. Maybe that is just me.

[ScientistPhysician]

The major problem identified in this article is NPs and PAs doing skin checks and biopsy decisions without any supervision from an attending physician. Why anyone thinks it is OK to have an NP/PA do derm care with only a few years of training versus a dermatologist with minimum 9+ is beyond me.

[JK]

Yes. Very shady stuff. He is actually a program director which makes it worse. I actually looked at his program for residency...but he basically is a slave driver and uses residents to increase revenue and bills everything under his name. Residents can double their income but at what cost...and how much are they actually learning. It's ashame how a few bad people paint a bad picture for dermatologists and doctors in general.

[Rando]

ScientistPhysician wrote:

The major problem identified in this article is NPs and PAs doing skin checks and biopsy decisions without any supervision from an attending physician. Why anyone thinks it is OK to have an NP/PA do derm care with only a few years of training versus a dermatologist with minimum 9+ is beyond me.

Click to expand...

I have to disagree with you.  The main problem isn't that NP's and PA's are unsupervised.  It's they've either been trained to be extremely aggressive, or more likely instructed to be be extremely aggressive by their supervising physicians.  I've worked with mid-levels for almost 30 years, and a good well-trained PA/NP doesn't pull this stuff.

[AR]

Rando wrote:

ScientistPhysician wrote:

The major problem identified in this article is NPs and PAs doing skin checks and biopsy decisions without any supervision from an attending physician. Why anyone thinks it is OK to have an NP/PA do derm care with only a few years of training versus a dermatologist with minimum 9+ is beyond me.

Click to expand…

I have to disagree with you.  The main problem isn’t that NP’s and PA’s are unsupervised.  It’s they’ve either been trained to be extremely aggressive, or more likely instructed to be be extremely aggressive by their supervising physicians.  I’ve worked with mid-levels for almost 30 years, and a good well-trained PA/NP doesn’t pull this stuff.

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I agree with you mostly. I'd say the problem is just poor training in general.  Remember, these extenders were biopsying a lot of stuff AND missing obvious cancers. If they were just trained or instructed to be aggressive, they wouldn't be missing the obvious ones.

[Lithium]

 

Vagabond MD wrote:

Rex wrote:

I didn’t read the entire article but I don’t agree at all with the idea that you shouldn’t treat or under treat non melanoma skin cancers in elderly unless they are fairly unhealthy and thus likely to die soon especially SCC.

Click to expand…

I am not sure that was the argument. It was more along the lines of not scouring nursing homes for Alzheimer’s patients with skin lesions so that you could have more cases to examine/biopsy/treat/bill.

I remember the days early on in my career when older, frail, debilitated people would be treated with a reasonable level of restraint, not medically flogged to within an inch of their lives, like I now witness daily.

Sometimes I wonder if it’s not a doctor shortage, but an excess of doctoring, that plagues our system.

Click to expand...

https://m.youtube.com/watch?feature=youtu.be&v=bCj4G9hwxmA

sorry if that offends any oncologists out there!

[wideopenspaces]

hatton1 wrote:

I am not going to consent to a biopsy being done by a PA or np without even seeing the doctor. Maybe that is just me.

Click to expand...

Same. I'm not saying PAs and NPs don't have a place in medicine, but I personally wouldn't put my own health in their hands. I'd want direct MD supervision.

[VagabondMD]

wideopenspaces wrote:

hatton1 wrote:

I am not going to consent to a biopsy being done by a PA or np without even seeing the doctor. Maybe that is just me.

Click to expand…

Same. I’m not saying PAs and NPs don’t have a place in medicine, but I personally wouldn’t put my own health in their hands. I’d want direct MD supervision.

Click to expand...

The bigger problem, in my opinion, is receiving care from a provider, whatever the credentials, with whom the profit motive has superseded the good care motive.

Perhaps I am old fashioned, but I have always practiced with the mindset that if you do a decent job and treat your patients like you would want yourself or your loved ones to be treated, the financial success will follow. I know for certain that I would not want an army of VC-backed PAs with sharp instruments descending on me!

[q-school]

wideopenspaces wrote:

hatton1 wrote:

I am not going to consent to a biopsy being done by a PA or np without even seeing the doctor. Maybe that is just me.

Click to expand…

Same. I’m not saying PAs and NPs don’t have a place in medicine, but I personally wouldn’t put my own health in their hands. I’d want direct MD supervision.

Click to expand...

we may not have much choice in primary care in the not too distant future.

direct md supervision may equate to reading the note

[janettebournes]

Vagabond MD wrote:

wideopenspaces wrote:

hatton1 wrote:

I am not going to consent to a biopsy being done by a PA or np without even seeing the doctor. Maybe that is just me.

Click to expand…

Same. I’m not saying PAs and NPs don’t have a place in medicine, but I personally wouldn’t put my own health in their hands. I’d want direct MD supervision.

Click to expand…

The bigger problem, in my opinion, is receiving care from a provider, whatever the credentials, with whom the profit motive has superseded the good care motive.

Perhaps I am old fashioned, but I have always practiced with the mindset that if you do a decent job and treat your patients like you would want yourself or your loved ones to be treated, the financial success will follow. I know for certain that I would not want an army of VC-backed PAs with sharp instruments descending on me!

Click to expand...

The post below is more about medicine in general, not to single out one specialty. FWIW, I tend to disagree with much of what the NYT publishes anyway when it comes to medicine as I find most of them to be clickbaity hit pieces. For the record, I STRONGLY DISAGREE with the idea of leaving skin cancers and pre-cancers on patients unless truly near the end of life

That being said, I do agree that there is a problem when desire for profit supersedes desire to provide appropriate care. The scary / sad thing is that many of these people (from physician down to midlevel provider) believe they are providing good care. They've been brainwashed or convinced that being overly aggressive is good and appropriate medicine (with the added benefit of being highly lucrative to boot). I still don't believe these physicians / providers would actually subject their own loved ones to as many aggressive medical procedures as they foist upon their patients but they can bring themselves to at least say they would. (I obviously believe this problem to be magnified in any VC-backed practice but I've noticed this is also becoming fairly prevalent in academics too. The hospital across town from where I trained is famous for being super aggressive)

I find this kind of medicine to be especially predatory towards new attendings. VC-backed groups are known to float very high salaries to new grads but the physician will soon find the only way to maintain that kind of income when they inevitably get switched to productivity is to practice medicine in a manner that is best for the VC-group's profit margin, not necessarily in a manner that is best for the patient.

[E5797]

In my area, all the derms are in private practice but don't take Medicaid.  The health systems have hired derm PA's and NP's though I'm not really sure who their staffing MD's are. Long wait to get into see the private derms, but they all seem to have their own PA's and NP's as well--maybe difficult to recruit another MD to their practice.

[RogueDadMD]

Overtesting and overdiagnosis plagues almost every sector of healthcare, including the majority of physicians, including many of those practicing in the ivory towers (such as myself) where we hold application of the evidence as sacrosanct.

I didn't read this particular NYTimes article, which based on the comments seems to be describing what is simply bad (and potentially unethical care), most doctors would do well to realize that many of us overtest.  And those that are cognizant of it and actively avoid it probably undertest to a degree.