The Dermatology MD-PA Relationship

In this episode, podcast host Larry Green, MD, chats with Risha Bellomo, MPAS, PA-C, about the MD/DO-PA relationship and how dermatologists can effectively collaborate with physician assistants.

Dr Larry Green:  Hi, welcome to another podcast with the dermatologist. I'm Dr Larry Green, clinical professor of dermatology at George Washington School of Medicine and on the board for The Dermatologist.

I'm here with Risha Bellomo who's a fellow board member of dermatologists and a PA. Risha went to the University of Florida School of Medicine and has been a PA for 21 years, almost as long as I've been a dermatologist. I'm way older than you. I'm proud that she's one of the founders of Diversity in Dermatology, which wrote education values in dermatology for PAs and MPs.

Risha, welcome to the podcast. We're here to talk about the dermatologists working in collaboration with the PA. Thank you. We really value your insight because we want to talk about the ideal relationship is that we should have. I'm a dermatologist, you're a PA, how should we work together? Let me ask you first. What brought you as a PA into dermatology specifically?

Risha Bellomo:  First I just want to say, thank you for having me today. Thank you, Dr Green and The Dermatologist. It's always an honor to these kinds of events and podcasts.

What brought me into dermatology? As you may know, when you go to PA school, you have a year of didactic, approximately, and a year of rotations in clinical practice. That can differ a little bit, depending on what program you go to, and the length of the time. When I was in my rotations, I chose my two electives to be dermatology. I'm not sure exactly why. I just had an interest in it.

I decided to do 8 weeks in derm, really liked it. When I graduated, I thought it would be a good idea first to go into family practice, to get a good base of medicine, because as a PA, we can practice in all kind of specialties or modalities of medicine.

I wanted to really get a good foundation of just internal and family medicine first, because I really thought that would help me as I move forward into my career, no matter what I did. I was also moonlighting in urgent care, and also on Fridays, in a dermatology office. This was in Gainesville. I was still working in Gainesville.

I loved dermatology so much that the doctor that I was working with, he decided to call...I was thinking of moving to Orlando, I was in Gainesville, and he called another dermatologist that had a practice over there, and said, "Hey, I have this great girl, and I think you should hire her," and he did. I have been in dermatology, full time, ever since. That's been close to 21 years in dermatology.

Dr Green:  That is a great hire. That's what every dermatologist wants for every person they have working in their staff. He's very lucky to have you. Let me ask you, from the PA perspective, how does the education background that you received benefit the dermatologists who you were going to be working for?

Bellomo:  There's actually multiple variables to this, and multiple components. For me, personally, I had a strong science background. My undergraduate degrees were in microbiology and chemistry. Then, I also worked as an EMT, or emergency medical tech, in the ER for several years during my undergrad.

By the time I went to PA school, I had a strong science background. Then, I also had a very strong clinical background based on ER. I could suture already. I could cast. I at least have an idea of diagnosis and treatment just by watching the physicians or the PAs that were actually practicing in the ER.

I had a lot of that going into PA school. PAs, unlike nurse practitioners that typically go through the college of nursing, we go through the college of medicine. We're being taught by the same professors that the college of medicine is being taught, and the medical students.

We get to do our rotations and our internship, a lot of times, with third- and fourth-year medical students. I know me, personally, I got to do a cadaver lab. I did gross anatomy, which was key, too, to my training. I felt like the University of Florida program that I went to was a very strong program. It condensed medical school in 2 years. The one thing is we don't get a true residency program as PAs.

With that said, those first 3 years are super important that there's great collaboration with the supervising physician, or maybe a senior physician or a PA that might be in the practice. Also, continuing medical education. Making sure that they are reading their journals, that they're reading their textbooks, getting medical education, going to conferences. For me, I also got into leadership a lot. I worked a lot with industry or worked with the organizations, or built organizations. I felt, when I could learn from other physicians, or be on advisory boards, and learn from other people, it was insightful. Then I could hear all different kinds of opinions or different ways to treat patients.

My always recommendation is get out there, network, collaborate, not only with your supervising physician, but with other colleagues as well. It creates a dynamic in your practice where you can have some great conversations.

I know with my supervising physicians, we would get articles and we'd discuss them. I would go to an advisory board, then I'd come back and go, "Guess what I just learned? I learned that there's this new drug that's going to come out to the market." I'm super excited about it. I'm talking to my supervising physician.

We're reading the published clinical trials and having those discussions. That's key to the team when you're dealing with a dermatology PA and their supervising physician.

It's building the relationship, just like any relationship. If it was a friendship, if it's a marriage, whatnot, that's what a relationship is with our supervising physician. Building that rapport is key.

Dr Green:  That's how I first met you many years ago as an advisory board. You were a great part of that advisory board. It was a pleasure to have you. You could tell you were an experienced member of the advisory board, and someone with a lot of experience in advisory boards, and knowledge of dermatology, because of the things you've done.

Let me backtrack, Risha. Let's bring up what you think should happen in the beginning. As you mentioned, PAs don't have residency like dermatologists. Most of our learning comes in residency, and not so much in medical school. Residency is so important.

When the dermatologist wants to hire a PA for the first time. Looking at their background in education, they find someone like you. It's fantastic. You're unique in what you've done. What should the dermatologist be looking for? If someone's, say, fresh out of PA school, with just a science background, like a medical school background, what do you suggest happens at the beginning for the dermatologist and PA to collaborate together? Then, what timeframe from there on? Should they meet? Should there be less need for supervision? I'll let you go through that.

Bellomo:  You have to look at a couple of things. Number one, if you look at a lot of job postings that are out there, a lot of the dermatologists or practices want some experience, two or three years of experience. Maybe that's because they don't want to put a lot of time and energy into training.

Then there's other dermatologists that do want somebody that's new. Then they can mold them and train them the way they want to train them. It depends on what that dermatologist is looking for too in that practice.

You have a busy schedule as a dermatologist. Now you want to bring somebody in, a PA, because you need help. You've got a big practice. It's growing. You want them to see patients at some point on their own, so they can be part of the practice, and contributing.

As a dermatologist, you have to figure that you need to put in some time for training. There is an investment there with any PA that you're going to bring on. No matter if it's a new PA, brand new out of school, or if it's someone who has tenure.

Even if you and I started working together, Dr Green, even though I have a lot of experience, we would probably want to see how each other works. Maybe there's something you do that I don't do. I do it differently. Doesn't mean that the outcome is bad or good. Maybe they're both good. There's different ways to get to a good-end outcome.

I feel like if you have a new PA that you're hiring, and they have less than 3 years' experience, it's important, and especially if they're brand new, you do need to take them under your wing. You have to have some training program within your practice, so that they can learn, they can be on a schedule of what to learn.

I would start with fundamentals first, if they're new. Making sure that they just understand how it's not even diagnosed, but just about distribution of rashes. About what a papule and a pustule is. Just looking at the fundamentals.

Then, it's show one, teach one, do one, or something like that. That's what you have to do. You have to do it for each fundamental clinical dermatology disease state as you start off. That's what I typically recommend, is that they need to learn about acne, warts, rosacea, and seb derm. All of the things that we see on a daily basis. That's important. Maybe you start with them just seeing those cases when you give them a little bit more reign, if they're new. They also should be getting supplemental education. They should be reading their textbooks.

They should also be getting supplemental education from maybe a foundational course that might be out there, that could supplement their on-the-job training, and going to conferences. They'll need some CME money to go to conferences. Also, learn that way, and network. That's key.

As they build that education and knowledge, then you can teach them a little bit more and give them a little bit more freedom. In the beginning, you should be meeting pretty regularly. Also, explaining their scope.

I'll give you an example. I've never liked blistering or bullous diseases. Don't see a lot of them. Never treated a ton, because they're not super common. I never felt super comfortable with treating bullous diseases. I would recognize it, then, I would either bring my supervising physician in or I would refer to a doctor that I always referred to that really had a passion for it, and was extremely skilled in that particular disease state or subspecialty dermatology.

Also, making sure PAs know their scope is extremely important. You don't want to ever practice outside your scope. That's when bad things can happen. That's very, very important, that there's this continuation with your supervising physician, and collaboration.

In the beginning, you might be meeting a lot. They might be shadowing you. Then, you may say, "OK, well, I want you to see these 5 to 10 patients today." They're acne, warts, regular thing. Then have a follow-up on that. Those are good things to do in the beginning. Now, if you have someone who's tenured, like myself, and has a lot of knowledge, then, in the beginning, you have discussions about different things that you're maybe comfortable or not comfortable with as a collaborating or a supervising physician. You may say, "OK, as I start to build trust for this person, and I see that they're knowledgeable, I'm going to give them more freedom. I may have them see patients. We might meet up once a month." That also depends on the trust level that's built. There's many variables to that.

Some PAs learn very quickly. They're super skilled, especially with procedures. Others may not be as skilled. The supervising physician or the dermatologist needs to recognize the strengths and the weaknesses of that particular PA, and help build up those strengths, but also, build up the weaknesses as well.

If you hover over them too much, that's not a good thing, either. You want to be able to have that trust and respect. That's a big thing, is respect. We all need to respect each other in the workplace. That's extremely important.

One other thing I will say—because this doesn't have to deal with clinical diagnosis or treatment—when you're young, let's say you're in your 20s, you don't have as much life experience yet. There may be things that have not happened in your life that might happen later. That could be getting married, having a baby, getting divorced, having death in the family, whatever that might be. As you have more life experience, you start to relate better to your patients. I noticed that. I started practicing in my 20s. I looked really young. [laughs]

I'd walk in, and it's almost like the Doogie Howser thing. You have to start building the confidence with patients. That's another for young PAs and NPs. Building the confidence to speak to patients, to understand the psychology behind different patients, is extremely important, in my opinion. I know that as I've gotten older, I'm able to relate and have conversations with my patients. A lot of things that they've gone through, I've gone through. I do believe that sometimes, experience, both clinically, but also having a rapport with your patients, it takes time. It does come with life experience and education.

To sum it all up, it is super important that we continue to collaborate. No matter if you're your first year out of school, or if you're like me, and been in this industry for over 20 years. Collaboration is key and teamwork is key to the best patient outcomes we can get.

Dr Green:  You brought up so many good points that I want to summarize, though. What I found the most important points is, one, when you have a PA, especially when they're new, but whether they're new or not, it's very important to get them outside your practice to get them networking, get them to conferences, get them to meetings, get them to advisory boards. Make them learn outside of your own office. They learn more value outside of your office. That brings more value to your office. That's important, to send them to conferences and meetings.

You talked about when a PA is younger, and they're first starting, the first things that the dermatologist should do is make sure they see basic dermatology. Basic acne follow-ups. You mentioned more follow-ups. You mentioned rosacea. Maybe basic psoriasis follows-ups, before they get into things that are a little more complicated. Maybe before they start seeing new patients, established patients should be seen first. People that are already on a regimen, so that you can see success.

The third thing you brought up that's important for a more experienced PA like yourself, is that although the meetings don't have to be the same and as frequent with the dermatologist, but you still say, you want to meet with them to discuss the things you're doing yourself. The things that you have learned. Things that she or he has learned, the dermatologist, so that you can meet together. That's important to grow together. You brought that up. It's a very other good point.

Bellomo:  It is, because we never stop learning. If you feel like you've learned everything, then you're absolutely wrong. You will never, ever stop learning. I learn something new every day. If it's dealing with clinic, or, I don't know, sometimes just being a mom, or business. Whatever it is. I always learn something new.

Collaboration is key. It's exciting, too. I wrote my essay for when I had to apply for PA school. I wrote it on the health care team, collaboration, and teamwork. We truly are a team. Autonomy, even though it's great...Hey, I love autonomy. I am very autonomous, not only my practice, but also, in my own personal life. That's great. As practitioners, we need to rely on each other when we're dealing with patients. It's not only within our dermatology practices. We also need to collaborate with outside specialties. Especially in dermatology, rheumatology, allergy, immunology, GI, are important.

A lot of our patients have certain disease states that are comorbidities that go along with the disease states that we see. It's important to have that collaboration. The biggest take-home here for PAs that are out there, as well as dermatologists, is build your report and collaborate.

Even if you feel like you know a lot, that's great, tt's still always fun to get together and have those conversations. I will tell you that there is many times that my dermatologist, a supervising physician and I, disagreed. We would agree to disagree. We found that even though I may do something one way. I might write one medicine, and he or she might write another medicine. In the end, if the patient is better, happy, and their quality of life is good, that's the main thing that's important. That they're safe.

Dr Green:  All great points. Let me ask you one more thing. Is there anything else that you think the doctor or the dermatologist can do to build trust with the PA that she or he hires for the long-term relationship?

Bellomo:  I do believe that respect is huge. One thing with PAs is—and I know it, because a lot of them speak to me—is that they feel like they're another staff member, and not a big contributor to the patient care sometime. That is disappointing. We all contribute.

Also, all the staff members, medical assistants, front staff, whoever's answering the phone, these are all important people within the practice. I feel that PAs, they want a level of respect from their supervising physicians and dermatologist.

They want to feel like they can have those conversations and not feel intimidated to go and ask a question, or to have conversations, or feel like a second-hand citizen. Unfortunately, there are some situations that are like that. For me, it's all about respect. That's huge.

You have to earn respect. You also have to give respect if you've earned it. That is a definitely a take-home point for the dermatologist to understand that this PA is bringing a lot to the practice. They bring revenue to the practice. A lot of the patients like to see that PA. They end up building a rapport as a patient. They want to see that provider.

They like that provider. They have a rapport with that provider. They want to continue to get care from that provider. Then, that contribution is huge within a practice. There's definitely the dermatologist who is employing the PA, needs to definitely give respect to that PA, and vice versa.

Dr Green:  That's all about a collaborative relationship, for sure. You brought up a point about PA asking for help. I think, in the beginning, that's very important.

Do you have any advice for PAs about knowing when to ask for help, and making sure? The last thing you want to have happen is PA not getting the advice they need, or being afraid to ask, and the patient not getting the best care.

Bellomo:  I think if you're second-guessing yourself at all, then you need to talk to somebody about it. We know. When you get really good, sometimes you can read what the medical assistant's even written down, and you go, "Oh, yeah, I know what this is," almost before going in the room. [laughs]

Then you sometimes get in the room and you're like, "Oh boy, this is a whopper of one." You're like, "OK, could be this, it could be..." so you're going through your differential, you're thinking, "OK, we might be scheduling a biopsy for this," so you've gone through all that.

If you ever get to point where you're like, "You know what, I've exhausted this," or, "I really don't know," and you're in your mind, second-guessing, then you need to stop, and then you need to be honest with the patient.

I did this a ton of times with certain things that came in, they were complicated cases. I was like, "Oh my gosh, this is beyond my scope. I can get my differential, I got my differential, I know what we're gonna do for a plan for biopsy, but then what are we gonna do for treatment?"

Sometimes, you get these obscure biopsy results that don't make much sense. I think that's another thing, just to circle back real quick, is understanding pathology, how to read it, and knowing how to write it up so the dermatopathologist understands what you're seeing, so they know how to look at it under the microscope. That's key to training.

To go back with the scope, you need to then just be transparent and honest. Don't go and bring your textbook in and do all of that. Never bring your textbook into the room with a patient anyway. [laughs] Just say to the patient, either, "I've never seen this," or, "This is a complicated case. I would love for my colleague and supervising physician, Dr so-and-so, to come and see this," or, "You know, you have this, and I'm not a specialist in this, but there's this great physician that does sub-specialty for bullous disease," example, "and I'd love to refer you over to him."

I will tell you that patients, they appreciate the honesty, the transparency. When they have somebody else come in and collaborate on the case, don't feel like you're embarrassed to do that. It's OK. It's actually what's best for the patient. If you're second-guessing yourself at all, then go ask for help. That's what I would say. You never want yourself in a situation where things just get out of control.

Dr Green:  Thank you. One last question I thought of is, then, what do you think about the role of the supervising dermatologist? How often should she or he check in on the PA? I know it depends on the PA's experience. What are your suggestions there?

Bellomo:  It really does. Every PA and NP is different. I know that our protocol was either twice a month or once a month to come by the office. Even with supervision or signing charts, that's all based off of state law.

What I recommend is, even if you're in a state such as mine, like Florida, where you don't have to sign off on charts, it's up to the supervising physician's discretion, too. Mine would always say, "Well, I know you know all the basic stuff first."

If we're talking about maybe a melanoma, or some more complicated case, then he would take so many charts and just review those, and then sign off on them. Not many, maybe 10 or 20 a month. That was what we agreed upon. I always had a cell phone. He would come by the office two Tuesday afternoons a month.

We would just see patients together, talk about things, take out some journals. We'd have lunch together. It all depends on your practice, how busy each provider is, and where they're located. All of that. I know there's so many variables with that.

For me, it was fun. I didn't think of it as negative. I thought it was actually fun. It really built my rapport and my friendship with my supervising physician.

Dr Green:  I like the way you said that. You wanted to make it fun. That's a great, great concept for the dermatologist, is to try and make the supervision fun, and not supervision. To make it a shared experience for both, even though the dermatologist is making sure everything is working right in her practice or his practice.

Bellomo:  We all have liability. We have to think of that, too. We've got to look at liability. We're in medicine. Medicine is a very liable profession to be in. You have to also respect that as well. Even prescribing certain things. Some providers don't like to prescribe certain medicines. They're afraid to prescribe them. They think that they could be liable for something, if, let's say, the safety profile for them isn't clean enough. I do believe that that's part of it, too, is that everybody's a little different about how they feel about liability.

Overall, making medicine fun is important. I feel like we've sometimes lost that, because you do have some practices that you're having to see too many patients a day, you're getting burned out, you're stressed, you're overworked, and then it takes the fun out of a job.

For me, if things aren't fun anymore, I don't want to do them. I want to enjoy it, I want to have passion. If I lose my passion and I lose my fun, then it's probably not something that I really want to do anymore because I don't enjoy it.

Dr Green:  Couldn't agree more. Thank you again. We want to have fun there. We talk about physician burnout or PA burnout, or burnout from it not being fun anymore, of course, we want to have it fun. Sounds like, the collaborative relationship can make it a fun experience for the both of you, because you're in it together.

Bellomo:  One last thing, Dr Green, is burn dermatology. It's one of the best, if not the best, specialty out there and it's hard to get into. No matter if you're a medical student trying to be a dermatologist and that's where you want to match in a derm residency, of if you're a PA trying to get into derm, is not easy.

I just would say, we're very blessed to be in this profession. I know I have felt that way, over the last 21 years. Embrace it. You know what, it's all about collaboration. I would say that that's my end statement -- have fun, collaborate, and be passionate about dermatology, because it's absolutely the best profession.

Dr Green:  Thank you very much. Great way to summarize. Thank you very much for being on the podcast, Risha. I look forward to hopefully seeing you live at a meeting soon.

Bellomo:  Yep, talk to you soon. Thanks, everyone.