The Dermatology MD-NP Relationship

Podcast host Dr Larry Green chats with Melodie Young, MSN, A/GNP-c, about nurse practitioners in dermatology and the importance of collaboration in the MD/DO-NP relationship.

Transcript

Dr Larry Green:  Hello, everyone. This is Dr Larry Green, clinical professor of dermatology at George Washington University School of Medicine in Washington, DC. Welcome to another edition of the podcast series for The Dermatologist, which I'm also on the board for.

I am pleased today to welcome Melodie Young, a nurse practitioner who has 34 years of experience in dermatology as a dermatologist nurse practitioner at the Baylor Healthcare System and also working in Dallas with Dr Jennifer Cather. 34 years. Melodie, you're not that old. Melodie's also incoming president for the Society of Dermatology NPs. She's past president of the DNA, the Dermatology Nurses Association. I know this is something unique and is I think where I first met Melodie years ago. She was the first nurse practitioner on the medical advisory board for the National Psoriasis Foundation.

Welcome, Melodie. Thank you for being here on the podcast with us.

Melodie Young:  Thank you. Thanks for inviting me. It's an honor.

Dr Green:  Let me ask a little bit about you, and then we'll broaden it out to nurse practitioners. What brought you to be a nurse practitioner, and especially into dermatology?

Young:  My story really goes back to being a nurse at Baylor Health Care System. I was working on VIP units. It's where all the C-suite people would hang out. Alan Menter happened to walk onto the floor to do a consult, and we just started chatting. I was so impressed that he could walk in. I still remember it, he walked in and said, "OK, that patient has Sweet's." I thought, "How could you know that, just that fast?" That intrigued me.

All the other physicians coming up to see patients would have to order all these tests, get out their stethoscope, and he just looked at it and said what it was. We just started chatting and I said, "How did you know that?" Anyway, he said, "Well, if you start working at my clinic a little bit, part-time, I'll teach you some dermatology."

I was working 3 days a week at the hospital. Started working a day a week with him, and then fell in love with psoriasis and psoriasis patients. Gave up a VIP Monday-through-Friday job as a nurse to start working smearing black tar on psoriasis patients, wrapping them in saran wrap, doing phototherapy, all the fun stuff, and then really just had a passion for it.

Then, in all truth, we were struggling to find clinicians that had an interest in taking care of psoriasis patients. Dr Menter would try so hard, invite people, they might come and work for maybe a year, to fill in their schedule, I guess, and then they would leave.

My boss at Baylor...At the time, Baylor was sending a few people back to school to become nurse practitioners to work in geriatric centers and work in the transplant population and things like that. He said we're going to have to get you credentialed. You're going to have to be an NP because we need somebody to start taking care of these patients and have continuity. That's how I fell into it. Then became a nurse practitioner in '99 and have been working in doing general medical dermatology is what I would say since that time.

Dr Green:  Melodie, you said you started smearing tar on patients. That does tell us a bit that you've been in the field for a long time because that hasn't been done for a while. I still can't believe you're that old.

You mentioned your education. Tell me about the education that a nurse practitioner has in a dermatology nurse practitioner as well. What type of education do they have? I want the dermatologists to know what you guys go through before you come to us.

Young:  Over 85% of nurse practitioners are educated to do primary care. We become family nurse practitioners or adult or geriatric or women's health, so really primary care. Every single nurse practitioner has to have a bachelor's in nursing, and then you apply to a NP program.

Generally, I'm not going to say all of the programs, but almost all of the programs require you to have a couple of years of experience as a nurse. I don't know, 4000 or 5000 hours of working as a nurse and then you apply because here is the situation. When you apply to go into an NP program, I have to know what I want to study before I ever start.

Do I want to do pediatrics? Do I want to do psychiatry? Do I want to do neonatal ICU? Do I want to be a nurse anesthetist? You have to know when you go into a program. Then you apply, and they will either say, "Yes, you're ready," or, "You need to do some more background." Then you spend 24 months straight studying.

You're already assumed to know pharmacology, physiology, the health care system, how to educate patients, how to work with family as a whole, wellness. You're supposed to know that before you get into the program. Then, of course, you start doing at a more advanced level and focusing on differentials and diagnosing and prescribing and things like that. That's what happen, then you get out.

I did a dual program. I did adult and geriatric. Quite frankly, I did it because there was some scholarship money available if you would get board certified in geriatrics as well, so I did it. Then got out, and then you have to take certification exams for whatever your preparation is. I did an adult certification, which is more in line with internal medicine, and then I did geriatrics as well.

Then, after you have 3000 hours of dermatology NP experience, you can sit for a certification exam. It's called a DCNP. It's the Dermatology Certified Nurse Practitioner. It's not considered a national licensing exam. It's more of a competency.

I hope someday it does become more the standard of care, but then you can sit for that and take it and make sure that you know dermatology. There's been about a 75% to 80% pass rate, but there are a lot of nurse practitioners out there working in dermatology clinics that haven't gone through that.

They just have gotten their education, got a job, started working in a dermatology office, and then have been trained with the dermatologist. There are a couple of post master's programs where you can study dermatology usually for a year and a lot of them are paid positions.

The first one started in Denver about 20 years ago, and then I think there are three on the East Coast, one at Case Western, and a few others that are scattered about. Some of these huge big corporate dermatology practices have created their own. They are hiring NPs and PAs and then putting them through this specific training program, but there's no certification exam at the end of those.

Dr Green:  Let me backtrack. NPs, and then we'll go to DNPs. NPs require 4 years to get an RN. Then once you're an RN, then you go another 24 months for NP, and that's didactic.

Young:  That's if you have in-clinical experience too, where you have to be one-on-one clinical experienced with a preceptor as well, to be able to pass the exams and hopefully know what you're doing. Not all of the programs are requiring 24 months anymore, and I still think it's preferred, and it's the primary way in which NPs are being educated.

There's a growing interest in getting a doctorate to become a nurse practitioner or a nurse anesthetist or a nurse-midwife, which are all lumped into this advanced practice nurse category. With those, it's 36 months straight.

Dr Green:  Advanced practice nurses, it's a little longer if there's a program that allows for that. When do people usually sit for the DCNP exam? I assume they're working for the dermatologists for a while first.

Young:  Yeah, you'd have to have 3000 hours. When you have 3000 hours working in dermatology in the role of a nurse practitioner, not in the role of an RN, not in the role of a clinical research coordinator, then you can sit for that exam. If you stop working in that field, then you won't be able to recertify.

One more thing I'll tell you that a lot of people don't know enough about nurse practitioners is my license allows me to do what I do, which is adult and geriatric dermatology. If I decided I wanted to do pediatrics, or I wanted to change jobs altogether, start working in again, psychiatry as a psych NP, I have to go all the way back. Start all the way over again.

You can't jump from being one type of nurse practitioner to another without starting all over again. That's one of the reasons that a lot of people will get what's called an FNP or a family practice, which is very wellness, very primary care based. They focus on life to death, but it's very much a lot of stuff that I didn't want to do.

When I was doing my training, I wanted to focus on adults because I liked more sick people, and I liked a little bit more of that internal medicine type of training.

Dr Green:  Perfect. After what you experienced in Baylor, yeah, you were perfect for all that. Let me ask you, what are some of the factors that dermatologists should consider when adding an NP to their team? How would you say someone like me should approach hiring an NP?

Young:  First of all, I think a lot of reasons that physicians have decided to add another provider into their clinic. You're looking for a dermatologist. You would really rather have a board-certified dermatologist, but struggling to find someone that can fit the need that you have at the practice. Maybe you have particular interest and you really need someone that can handle a particular group of patients. Then a lot of times, when you're thinking about that, what is it that you want them to know? What is the background that you want them to have?

As nurse practitioners for over 20 years, it's been about almost 30 years, nursing has been the highest-rated or the most trusted profession with one exception and that was after 9/11, and firefighters went to number one. Other than that, every other year, nursing has been rated the highest.

Almost every physician, especially in their training and hanging out in hospitals and all of that, they have really seen what nurses bring to the table and understand that they like that and all. I'll tell you that was one of the things when Jennifer Cather and I started working together, and there's tons of stuff she knows that I don't know.

Sometimes, it's, "Hey, Jennifer, this is something funky going on. Can you just pick the place that I biopsy? What's going to yield the most information? Give me a differential. Tell me some obscure thing you've read about that you know that I don't know."

Then sometimes, she'll have me come in and talk to patients as well and say, "Hey, Melodie knows this." Especially related to phototherapy or things like that. One day she said, "One of the things I've noticed, Melodie, is when I'm with a PA, I know what they know, but I don't know all the stuff you know. You know stuff I don't know."

I said, "Well, it's that nursing background and that wellness and really trying to look at the total patient in the disease." That's one of the things that NPs bring. NPs tend to be a little more established. The average age of nurse practitioners, unfortunately in the US right now, it's almost 50. They've been around a while.

It's hard to be a nurse practitioner by the time you're 30. It's really hard. You're going to probably find somebody who's a little older, maybe even a little more established. That may be appealing, it may not be appealing to a particular practice. I think that you're going to just find somebody that you think can fit that need.

Now, a lot of people, as we both know, will say...My number one question I get on social media for dermatology, NP sites, and things that I'm involved in, number one question is, "How do I get into dermatology? I'm a nurse practitioner, I want to be in dermatology." Most of the time I'll ask them, "What do you mean by that? Tell me what you want to do."

They think they want to do skincare dermatology, which I consider aesthetics, or they're very interested in aesthetics. I tell them, "In my opinion, that's not really dermatology. That's just a subgroup." Yes, the bulk of dermatologists offer those services, but there are a whole lot of other...

We've got medispas in my city that are medical directors or radiologist and dentist and other sorts of things. It doesn't necessarily mean aesthetics and dermatology are not one and the same. People want to get into it. They're trying to figure out how to do it, and then when they really come and start to learn and are impressed the same way that I was with it, where you can really look at something and always say dermatology is easy. I was really good at hunting Easter eggs as a child and figured a way to turn it into a career to dig through and look and find things on the surface that otherwise might be hiding.

The education, the longevity in health care. We know health care. We know all the different players in health care. Another thing about NPs. About half of them have worked in management in some capacity because they have risen to the top within their respective areas. Someone's identified them in a hospital setting or a clinic setting and started saying, "You've got something extra here end up doing management. You don't really want to do that. I did it." You often bring a lot of that into it as well.

Dr Green:  You bring up a good point. If a nurse or nurse practitioner wants to go into dermatology and they're interested in the aesthetics, I've heard this before, that's being a technician, not working alongside a dermatologist. The idea of technician as a practitioner, that's seeing the patients, treating the patients for wellness, that's what most dermatologists want when you're looking for a nurse practitioner, is not a technician. We want someone who's a practitioner. It's a whole picture that may be it's for medispa, but it's not for dermatologists' office.

Young:  You couldn't have said it better. You could not have said it better, because that's the thing. That's why I think so many nurse practitioners now take care of atopic dermatitis patients. I know several that specialize in melanoma. They work in taking care of the patients that are on medications now for melanoma. Who would have imagined that we would have had that group emerge?

Cutaneous T-cell lymphoma, working with most surgeons alongside of surgical as that is a little bit of a technical piece, but there's definitely some higher skill. A lot of those people have been first assistant in OR somewhere along the way or worked in ICU. They really are great at handling patients that could crumble, and you've got that nursing background right there at your side. Atopic dermatitis and all of these complex medications that are entering the dermatology world that a lot of dermatologists are maybe not that excited about. I'm telling you NPs and I'm going to say PAs too, but I do think they should speak for themselves.

I'm going to say that NPs and PAs, both found a niche, and enjoy these patients, will either have more time for them, take more time for them, and hold their hand through all the complexities of getting on and staying on drugs that are in the derm world.

Dr Green:  The wellness aspect is key, and it's a great aspect that NPs add. Say, Melodie, a dermatologist, wants to hire an NP. What should they look for? How should they train the NP? If the NP is just finishing NP school and they're an FNP, they want to get into dermatology, they haven't had training, what should the dermatologist do? What would be the best way to train them?

Young:  I would assume they know nothing about dermatology. You're probably going to get 20 hours or so. I did the lectures for over 10 years at the largest public nursing program in the country...University of Texas at Arlington. They're massive. I did the dermatology lectures.

They tell you what they want you to teach them because that's what's going to be on the certification exams, but it's not necessarily what I think they're going to need to know. How to identify an actinic keratosis? Understanding the pharmacology associated with dermatology and those sorts of things. You're going to get maybe 20 hours in your program.

You're going to have some questions on your certification exam. We tell them, go to every conference you can go to, get hold of every textbook that you can get your hands on. It's difficult to read medical journals because we don't have access to those. We're not members, but you can get some nursing things.

Then I get calls constantly wanting me to precept people just so they can get some experience, but assume pretty much that they know very little. It's important to not push them off to do things by themselves too soon.

I do see that happen around the country that bothers me where you've got NPs, and again, not PAs, but since we have a lot of interchangeable skills they are just stuck out in a little satellite clinic somewhere after maybe three months of working with a dermatologist. That freaks me out. I really think that working along with them, and I usually say teach them one or two things. Teach them all about isotretinoin, all about biologics, all about managing itch, whatever, that you want to really focus on, teach them that. Then have them just see those patients for a while. Then just keep adding to it and adding to it, acne, just keep adding to whatever it is that you think that they have skill with, that particular population. Then that's how you begin to expand.

Nurse practitioners are not job-hoppers in general. Longevity is another thing that we saw with a survey that we did of dermatology nurse practitioners. When I was working with DNA about 8, 9 years ago, we did a big survey. People stay in their job. The average at the time was almost 8 years that they had been working as an NP with one particular area. I think that's important. That's one of the things that I would want to know.

If I treat you right and you treat me right, let's make this a collaborative or a partnership-type of situation where I'm going to depend on you. You're going to depend on me. Then we're going to take great care of our patients. Jennifer Cather and I have worked for 20 years together. I see her at the end of the hall. We wave, and we fly by one another. Most days, we don't see patients together. If I saw something was weird, like I found two melanomas in one person, I'm going to go, "OK, next visit you're going to see Jennifer Cather." Generally, we have our own schedule, our own sets of patients.

Dr Green:  Can I ask you, Melodie, because you've been working with Jennifer for so long? How did it start when you were first an NP in derm? How often did you work with the doctor to go over patients? When did you start seeing patients alone? If I'm a dermatologist, I want to learn from you and what you've done with Jennifer and emulate that. Go through what you've done and what's best when you collaborate?

Young:  We try to just really get to know one another, hang out a little bit, and talk about patients. She would say, "Hey, do you know what to do with this situation?" She knew I'd had geriatrics. That maybe wasn't her favorite thing. I was very comfortable. I'd spent a lot of time in nursing homes and doing those sorts of visits. "Let me handle that. I can handle that."

A lot of keratoacanthomas and things like that you see in the population. A lot of leg ulcers, bandages. We again just started saying, "I know how to do this. I know how to do that if you want to see." With medical assistants at our clinic, they have a check sheet. They have to do something. One of us has to see them do it before they can do it on their own.

Whether that's giving a Kenalog injection IM, whether that's numbing up the patient because there's some tricks to it. I'm real finicky because, again, I've given lots of injections. I'm very, very particular because there's no reason for a person to have pain when they're being numbed. I want the medical assistants to show me they know how to do it before they're allowed to do it on their own. I think that that's what a physician should do as well if you're working with an NP.

If you were to hire someone who had a lot of skills, don't assume they know how to do it the way you want to do it because again, we see that all the time, even among physicians, who will tell me right out of residency and say, "I had one person on a biologic agent. That was it, in my whole career. I'm going to need some help with that." They know that I'm comfortable with that, and vice versa, they've got more skills with other things that they've done. I usually say, "Hey, what do you like? What are you good at? What do you hate?"

A lot of times, the NPs end up doing the things that the physicians don't like, don't want to do, and they say right off the bat, "I don't want to work afternoons. I don't want to see acne. I don't want to see people a certain age or certain group." Then tell them what those are, and then you've got to work with the front desk to try to make sure that when they're scheduling that they know who they're going to put on which schedule. If something shows up and if a pediatric, a 4-year-old, were to be put on my schedule right off the bat, I'll be like, "OK, I'll work them up. I'm going to get everything ready, but Cather is going to have to come in and see them because I'm not insured. I didn't set up my licensure that way." She'll come in see it.

You have to write the scripts for this patient, that sort of thing, and then go on. Generally, we just kept working to what I know, what I don't know, and it's a challenge. That's the scariest thing to figure out what you don't know. The prayer every day is, "God, let me be humble and let me not miss anything." To say, if there's something that I don't have...and I tell patients that.

I have to have 100% confidence that I know what everything is on your body. If I don't, then it's either going to be biopsied or I have to get somebody else to look at it. There's rashes every week. There's things that show up every week that I may not know what it is and that's when I'm going to end up.

Now with photos, it's awesome because, with the pictures, I can get the photos and get something started and go over the case with her. At another time, send them to her and say with pathology, "Look at this pathology on this patient. What I do with this," and get me some help, so it doesn't slow down the clinic.

If you get a nurse practitioner that's worked with another dermatologist because the variation from doctor to doctor is so...It seems to me there's such a chasm between generations, or interest levels, skills, it's really or just bravado maybe, but if you've worked with someone who is maybe a country dermatologist...I'm not disparaging them because there are 12 people in my graduating class from high school, and it was a public school, I'm a small-town girl, but sometimes they just don't do as many things.

When an NP comes to work, where there is a more progressive dermatologist, they're going to say, "Oh, yeah. Let's give you this treatment." Don't assume that they know how to do it the way you want to. You really need to do it, I would think, for 6 months to a year. You're going to have to assess it constantly.

That's one of the things, whether it's through a contractual arrangement, or it's through just a handshake and a confirmation that, "Look, I'm willing to partner with you, and let you learn this, and I'm going to be here. I'm not going anywhere," to keep that going. That's the way I would look at it.

Dr Green:  It sounds like it's about the long-term collaborative and working together and trusting each other and asking questions and being there for each others is the way to go, and it builds and builds. It's still happening with you and Jennifer after 20 years.

Young:  Absolutely. It's the same when you get a great medical assistant. You don't want to lose them because they can make your life so much easier. You know you can trust them to do something when they say they will do it, or the way you want it done. That's the way it is also with an NP.

Dr Green:  Thanks, Melodie. Is there anything else you think you want to add or anything you want to say to talk to the dermatologists? I don't mean just about the podcast here, the dermatologists in general, about working with an NP or hiring NP. What else can we do to make life better for the NP who is in our office?

Young:  If you think you might want to hire one, and there's a program anywhere around that you think it's a reputable NP program, a lot of times you'll meet somebody through a friend, or through a friend of a friend, or through a patient. If you see somebody that says, "I want to do this," then the great time to do it is when they're in school. You don't have to pay them. You're precepting them.

A lot of NPs that end up getting hired, that have no experience, that's the way it happens. That's one of the other things we tell NP students or nurse practitioners who would finished and graduated and they want to work is number one, be willing to move because if you're planning on being a dermatology NP in Dallas County, we have so many physicians. You're probably going to have a hard time making it unless you really got an exceptional skill, or in Chicago, or someplace else. If you're willing to move, there's people that would love to have your help. Then the other thing is try to see if they would precept you. They need to meet you because I'm old. I know that. Face-to-face, having the chance to see someone, and get a feel for their personality, and whether or not they're going to be fit in the clinic. Then decide if you want to have them. Always say, "Look, I'll commit to a day." I never commit to more than that because I want to even with the NP students. I want to find out if it's somebody that I want to invest my time in to try to help them to work.

People that are working in little towns in Texas, I'm definitely going to try to help those people out because I feel like they're going to go back in and work because we've got a lot of counties in Texas. They have to drive 200 miles to find a dermatologist. Those dermatologists in those little areas need all the help they can get.

Dr Green:  Thanks, Melodie. Thank you for being with us and talking about the NP dermatologist or MD relationship. I learned a lot. I appreciate your insight, and what you add, what you've learned in your life experience for this podcast. Thank you very much for everything you've added to this.

Young:  Thank you. I enjoyed it.