OP-ED

The P.A. Problem: Who You See and What You Get

Recently, the New York Times published an article on excessive costs incurred by mid-level providers over-treating benign skin lesions. According to the piece, more than 15% of biopsies billed to Medicare in 2015 were done by unsupervised PA’s or Nurse Practitioners. Physicians across the country are becoming concerned mid-levels working independently without proper specialty training. Dr. Coldiron, a dermatologist, was interviewed by the Times and said, “What’s really going on is these practices…hire a bunch of P.A.’s and nurses and stick them out in clinics on their own. And they’re acting like doctors.”

They are working “like” doctors, yet do not have training equivalent to physicians. As a pediatrician, I have written about a missed diagnosis of an infant by an unscrupulous midlevel provider who embellished his pediatric expertise. This past summer, astute physician colleagues came across an independent physician assistant, Christie Kidd, PA-C, boldly referring to herself as a “dermatologist.” Her receptionist answers the phone by saying “Kidd Dermatology.”

The Doctors, a daytime talk show, accurately referred to Ms. Kidd on a May 7, 2015 segment as a “skin care specialist.” However, beauty magazines are not held to the same high standard; the dailymail.com, a publication in the UK, captioned a picture of “Dr. Christie Kidd”, as the “go-to MD practicing in Beverly Hills.”

The article shared how Ms. Kidd treats the Kardashian-Jenner family, “helping them to look luminous in their no-make-up selfies.”

While most of us cannot grasp the distress caused by not appearing luminous in no-makeup-selfies, this is significantly concerning for Kendall Jenner. At the tender age of 21, she inaccurately referred to Ms. Kidd as her “life-changing dermatologist.” Cosmopolitan continues the charade, publishing an article on the Jenner family “dermatologist.”


It astounds me how some medical professionals can contentedly live in the gray, south of brutal honesty, yet somewhere north of deceit. Until a few months ago, the Kidd Dermatology website erroneously listed her educational background as having graduated from the USC School of Medicine with honors and made no mention of her supervising physician. It was later modified to reflect she graduated from the Physician Assistant program at USC.

There are laws mandating physicians display diplomas and certifications prominently in the interest of transparency. According to Title 16, California Code of Regulations sections 1399.540 through 1399.546, a PA in “independent” practice is limited to the scope of his/her supervising physician by law. A board-certified plastic surgeon is supervising “skin specialist” Christie Kidd, PA-C, not a dermatologist. The website of the plastic surgeon states, “Trust only a Board-Certified Plastic Surgeon;” which in my opinion, seems astonishingly tongue-in-cheek. He may believe treating bullous pemphigoid disease is just another day in the life of plastic surgeons everywhere, but plastic surgery is a far cry from practicing dermatology and vice versa.

When asked about this, the Public Affairs Manager, Cassandra Hockenson, at the Medical Board of California responded “there is not a huge difference between plastic surgery and dermatology.” She suggested contacting the Physicians’ Assistant Board for the State of California instead. She kept repeating that the supervising plastic surgeon had no complaints against him. I learned two important lessons from contacting the Medical Board of California: 1) Without complaints, a physician can supervise midlevel providers in any specialty they choose, and 2) while required by law to supervise mid-level providers, the safety of patients is not a high priority for the Medical Board of California.

At a minimum, physicians complete four years of college, four of medical school, and between 3-7 years in residency. The years of education required for obtaining a PA degree are considerably fewer than that of an MD. For all intents and purposes, Christie Kidd, PA-C is running an independent dermatology practice directly under the nose of an apathetic California State Medical Board indifferent to regulations. PA’s can be fined and disciplined by their own board for misrepresentation, however, her “supervising” physician is, in fact, also out of compliance with the law.

While not all celebrities understand the difference in education between an MD or PA, mid-level providers and their supervising physicians should not be immune to the rules and regulations. Honesty, trust, and transparency are ideals essential to the medical profession. Physicians are held accountable for the health and safety of the patients we serve. Google Business modified the Kidd Dermatology listing from “Dermatologist” to “Medical Spa.” The unsinkable Christie Kidd struck a compromise, settling on the designation as a “skin care clinic.” Carpe Diem, Ms. Kidd, Carpe Diem.

Niran Al-Agba, MD is actually a physician. She practices in Washington state.

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William Palmer MDDronning MargaretheSheepDocglcornettAnon91 Recent comment authors
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SheepDoc
Member
SheepDoc

I’m a former PA. I’ve been a physician for 12 years. PA school was very challenging. PA school is as competitive as med school so the IQ of a PA is very high. Any RN can go to NP school and most now do it online. RN’s love to tout how their RN exoerience should count fir something toward their NP. It’s apples and oranges. Until you’ve been both you can never understand how you just can’t know what you don’t know. The eyes cannot see what the mind does not know. This article is about a PA gone rogue.… Read more »

glcornett
Member
glcornett

Being neither MD, PA, NP, RN or anything else with initials, I don’t have a dog in this hunt. But as a reader and interested inhabitant of the peanut gallery, perhaps I can suggest a bit of clarification. Perhaps Dr. Al-Agba could ask the editor to restore her original title, as the current title appears to be a point of contention with the mid-level practitioners. Also, the first paragraph, about mid-levels over-treating benign skin lesions, does not logically lead to the content of the remainder of the article, which Dr. Al-Agba states is about transparency and which discusses the case… Read more »

djwatt21
Member
djwatt21

Absolutely nailed it. Couldn’t have said it better. Thank you.

Niran Al-Agba
Member

I think your comments are very fair. Thank you for the constructive criticism on this piece. I have much to learn in the world of writing and am always looking to improve my skills. I do see your point about the flow. My intention was to introduce that the lines between physicians and mid-level providers are increasingly becoming blurred and then go on to describe a situation where one individual has taken misrepresentation to a higher level. I think all MDs, DOs, PAs, and NPs should be aware of this and help us all stay within our boundaries. As to… Read more »

Anon91
Member
Anon91

As a PA, this is concerning. It seems like Christie Kidd was intentionally trying to mislead the public as to her degree and qualifications. I always correct my patients when they refer to me a Dr. Anon, and explain that I am a PA and work in collaboration with physicians. What are your thoughts on DNPs who open their own clinics and refer to themselves are Dr. SoandSo? I see this quite frequently as I live in a rural state that grants NPs independent practice, even as new graduates. Unfortunately when I express my concern about this to NPs, the… Read more »

Niran Al-Agba
Member

Anon91, Great question. Glad you asked…. this is my opinion: https://thehealthcareblog.com/blog/2017/05/29/md-vs-dnp-why-20000-hours-of-training-and-experience-matters/
You will find that piece was almost as controversial as this one. Up next, is a story about an MD who needs an ethical reset. 🙂 Then everyone will be unhappy with me, but will they talk about how to make things better for all of us? I hope so. Thank you for your comments.

insureallplease
Member

As a physician, the insecurity by PA’s here is astonishing. Dr. Al-Agba was only stating that it’s not correct to misrepresent yourself and to not reveal to patients that you are trained much differently from physicians. It was well-written and her critique of the PA in question was restrained and fair also.

Dronning Margarethe
Member
Dronning Margarethe

Respectfully, most of us don’t. Do you really want to compare the PAs who daily labor to provide care to average Americans to those who cater to the KARDASHIANS? To be honest, I would never want to work in dermatology. Even dermatologists often cannot make a diagnosis, and treat empirically accordingly. I am sure that Dr. Al-Agba has faced unfair prejudices. Perhaps based on the fact she may not look like me. I have experienced white privilege on a daily basis. I know that I am treated differently than my African American colleagues, as well as other minorities, when their… Read more »

Niran Al-Agba
Member

For the record, dermatology is not a specialty that I enjoyed either. Being white myself, I have faced most prejudice in a situation like this where my name conjures up a preconceived notion of what someone of Arabic descent looks like. Some new patients show up in my office and can’t believe I look and talk “just like them” (their words not mine.) You should see their faces when they find out I am an Irish Catholic… Regardless, I agree with you that collaborative environment with respect amongst colleagues is the best choice and yes, many of us in rural… Read more »

Horses22
Member
Horses22

So, where is Ms. Kidd? No comments? Has she changed her misrepresentation? She must know the shock wave she has sent through her profession…does California have a law against false advertising?

Perry
Member
Perry

Aside from everything else discussed here, taking the medical advice of a Kardashian/Jenner is a recipe for disaster.

Rn29414
Member
Rn29414

So true

Rn29414
Member
Rn29414

I do not believe PA’s and NP’s should be referred to in the same breath. I agree PAs must have doctor oversight at all times, unless employed by a federal program. They only need a BA in any subject, ex: art history. Then they attend PA school. It used to be they didn’t need any clinical before they began practice. Now at least clinical hours are required. On the other hand even a nurse who graduated and goes straight to NP school has 2 years prerequisite, 2 to 4 years nursing school and then 2 to 3 years NP school.… Read more »

djwatt21
Member
djwatt21

Okay let’s reel that one in a little bit. Don’t forget the history of the PA profession is one of battlefield medics being converted to civilian medical providers. Yes our field has evolved tremendously since that time, but there is still an enormous number of second career folks, many from the medical field. Regardless, admission to PA school, subsequent training, clinical rotations, and certification are extremely rigorous. Please do not insinuate otherwise. This is not a competition among license types. With respect to education and training, the typical PA program, while similar in length to NP training programs, averages 1000… Read more »

Anon91
Member
Anon91

There is a lot of misinformation in this comment. Lets break it down: 1. “They only need a BA in every subject, ex: art history”. True, you can have a 4 year degree in anything. However, no matter what degree you obtain, there multiple prerequisite course requirements in biology, inorganic chemistry, organic chemistry, statistics, and upper-level science courses ranging from microbiology to embryology. Here is an example: https://medicine.uiowa.edu/pa/education/prospective-students/course-requirements . Exact requirements may differ between schools, but overall you must have taken courses in the hard sciences regardless of your undergraduate degree. 2. “It used to be they didn’t need any… Read more »

Dronning Margarethe
Member
Dronning Margarethe

You don’t really want to go there, do you?

Peter
Member
Peter

As I said, I’m happy with my PA, and apparently are most other people. This article shows their value, and as noted, most go into primary care – a much needed practice.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4730953/

Peter
Member
Peter

I wonder how many people are killed by docs every year as opposed to PAs?

TNPA-C
Member
TNPA-C

Nobody disagrees with the perils of misrepresentation. Interestingly this article has touched on a different issue, the role of midlevels or perhaps just PAs in healthcare. The PA training is a much abbreviated mirror version of med school. In practice PAs are being given virtually identical roles and responsibilities. I have heard some good Physicians say that after about 5 years of practicing, a good PA who studies the evidence and is mentored by Physicians can be every bit as knowledgeable as any Physician, especially given our rapidly changing medical environment. I also believe that there are many other important… Read more »

Niran Al-Agba
Member

What you have written is excellent commentary. We are having an important conversation about collaboration and better defining roles on the healthcare team. Thank you. In the media, sometimes there needs to be a little controversy to get the ball rolling. While you may feel this piece was demeaning, it was truly not intended that way.

Marion Mass
Member

To have professionals misrepresent who they are and professional policing organizations lack understanding erodes the trust of the public and makes it harder for anyone who treats patients. This article pointed to a state medical board spokesperson who clearly does not recognize differences in specialties, a physician supervising a PA in a specialty in which he himself is not boarded, a PA misrepresenting herself, and layers of the press, misunderstanding the training of a myriad of professionals. If all professionals do not insist on the honesty and transparency called for in this article, we ALL… our boards, physicians, PA and… Read more »

Allan
Member
Allan

The lines in healthcare have been intentionally blurred by all parties involved. The HMO blurred the lines using the term “healthcare provider”. Is a healthcare provider a doctor, a nurse, a PA or an NP? The use of physician extenders is and was an attempt to save money. A hospital might use non-M.D.’s for the same reason and a physician might use them to increase his income by increasing the number of patients being seen. Somewhere in that blurred line trouble is brewing. It is not uncommon for the sicker patients to be given appointments with the physician extender because… Read more »

Niran Al-Agba
Member

Great questions Allan, as usual. I don’t have the answers but wanted to open the discussion. Thank you.

Allan
Member
Allan

Thanks, Niran, I was hoping some from the PA / NA community would comment on those questions. We can’t simply talk about blurred lines rather we need to talk about what suddenly precipitated these blurred lines and whether or not the patient should be provided choice over their own bodies.

Right now it seems too many responders are in a defensive position rather open to debate on policy considerations.

TNPA-C
Member
TNPA-C

see my comment above. I don’t think we can make generalized statements about the quality of current PA and NP graduates but certainly the more we have the greater the variety. In essence, I feel the appropriate way to utilize PAs is for Physicians to take the lead in defining their role which may be unique to the Physician or environment they work.

Allan
Member
Allan

” I don’t think we can make generalized statements about the quality of current PA and NP graduates ”

Are you saying that such assessments should not be considered?

“I feel the appropriate way to utilize PAs is for Physicians to take the lead in defining their role”

In today’s world is the physician defining their role and if he is, is it based on the needs of the patient or the desires of the insurer?

TNPA-C
Member
TNPA-C

How exactly would you measure the quality of PA graduates and for what reason? If we did so then why would we not also measure the quality of MD graduates? If you understood the history of PAs and their current educational standards and the accreditation process then I don’t think any measure of the quality is needed. And are you serious that anyone should be defining their role as a provider of medicine based on the desires of the insurer? Who would ever even ask that statement? PAs are trained like Physicians and take the same Hippocratic Oath and would… Read more »

Allan
Member
Allan

MD graduates are measured all the time and their measurements frequently start before college. Right or wrong our nation took a path to provide the best education and assumedly provide the best care. That is why the MD supervises the PA and not the opposite. I’m not saying this is the best way to manage things, but it is the gold standard today. Therefore it is up to you to prove the scenario you prefer. As far as grading we could have PA’s take the same test FMG’s take when they enter the country and then for generalists they could… Read more »

TNPA-C
Member
TNPA-C

Why are you so bent on trying to put down the PA profession by pointing out what you perceive as the differences in training or in practice? PAs are measured all the time, it is incredibly difficult to get into a quality accredited PA program, many say it is harder than med school. We take a difficult board exam, are required to do CMEs and repeat boards. Most importantly we are being placed in roles where we are doing exactly the same thing as Doctors. We are providing the exact same care in many areas of medicine so statements like… Read more »

Allan
Member
Allan

“ Why are you so bent on trying to put down the PA profession by pointing out what you perceive as the differences in training or in practice? “ TPNA, where do you come off saying that? You keep assuming others are putting down PAs. You are touchy and defensive to anyone that questions anything about your profession. If you look again at my earlier comment I had two questions that were very neutral. “1) Are we appropriately utilizing our physician and physician extenders for the benefit of patients rather than profit or ego? 2) Not that long ago I… Read more »

William Palmer MD
Member
William Palmer MD

Good discussion, Allan. I worry that with unusual diseases the correct diagnosis might not be made by the PA or the NP. Say someone with Hgb SC disease or someone with paroxysmal nocturnal hemoglobinuria or the superior mesentaric artery syndrome. But, we are all fallible people and unless you see these things once in awhile, we are all going to miss them, including the sharpest doc. Our longer training means that we might have a trace of memory for a few more rare things and even these traces help us look stuff up. Maybe with artificial intelligence, PAs and NPs… Read more »

Allan
Member
Allan

Thanks Bill you adding some extra incentives to the mix.

Peter
Member
Peter

This is an example of the Republican plan to let market forces bring down the cost of medical care. Don’t need no stinkin regulations.

I will say the PA I go to is great at diagnosis and treatment. I have a lot of experience with bad docs to compare him to.

Taz
Member
Taz

In my opinion, the gist of the article is a failure to be truthful in advertising one’s title, education and practice. Perhaps many of the respondents may have taken offense by Dr. Al-Agba’s delivery, but do not allow that to cloud the issue. To intentionally misrepresent one’s self as something he/she is not, especially in healthcare, seems especially egregious to me. Patients can hardly be expected to understand the myriad of titles that come before and after a practitioner’s name. It is confusing, even to those of us who work within the medical industry. But blatant lying is despicable. Ms.… Read more »

Rn29414
Member
Rn29414

I am truly sorry you have stopped precepting NP students! NPs are usually very open to learning and criticism. We are the only advanced practice who have to secure our own preceptor. I hope you will agree with me that most NPs do not want to be physicians, if we did we would go to med school. Most NOs take a cut in pay when they leave the bedside and many still pick up shifts at bedside to make up for that cut in pay. We are paid less but able to spend a little more time with patients, this… Read more »

jhmd
Member
jhmd

This is such a timely well written article! In this day, it is so important to shed light when an individual or group fails to comply with truth in advertising and proper supervision in the medical setting. Mid levels I know agree with this sentiment wholeheartedly. It’s sad when there are some who take offense when no offense was intended however. So I personally thank you. More importantly patients thank you!