Young, Peter A.

Introduction: Limited research explores dermoscopy use among physician associates (PAs), outside of one prior study examining dermoscopy in PA student education. This study sought to investigate dermoscopy use among practicing PAs and its impact on their overall diagnostic confidence, including in darker skin tones, when differentiating between benign and malignant skin lesions. Methods: An anonymous survey was developed in 2023 with input from experts in dermoscopy and survey creation to assess PA confidence in skin lesion evaluation as well as PA dermoscopy knowledge and use, perceptions, barriers to use, and prior education. The dermoscopy survey was included as an optional module in the 2024 American Academy of Physician Associates (AAPA) Salary Survey. Results: Of 3,174 invited PAs, 995 (31.4%) responded. Most had never used dermoscopy in practice (81%) but knew or recognized the term (71%). A majority (53%) believed PAs should be trained in dermoscopy during PA school, and 26% reported no interest in future dermoscopy use. Dermatology PAs reported more frequent dermoscopy use and generally greater confidence in evaluating skin lesions, both overall and in darker skin tones, than PAs in other specialties. PAs in surgical (OR=0.2, 95% CI 0.1-0.6) and medical (OR=0.3, 95% CI 0.2-0.5) subspecialties were less likely to use dermoscopy at least annually compared with PAs in primary care. PAs in rural areas were more likely to feel confident in differentiating skin lesions than those in urban areas (OR 2.9, 95% CI 1.7-5.0). Conclusion: Dermoscopy use is associated with higher overall skin lesion assessment confidence. Wider adoption, especially outside dermatology, requires training, increased advocacy, and expanded education.

Importance: Dermoscopy is increasingly recognized by skin cancer experts and professional leaders as an essential skill for physicians in dermatology and primary care. A substantial number of patients in both settings also receive care from physician assistants (PAs), who provide additional opportunities to evaluate patients with concerning skin lesions. Earning dermatology-specific credentials from the National Commission on Certification for PAs requires passing a written exam with dermoscopic content, and 77% of practicing PAs (all specialties) believe dermoscopy should be a standard element of their formal education. No published studies have identified precise learning objectives that would represent appropriate foundational proficiency in dermoscopy for PAs. Objective: We sought to identify common diagnoses with distinct dermoscopic features and delineate which of these represent appropriate proficiency expectations for early-career PAs in primary care and dermatology. Design, setting, and participants: A panel of 14 dermoscopists was assembled (8 dermatologists; 6 PAs), reflecting contributors to existing consensus statements on physician dermoscopy proficiency benchmarks, dermatologist-recommended competencies for PAs, and/or standardized test content for dermatology PAs. Panelists completed a modified Delphi consensus process involving electronic surveys and roundtable discussions. Main outcomes and measures: Consensus on which specific dermoscopic diagnoses reflect appropriate foundational proficiency expectations for PAs in both primary care and dermatology. Results: Twelve of 14 panelists (86%) reported using dermoscopy for over 12 years (mean: 15.5 y). All panelists completed 2 iterations of an electronic survey regarding 54 diagnoses, with 39 (72%) reaching a final consensus for inclusion in PA curricula and 15 (28%) being identified as non-priority items for early-career PAs. Panelists recommended 14 conditions for primary care PAs and 25 conditions for dermatology PAs. Conclusions and Relevance: Consensus achieved in this modified Delphi process identified diagnoses that represent pragmatic learning objectives to achieve foundational proficiency in dermoscopy for PAs in both primary care and dermatology. This list of validated objectives provides a consensus-based guide to help educators, supervising physicians, and professional leaders to cultivate specialty-appropriate dermoscopic proficiency among early-career PAs.

Background: Proper diagnosis in primary care is crucial due to the large number of skin cancer diagnoses each year and its associated growing economic burden. Understanding how primary care providers can be best trained in dermoscopy is instrumental in helping primary care providers differentiate benign and malignant cutaneous lesions so that appropriate action can be taken (eg, biopsy/referral to dermatology or reassurance). Objective: To assess the success of concise dermoscopy training among primary care providers. Design: A cohort study was conducted in primary care at Mayo Clinic, Rochester, including primary care physicians, nurse practitioners, and physician assistants in internal medicine and family medicine. Diagnostic accuracy was measured on standardized testing through image-based recognition and in clinical practice through observation of referral and biopsy patterns both before and after dermoscopy education, focused on the TADA plus method. Results: Forty-three primary care providers completed the image-based recognition tests, with significant improvement in mean score measured after dermoscopy training workshop (20%). Among the thirteen primary care providers who continued to use dermoscopy in clinical practice, a significant improvement (31%) in mean clinical diagnostic accuracy was observed comparing 1 year of practice data before versus after dermoscopy training. Conclusion: Improvement in diagnostic accuracy with utilization of the TADA plus method translates into clinical practice. Therefore, training primary care providers in dermoscopy may improve the dermatologic care patients receive in primary care, especially in rural or medically underserved areas where access to dermatology is limited.