A look back at how chronic disease management, physician shortage, and newer therapies shaped the modern care team.
Melodie Young, MSN, ANP-c
The history of progressing nurse practitioner (NP) and physician assistant (PAs) roles in dermatology starts far earlier than the traction it’s just received in the last decade. By the account of Melodie Young, MSN, ANP-c, it’s spanned since she first had her state in the specialty.
In an interview with MD Magazine®, Young, of Modern Dermatology at Baylor-Health Texas in Dallas, shared her perspective on the evolution of team-based care in dermatology, and how factors including chronic disease and advancing therapies have helped shape the current role of NPs and PAs.
MD Mag: What does the network of care for plaque psoriasis currently look like?
Young: The role of NPs and PAs has been increasing, in that physicians seem to be spending more time doing procedures, surgeries, aesthetic procedures. And the amount of care that's being given to people with chronic skin diseases—that role is expanding for people like myself.
And because of that, we're seeing more prescriptions being written for the drugs associated with taking care of psoriasis patients and managing people. So, for the long term with those diseases, those prescriptions are coming from nurse practitioners and PAs. They're still doing a lot of diagnosing, and a lot of education and assisting in accessing drugs, and also having more and more of a role with the pharmaceutical companies and patient education companies.
They're saying that they want to have more understanding of what NPs and PAs do. And people who are coming patients themselves are becoming more comfortable with seeing us around, and they do see the whole team approach. They realize that it's not just, you go in and see a dermatologist or physician and get everything you need and walk out with a prescription. You know, it's everybody. It's biologic coordinators, nursing staff, all of the people that are involved in it.
But the great thing is, we're just really affecting a lot people's lives in a positive way, which is great. I mean, seeing so many advances with medications makes it so much easier, makes it so much more gratifying and fun. And it's not as difficult anymore, which also makes it fun.
MD Mag: Is there a lot of overlap of care across specialties?
Young: I've been a nurse practitioner for 20-plus years, and in my training 20 years ago, we were really talking about the role of nurse practitioners in chronic disease management. And that was because the relationship aspect in managing chronic disease—as far as whether you're talking about diabetes management, weight loss, congestive heart failure—there are a lot of these chronic disease clinics that are absolutely run by nurse practitioners. So, that's kind of what we're trained to do.
And historically, more than 85% of nurse practitioners work in primary care. And so, now that in the dermatology world we finally have ways to stabilize diseases and have long-term plans, we're changing our strategies. The drugs and the therapies have allowed us to change our strategies. And I feel like the specialists themselves are starting to adopt the care model that has been out there for decades.
There weren't chronic disease strategies or care plans at all, until the last couple of decades, and I think it will continue. So, I would say it's more of a chronic disease issue, as opposed to just an autoimmune, and the only reason it's auto immune or immune-mediated diseases is because the advancements in therapies happened to be in those specific diseases, and then you're going to have to have somebody who has the ability to diagnose, prescribe, monitor.
And that just seems to fit the role perfectly for what NPs have been trained to do for decades. And I would say, with PAs being as very similar in role, they've a lot of times done more surgery, assistance to surgery. They came primarily from out of the military, assisting in acute care situations. But they're also becoming much more chronic disease-oriented. And I don't know who's driving it—if it's pharmacologic advancements, or they're looking to see what's working.
I mean, 20 years ago, I was doing papers on proposing using nurse practitioners for chronic disease management, the places around the world that were doing it, and how much success they were having. They had asthma clinics in England, they've had congestive heart failure clinics, diabetes clinics, and they've just been successful.
So, I'm glad to see dermatology and these other disease-focused specialties are jumping on board—GI, rheumatology, allergy, they're all starting to want to add nurse practitioners and PAs to their clinics. Even hospitals are doing it.
MD Mag: The discussion of advancing therapies and what it means for these changes is pretty interesting. When exactly could you pinpoint, in your time of work, did these new drug classes begin to influence that network of care, and responsibilities that were designated?
Young: I started in dermatology 32 years ago. And one of the reasons I became a nurse practitioner, went back to school, was because they were starting to get rid of nurses in hospitals because they were shutting down all the dermatology beds, because you could no longer get people admitted—because we were getting some therapies that would keep people out of hospitals. They can do things to get them better faster.
At the time, no doctors wanted to take care of psoriasis patients. I mean, quite frankly, we had very little to offer them, they would all complain about how cumbersome they were to manage. They were sickly, they were grumpy, they were messy, they were flaky, scaly. You would be seeing patients and moving through your day great, and you'd open the door, and there'd be a patient who's just going to be a train wreck, and it's going to put you an hour behind.
At the time, that was one of the reasons I became a nurse practitioner—because we could not find any physicians who wanted to come and help us at the Baylor Psoriasis Center. They didn't like it. Nurse practitioners, we had some skills that we were trained in, to offer to help people with frustrating diseases, and trying to keep them on track.
I would say, when those when those therapies began to come available, it sort of became fun. And doctors were saying, 'Hey, I'm busy, I've already got so much going on. I'm going to have to have some help so that we can implement all these things.' I've seen the process going for at least 2 decades, but I would say that physicians, pharmaceutical companies, and even the public have really only noticed within the last 10 years.
And even state licensure boards and professional associations, grant money for nurses over 20 years ago—because they knew we were going to have a shortage—they began to look dermatology practices, which had only had the dermatologist and then medical assistants. There was no licensed nurses in the clinic. They just had to have some help, because now we had drugs that were going to take a little bit more work and understanding.
And they learned more about the disease, and how they need to be more aggressive. With treating people with chronic skin diseases, you cannot just give them a cream and send them out the door. We now had a way and get their disease stabilized and under control, and they they wanted to find somebody to take that on that responsibility. So, I would say it's really boomed in the last 10 years.
But 20-plus years ago, we had a dermatology nurse practitioner group of people, who were either doing it already or trying to get into it. There were a lot of them working in the VA system. They were the smartest nurse practitioners that I knew, 25 years ago. They were all over, from coast to coast.
And then when people start to see that that was working, and some of the dermatology residency programs began to be exposed to nurse practitioners, they started deciding they wanted to bring them on board. Even the insurance recognition began, so that they would pay for those visits. It just came a way for you to increase the number of people, increase accessed care. And also, it was a multi-faceted demand, coming from all sides. And it just worked. It's worked really, really well.