Spring 2007 Vol. 3, No. 2

Editor’s Letter & Contributors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3Managing Warts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4Counseling Patients About HPV . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5PRQI and Provider Incentives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5

While conflicts can arise within anyworking relationship, there’s nodoubt medical practice presents

ample opportunity for disagreements. It iscritical that PAs in practice be prepared tohead off problems or to effectively deal withthem when they arise. Communication is keyto establishing good relationships, addressingnascient tension, and diffusing clashes thatdevelop. Following are some suggestions foravoiding conflicts through good communica-tion along with strategies for diffusing com-mon challenging scenarios.

Communication FrameworksCommunication with the Physician. Theinterview and contract period is a time for thePA and the physician to lay the foundation fortheir long-term collaboration. Open commu-nication is critical to success. If communica-tion during this period is strained and answers

Minimize and Diffuse Conflicts ThroughEffective Communication

Since intertrigo often affects infants, physicians shouldconsider the various factors contributing to the condi-tion as well as preventive measures to share with parents

of infants, suggests pediatric dermatologist, Vicky Barrio,MD of the Department of Dermatology at University ofCalifornia, San Diego.

Ensure that the diagnosis is correct and all contributingfactors are treated. “A rash in the creases can be simple inter-

trigo or, as frequently occurs, can be aggravated by C. albicansinfection,” she notes. Satellite lesions can be a clue to concur-rent yeast infections.

“Another contributing factor that Dr. Paul Honing et al.described well in the pediatric literature1 is the incidence ofStreptoccocal intertrigo,” she adds. This is an under-recog-nized entity in the community that can lead to prolonged

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By Abby Jacobson, PA-C

Vol. 3 No. 1 • Winter 2007

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Supported by an unrestricted educational grant from Coria Laboratories.

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Combat Tough Cases of Diaper Dermatitis

DermPerspectives Copyright 2007 by Avondale Medical Publications, LLC630 West Germantown Pike, Suite 123, Plymouth Meeting, PA 19462

Postmaster, please send address changes c/o Avondale Medical Publications, LLC.

Cloderm ad

Dear Physician Assistant:

Anyone involved in patient care in the field of dermatology recognizes the importanceof one-on-one patient education. So many of the conditions we treat on a daily basiscan be associated with patient distress, discomfort, and frustration. Although we havemade tremendous strides in pharmaceutical development in the recent past, there arefew if any instant fixes. Taking the time to explain these facts to patients and to provide reassurance is a critical element of patient care—one too often overlooked.

One of the most significant contributions Physician Assistants make to dermatology istheir emphasis on the patient. In addition to being qualified care providers andskilled diagnosticians, PAs endear themselves to patients by building rapport andserving as a dynamic patient resource. As discussed in this month’s issue, care ofpatients with warts is just one area in which PAs’ interpersonal skills can shine.

The personal touch is increasingly absent in today’s society. By continuing to emphasize the needs of the individual patient, PAs help to remind all of us in the fieldof dermatology of the importance of individualized attention. I hope that this issue ofDermPerspectives, made possible through the generous support of Coria Laboratories,assists you in providing personalized care to your patients, and I wish you continuedsuccess in your clinical endeavors.

Best wishes,Coyle S. Connolly, DOMedical Editor

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Lette

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Opin

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Let us know how to make DermPerspectives more useful for you. Send

your thoughts and story ideas to us.

Send comments via e-mail to:pwinnington@avondalemedical.com

Or via traditional mail c/o:Avondale Medical Publications, LLC

630 West Germantown PikeSuite 123

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Coyle S. Connolly, DO, EditorAssistant Clinical Professor ofDermatology, Philadelphia Collegeof Osteopathic Medicine. President,Coyle S. Connolly, DODermatology and DermatologicSurgery, Linwood, NJ.

Abby Jacobson, PA-CDermatology Associates of Lancaster.Guest Lecturer, Drexel University andPhiladelphia College of OsteopathicMedicine, Philadelphia.

Gerard W. Stroup, PA-CCoyle S. Connolly, DO Dermatology andDermatologic Surgery, Linwood, NJ.

Tell Us What You Think

Cloderm PI

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Though warts are a commoncomplaint in dermatologyoffices, their management israrely routine. Response totreatment varies significantly,

as does patients’ willingness to initiate vari-ous treatment regimens. Factors such aspatient age and social or professional historymay influence therapeutic preferences andcompliance.

Perhaps the lone “common denominator”essential to wart management in every case ispatient education. The fact of the matter isthat patients present already knowing thediagnosis, usually due to failed treatment atthe primary care level or from internetsearches. The clinician must help to establishrealistic expectations from the first officevisit, and patients must understand thepotentially chronic and recalcitrant nature ofthe virus and the multitude of treatmentsavailable. Time spent in patient educationwill reduce patient dissatisfaction when mul-tiple return office visits are required andprogress is slow.

Diagnostic TipsDiagnosis of verruca is generally straightfor-ward. As just noted, many patients havealready received a diagnosis from a primarycare provider or even from another dermatol-ogy office. However, it is essential to proper-ly evaluate every patient who presents fortreatment and for the clinician to be confi-dent of the diagnosis. Verruca can be similarin appearance to a hypertrophic actinic ker-

atoses or verrucous seborrheic keratoses.Careful inspection of the lesion is paramountto allow full consideration of differentialdiagnoses.

Once the diagnosis of verruca is con-firmed, no one therapeutic regimen caneffectively be used for all patients, as variousstudies over the years have indicated.Choosing from a myriad of treatmentsdepending upon age, occupation, and socialstatus of the patient is the earmark of our spe-cialty. Knowing what method to employ inwhat patient demographic means the differ-ence between success and failure. One thera-py may work for a child but may not beaggressive enough for an adult.

It is important to know the various meth-ods available in order to have flexibility indevising the treatment regimen. It is alsoimportant to keep up with the literature, asnew studies and reports may offer insight. Arecent study incorporated the use of 5-FUcreams, while another advocates the use ofCandin injections (Candida albicans skin testantigen). In our clinic we commonly use top-ical immune modulators in combination withtopical retinoids and aggressive liquid nitro-gen therapy. The diverse methods availablespeak to the fact that there is not one bestmethod currently available but rather a cor-nucopia of therapeutic agents that will elicit asufficient clinical outcome if applied properly.

Patient Education: The Key toSuccessful Wart Management

Although diagnosis of verruca is typically straightforward, effective treatment requires time and patientcompliance. Establishing trust and choosing the best treatment for the patient promote success.

By Coyle S. Connolly, DO and Gerard W. Stroup, PA-C

Pediatric Population:1. Topical EMLA or ELAMAX 1-2 hours prior to

procedure with occlusion

2. Topical application of blistering agent

Canthacur and rinse off in 45 minutes to 60

minutes.

3. Once areas healed start at home therapy

including Occlusol HP, Compund W,

Transversal patches

4. Consider covering areas with duct tape at

night and removing in morning.

Adolescent Population/Adult Population:1. Liquid nitrogen applied directly to verruca,

minimum of two freeze-thaw cycles.

2. Once areas heal, begin application of OTC

therapies: Occlusol HP, Compund W,

TransVerSal Patches.

Recalcitrant Verruca Treatment Options:1. In addition to liquid nitrogen therapy and OTC

therapies at night, start topical retinoid cream

or gel in the morning after removal of tape

three times weekly. Alternate with application

of Aldara cream on opposite days.

2. Consider Candin injections, although not

FDA approved for verruca and not covered

by insurance. Intralesional injections every 2-

4 weeks for a total of 3 serial visits.

3. Laser therapies available e.g. pulsed dye

laser, expensive and not always covered by

insurance.

4. Topical 5-FU applied twice daily after self-

debridement with pumice stone.

5. Apply topical Canthacur followed by liquid

nitrogen therapy.

6. Local infiltration of !% lidocaine prior to liquid

nitrogen therapy and 3 freeze-thaw cycles.

All populations: Consider debridement with #11 blade prior to

procedure.

Recommended Treatments

Increasing ComplianceCareful assessment of the patient at the timeof the office visit will lead the practitioner tothe appropriate method for initial treatment.A teenager actively participating in sports maynot desire aggressive liquid nitrogen therapydue to possible hindrance of performance ofsports activities. A middle-age cocktail servermay not want to wear bandages after therapywhile at work due to customer perceptionabout hygiene. A five-year-old will not toler-ate liquid nitrogen but will respond well to atopical blistering agent combined with a top-ical exfoliant.

Discussing the many treatment optionsavailable before initiating treatment andattempting to develop a treatment regimenaround the patient’s age, lifestyle, occupa-tion, and pain tolerance is very important inpromoting compliance and overall treatmentefficacy. A patient will not be compliant orfollow-up if the therapy selected causesundue pain or social or physical handicaps.Many times in our office, initial therapy mayconsist simply of patient education, a testarea with liquid nitrogen with only a lightfreeze-thaw cycle, and the initiation of at-home therapy. At the follow-up office visitthe patient will relate their response to thera-py. Initial results direct how aggressive thenext treatment should be.

A child that presents with multiple verru-ca is a challenge. The most difficult aspect ispatient compliance at home and overcomingthe child’s fear of pain caused by treatment.One golden rule to follow: never initiatepainful therapies at the first visit. Instead,spend a few moments establishing a rapportwith the parent and child and determiningthe least invasive method that will allowintroduction to the treatment course. Often,starting with a blistering agent and topicalretinoid will establish trust because painfultherapies are not thrust upon the child.

At the initial visit, educate the parentabout topical anesthetics and their use beforefuture visits. The application of topical lido-caine cream under occlusion a few hoursprior to a visit will numb the treatment areaand allow the use of potentially more aggres-sive therapies. Key to managing pediatricpatients is to establish trust and set realistic

at-home therapeutic plans: keep the regimenuncomplicated and have frequent follow-upswith the same practitioner. Emphasize realis-tic expectations about the time to therapeu-tic improvement and cure with the parent orguardian. Compliance in many cases is basedupon simplicity of treatment and parentalunderstanding of the purpose of repeatedtreatments.

Addressing the TruthCommon misperceptions about causes andtreatment of verruca abound. Patients oftenexpect treatment to be as straightforward asdiagnosis, however this is rarely the case.Many patients present to the dermatologistfrustrated and potentially scarred either from

home therapy, self-surgery, or therapies ren-dered by the primary care physician. Thepatient comes to the dermatologist’s officewith the expectation of a ready, reliable andinstant cure.

Indeed, we are the “experts” and the onusis upon us to “cure” the patient when othertreatments have failed. However, patientsmust recognize that successful treatmenttakes time. Given the fact that there is noone appropriate regimen and that successfultreatment may depend upon individualcases and patient comfort/pain levels, hon-est communication is often more importantthan the therapy rendered, especially whendiscussing the method and duration of ther-apy. n

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The Physician Quality Reporting Initiative (PQRI)will pay a bonus to Physicians, Nurse Practitioners,and Physician Assistants who meet or exceed quality-

reporting measures for services provided to Medicare benefi-ciaries beginning July 1 through December 31. Providersneed not formally enroll in PQRI; simply reporting qualitymeasures establishes participation.

Quality measures available for reporting in dermatologyrelate to malignant melanoma. To be eligible for bonuses—which are to be paid in mid-2008—dermatology providersmust report completion of:

1.) patient medical history, 2.) complete physical exam, and 3.) counseling on self-examination

in at least 80 percent of all patients with a current diagnosis orhistory of cutaneous melanoma who are seen by that provider.The bonus will be 1.5 percent of total allowed charges (to a cer-tain cap) for services provided. Payments are made to the hold-er of the Tax ID number under which claims are reported.

Reporting codes are available online at www.ama-assn.org/gocpt. For more on PQRI, visitwww.cms.hhs.gov/PQRI. n

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Managing HPV

PQRI: Is There a Bonus in Your Future?

HPV is most commonly manifest in the dermatology office as the chief complaint of a malewith “bumps” on the genitalia. Condyloma are easily treated with various methods, but theemotional ramifications and shame of these lesions cannot be overlooked. Patient educa-tion at the time of initial presentation is critical. Ensuring that the patient understands thechronic, recalcitrant, and contagious nature of the disease is extremely important.Explanation of barrier protection and partner evaluation to prevent the risk of transmissionand cervical cancer in females cannot be overlooked and must be reiterated upon eachreturn office visit. Taking the time to answer patient questions and establish a trust where-by the patient does not feel you are judging them will allow you to effectively communi-cate the many unfortunate sequale to this common and insidious disease. The most signif-

icant role for the dermatologist in HPV isearly detection, diagnosis, and treatmentcoupled with comprehensive patienteducation.

to your questions are avoided, consider ifthis may be a red flag suggesting a long-termproblem.

The contract can be a valuable tool forstructuring communication and outliningstrategies to deal with challenging situationsthat may arise. The contract should addressresolution of disputes.

Disputes are bound to develop, even with-in the best professional relationships or withthe most well-thought and executed contractsin place. The contract should describe thehandling of disputes, specifying whether dis-putes will be handled through arbitration orin court. There are pros and cons to eachapproach. At the most basic level, arbitrationtends to be more expedient and less costly, butrulings are usually binding. Court hearingscan be longer and more costly, but the partieshave the opportunity to appeal.

An important but sometimes overlookedelement is the payment of legal fees. Thefairest scenarios are those where each partypays its own lawyer fees or the non-prevail-ing (losing) party pays fees for both sides.Some contracts assign responsibility for alllawyer fees to one party—usually theemployee—regardless of the outcome.Beware of such provisions.

Whether in the contract or simply earlyin the professional relationship, establishregular, scheduled clinical meetings with thephysician to ensure frequent communicationand the opportunity to address developingconcerns before they blossom into more sig-nificant problems. Also, establish a perform-ance review policy and schedule that is fairand optimizes the usefulness of reviews forall parties.

Particularly if you will receive a produc-tion-based bonus, you must have access tobillings and collection data. This sets a tonefor honest and open communication fromthe practice. Regular review of billing/collec-tions will allow you to track productivityfrom month to month to help set goals andmotivate increased productivity. Fur-thermore, reviewing billing reports can bedidactic, allowing opportunities to learnmore about Medicare discount rates, bun-dled services, and other billing issues thatmay impact future coding/billing to opti-mize reimbursement.

Finally, the contract should allow for ami-cable partings. Throughout the negotiationand employment period all parties should rec-ognize that partings aren’t always negative.Sometimes there just isn’t a good “fit.”Perhaps practice styles or bedside mannerssimply don’t jibe. Sometimes patients don’trespond to the PA, or the PA determines thatdermatology isn’t the best field for him or her.A contract that allows for amicable separa-tions in such scenarios will spare a great dealof grief, anxiety, and expense for both parties.

Communication with Staff. As a PA, youshould be treated like another physician in

terms of “rank” or “status” within the practice.But you may be in a unique position to devel-op a more friendly relationship with staff thatmay in turn translate to smoother interactionsand an enhanced image of you reflected topatients by the staff.

Set the tone for a good relationship fromthe start. During the initial meeting withstaff, give a brief introductory “speech,”establishing your role but also suggestingthat you want to be able to be friendly withthem. I have always found it helpful to offerservices to the staff. Staff members may feelintimidated to approach the physician for

free advice about a rash, lesion, or othercutaneous concern. Let them know that youare available and willing to discuss such con-cerns with them.

If you can use a shot of triamcinolonekenalog to help the receptionist banish apimple before a big date, she will forever bein your debt.

Friendship need not undermine authori-ty. Assert your role as a team leader as well assupervisor of those staff members assigned towork with you. Ideally, you should conductor have significant input in their periodicperformance reviews.

Communication with Patients and Others.To avoid potential problems from the start,referring physicians must know that the prac-tice is adding a PA and that new patients maybe seen by the new hire. Patient referral isbased on trust, and the referring physician hasan expectation of the type and quality of careher/his patients will receive from the special-ist. Simply handing off referred patients to aPA or NP without the referring physician’sknowledge—no matter how well qualified thePA or NP is—may be viewed as a breech ofthat trust.

Physicians who frequently refer patients tothe practice (and all other potential referringsources, for that matter) should receive a let-ter of announcement that details the PA’s cre-dentials and role within the practice.Referring physicians should understand thatthe dermatologist they have long trusted willcontinue to oversee the care of patients and isalways available to be involved in their care.

Make it clear to referring physicians thatthey can address any concerns at any timewith the dermatologist. Also, leave open theoption for referring physicians to specify thatthey do or do not wish that their patients seethe non-physician provider.

All patients in the practice should alsoreceive a letter introducing you, describingyour education/training, and explaining yourrole in the practice. During the initial integra-tion process, you may “shadow” the physi-cian, seeing patients with him or her, or mayhelp with history taking, etc. This is a greatopportunity for patients to meet you andbecome familiar with you. It’s also a greattime for the physician to begin funnelingpatients to you. It’s as simple as ending thepatient encounter with a comment such as,“Come back to see [NAME] in four weeks.She’ll make sure you’re healing the way wewant you to and can make any changes toyour treatment if necessary.”

Additionally, some practices will establisha routine for particular conditions, such aspsoriasis, in which the PA almost always han-dles follow-up. The physician can conduct theinitial evaluation and develop a treatment reg-imen, but given the comprehensive nature ofpatient education and the need for ongoingfollow-up, evaluation, and treatment adjust-ments—especially with the newer biologicagents—long-term patient care is best suitedto the strengths (time and good educationskills) of the PA. Again, the patient shouldunderstand this team approach to care andunderstand that the PA is able and ready tomonitor their therapeutic success.

The practice should not simply startassigning patients to a provider based on theircomplaints. This may cause patients to feel“abandoned” or “pawned off ” by the physi-cian. However, every appropriate patient,when scheduling, should have the option tosee the PA or NP.

Common Problems and their ResolutionThe Problem: When making an appointment,

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CommunicationContinued from p. 1

“Referring physicians should

understand that thedermatologist they

have long trusted will continue to overseethe care of patients

and is always available to be

involved in their care.”

every patient should be told whether he or shewill see the physician or the PA. However,from time to time, patients will feign surprisewhen you enter the exam room or evenbecome argumentative. Perhaps at themoment the appointment was made, harriedstaff didn’t make clear to the patient whichprovider they would see, the patient just didn’thear or listen, or they simply forgot.

The Resolution: Confronted with these sit-uations, the practice cannot always juggle theschedule to place the patient on the physician’sdocket. Therefore, you should plan to conductthe exam but should begin the encounter byaddressing the patient’s concerns and assuringhim or her that the doctor will be available atthe end of the visit, if the patient desires. Atthe end of the exam, simply ask the patient ina casual, non-accusatory tone, “Did you stillwant to see the doctor?”

In many cases, the patient will not want tosee the doctor. If they do, the doctor shouldbe as affirmative and supportive of you aspossible. It’s also helpful for the physician tooffer a “plug” for the PA by stating somethingto the effect of, “I’m glad you got to see[NAME] today. We’re really happy to havehim/her on board.” The physician may alsoend the encounter by recommending thepatient return to the PA for follow-up.

The Problem: As the individual ultimatelyresponsible for care provided to patients, thedelegating physician certainly has a right tolimit or restrict the actions of the PA (of coursecompliance with all local regulations is manda-tory, i.e. laser delegation). A responsible PArecognizes his or her own strengths and weak-nesses and, in the best interest of patients, iswilling to advise the supervising physicianwhen he or she feels that a particular case isoutside his/her comfort zone. However, thereare certain instances in which you may beinterested in broadening responsibilities with-in the practice and may wish to master a newtherapy or procedure. Surprisingly some prac-tices respond to such interest with no conver-sation and an absolute refusal.

The Resolution. Determine the physi-cian’s concern. Perhaps he or she perceives a

lack of patient demand for the service or apoor “fit” for the practice. If the concern issimply that you require specialized training totake on the service or procedure, recommendan education/implementation plan thatmight look something like this:

You will attend a conference(s) dedicated tothe therapy or procedure and gain hands-ontraining or observation hours. When you reacha comfort level, you will present your acquiredknowledge to the physician and then proveyour competency to him or her. In the case ofa cosmetic procedure you could treat staffmembers, the physician, or friends. Proposelimitations on the first series of patients yousee (such as, the physician must be present toobserve the first 10 treated patients).

The Problem. You should always feelcomfortable approaching your supervisingphysician with questions or for collaborationwhenever you deem it necessary. However,you may sense that your supervising physi-cian is bothered by interruptions. You maynote eye-rolling, huffiness, or delay tactics.

The Resolution. You must address this withthe physician at an appropriate time and in anon-accusatory manner. Remind the physicianthat you rely on her or him as your supervisorand must feel comfortable seeking advice.Make it clear to him or her that you do notwant to act alone without his or her consent.

The Problem. The physician is delegatingall “difficult” patients to you.

It’s easy to see why a physician may betempted to transfer care of his or her most“difficult” patients—cranky, slightly mental-ly unbalanced, or those with poor hygiene—to the non-physician provider. Office visitsfor these “difficult” individuals can be time-consuming and often involves a fair amountof time spent eliciting information, answer-ing questions, and counseling. Such patientsmay be ripe for referrals, require long-termfollow-up, and crave handholding. Whilethese are all clinical skills that PAs may havein abundance, simply “dumping” patients asan avoidance measure is not a wise use ofyour skill. Nor is it particularly fair.

The Resolution. “Difficult” patientsdeserve the best care, and for their sake andthat of the staff, sharing patient care respon-sibilities may be reasonable. Suggest a plan toequitably split the patient load. Express yourconcern that patient dumping is not makingbest use of your skills and expertise and islimiting your ability to see other patients in atimely and efficient manner. Remind thesupervising physician that some of the most“difficult” patients are also the most poten-tially litigious, and he or she should take pri-mary responsibility for any patients who mayseem to fit this latter group.

Early InterventionEffective communication can set the stage forinteractions and promote good long-termrelationships. Efficient conflict resolutionrequires early intervention. Few if any prob-lems “solve themselves;” most simply becomemore complex with time. Address developingproblems early on. Be proactive and creativein providing possible solutions. n

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treatment courses. “I have seen a few cases complicated by S.aureus as well. It is also important to consider bacterial super-infections in infants with prolonged unresponsive courses, foulsmelling lesions or psoriasiform plaques. In these cases, I rec-ommend performing a culture.”

Dr. Barrio suggests that in the event of a prolonged andunresponsive course in which cultures are negative, cliniciansshould consider other causes of intertrigo in infants, includingseborrheic dermatitis and psoriasis, both of which can presentwith a diaper rash. Lastly, scabies, Langerhans’ cell histiocyto-sis, and acrodermatitis enteropathica are rare but importantmimickers that should not be missed, she says. n

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1. Pediatrics 2003; 112(6 Pt 1): 1427-9

Continued from p. 1

Diaper Dermatitis

Set the Stage for GoodCommunication and GoodRelationships • The contract should structure com-munication and outline strategies todeal with challenging situations.

• Establish regular, scheduled clinicalmeetings with the physician.

• Establish a performance review poli-cy and schedule that is fair and opti-mizes the usefulness of reviews.

• During the initial meeting with staff,establish your role but suggest thatyou want to be able to be friendly.

• Referring physicians must know thatthe practice is adding a PA and that newpatients may be seen by the new hire.

• All patients in the practice shouldreceive a letter introducing the PA,his/her education/training, and role.

As a dermatologist, you face a new challenge with each patient.At CORIA, we understand the nature of these challenges and help you meet them.Through our commitment to quality and innovation, we develop products for conditionsthat affect the skin, hair, and nails of your patients. In fact, our name is inspired by the Latin word “corium,” which means true skin. This lets you know that our passion is dermatology and our focus is on making a difference in the lives of your patients.

www.corialabs.com

Because no two patients are completely alike.

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