Maximize the benefits of physician extenders while minimizing the risks

Your schedule is booked way in advance. On patient days, your office is full to capacity. Every new patient who calls for a consultation appointment or a filler injection is told that your next opening is in 6 weeks.

There is a high patient demand for aesthetic treatments and procedures that often cannot be fulfilled in a timely manner by physicians in solo or even group practices. Busy aesthetic surgeons are faced with this dilemma daily as they try to grow their practices and at the same time deal with noncosmetic patients and follow-up visits.

The solution is often a choice between taking on an associate and adding a physician extender. An increasing number of plastic surgeons, dermatologists, and other aesthetic specialists in the United States are hiring physician extenders to lighten their workloads and expand their practices. Extenders are usually not as rushed as physicians are, so they will have more time to spend with patients—which often results in happier patients and a less crowded waiting room.

The category of physician extenders in the medical aesthetics practice has expanded to include licensed practical nurses (LPNs), registered nurses (RNs), nurse practitioners (NPs), physician assistants (PAs), medical assistants, and aestheticians. Clearly, each type of physician extender has a distinct scope of practice. They may see repeat patients for follow-up visits; see patients before the physician does; assist in many procedures, including biopsies, surgeries, and laser treatments; and administer peels and injectable treatments.

Hiring Physician Extenders
Visit these Web sites for more information.

Registered nurses
• National Council of State Boards of Nursing:
• American Society of Plastic Surgical Nurses:
• Dermatology Nurses Association:

Physician assistants
• American Academy of Physician Assistants:

Nurse practitioners
• American Academy of Nurse Practitioners:

An Existing Need
The primary justification for employing physician extenders is that there are simply not enough physicians to go around to handle patients in a timely fashion. Adding another set of hands increases the number of patients that can be dealt with efficiently, which translates to additional revenue for the practice.

Hiring an extender is also cost efficient, because the additional fees physicians can bill for their services will cover the higher compensation and benefits they pay to a qualified PA or NP. PAs and NPs, and even RNs in many cases, can perform many of the routine services that physicins would otherwise have to provide directly, including taking medical histories; ordering medications, lab tests, and x-rays; educating patients; removing sutures and dressings; and delivering postsurgical care. This can free up the physician’s time to focus on patients who require a higher level of care or to attend conferences and trade shows.

Michael H. Gold, MD, a dermatologist in private practice in Nashville, Tenn, says “Our nurse practitioners work side by side with me. If you have one extender, consider adding a second to grow your practice even more. They are great assets and have become a mainstay in busy cosmetic practices.”

However, physicians are often divided on the issue of the roles physician extenders should play in medical offices. Proponents claim that extenders have changed the landscape of the way they run their practices and enable them to keep up with the demands and needs of a savvy patient population.

But others think that teaching staff to perform some of the treatments that physicians are trained to do is akin to training their competition. The topic often sparks a heated debate among colleagues in all specialties.

Training and Supervision
Each medical society is addressing the issues related to recruiting, training, and supervising physician extenders in its own way. General guidelines suggest that the supervising physician ensure that the physician extender is properly trained for the services that he or she will perform.

At the moment, this is an evolving area and there is no standardization in the training of physician extenders. The industry as a whole is calling for the establishment of standards that will include reasonable methods of credentialing to indicate that the people who are serving in these roles are indeed qualified.

“Training is very important, and physician supervision is critical,” says Ariel Ostad, MD, a dermatologist in private practice in New York City. “I expect the physician extenders in my practice to commit to offering good patient care, to seek my advice and guidance when needed, and to consistently continue their professional education.”

The best way for a physician extender to enhance his or her skills in medical aesthetics is to learn techniques and treatments by attending national and local conferences, taking additional courses, reading peer-reviewed journals, and observing physicians. To encourage continuing education, many physicians offer their extenders the benefit of attending some key conferences as a perk. This enables extenders to enhance their skills and expertise, which adds more value to the practice.

Consumers: Be Aware
Regulations regarding physician-extender duties are determined by each individual state. For example, each state authorizes PAs to practice medicine under the supervision of a licensed physician, but not all states give PAs prescription privileges.

Regulations can also be open to a wide degree of interpretation. However, it is ultimately the physician’s responsibility to determine where to draw the line. This often depends on the level of confidence the physician has in his or her assistant, the length of time the assistant has worked in the practice, and the assistant’s individual abilities.

Because regulations vary from state to state, most consumers do not know what is acceptable or considered safe practice. The diagnosis and practice of aesthetic procedures are increasingly performed by nonphysicians without direct medical supervision, and as a result, patients have been injured with increasing frequency, according to the American Society for Dermatological Surgery (ASDS).

Recent cases in the news, for example, have created awareness of some of the potential dangers of allowing untrained personnel to deliver treatments without having a physician on site or even nearby. In 2005, the North Carolina Medical Board disciplined two physicians at a Raleigh medical spa after a young woman died of a lidocaine overdose from using a topical gel after a laser hair-removal treatment.

As ASDS President Gary D. Monheit, MD, explains, “A physician may delegate certain procedures to certified or licensed nonphysician office personnel. Specifically, the physician must directly supervise the nonphysician office personnel to protect the best interests and welfare of each patient. The supervising physician shall be physically present on-site, immediately available, and able to respond promptly to any question or problem that may occur while the procedure is being performed.”

According to the US Food and Drug Administration, lasers and other medical devices are to be sold only to physicians. However, Monheit says, “We are witnessing a worrying trend toward ‘ghost’ medical directors: physicians who buy devices for spas, salons, and beauty centers, and medical directors who are not present in laser clinics and spas.

“The consequences include burns; scars; pigmentary disturbances; ulcers; wounds; and life-threatening reactions to medications, bootlegged devices, and drugs,” he continues. “Misdiagnosis and failure to treat are also potential problems.”

The American Society for Laser Medicine and Surgery states in its current “Best Practices for Lasers in Clinical Practice” that “No one should be allowed to use or operate a laser without having attended a wavelength- and specialty-specific workshop or having had appropriate training during residency. Lasers are utilized only by individuals who have been credentialed for the use of specific types of lasers. The individual may not utilize laser technology for purposes and scenarios for which she/he does not have active privileges and appropriate training and experience.”

“The American Society of Plastic Surgeons is in the process of developing guiding principles on the delegation and supervision of medical procedures and treatments performed by nonphysicians,” says ASPS President Bruce Cunningham, MD. “Patient safety is our primary concern.”

For the future, the industry faces the challenges of domestic and global standardization to address key issues, including credentialing and compliance.

Wendy Lewis is a contributing writer for Plastic Surgery Products and the author of nine books, including America’s Cosmetic Doctors (Castle Connolly). She is also editorial director for, a medical publishing group. She can be reached at [email protected].

American Society for Dermatologic Surgery. Available at: Accessed August 1, 2006.

American Society for Laser Medicine and Surgery. Available at: Accessed August 1, 2006.

American Society of Plastic Surgeons. Available at: Accessed August 1, 2006.

The International Medical Spa Association. Available at: Accessed August 1, 2006.