Do you know what a physician extender is? Or maybe you have heard the term mid-level provider? It is the umbrella term for physician assistants and nurse practitioners. You may have seen a physician assistant or a nurse practitioner for healthcare services. We are newer professions to the healthcare team. We diagnose and treat patients. We aren’t doctors and we aren’t nurses. Are we less than doctors? Are we well educated? Are we capable? Can we do what a doctor does? We are a group of healthcare providers who haven’t been around as long as doctors have been practicing and when something is somewhat new we all have questions. This blog hopefully will answer those questions.

Since I am a nurse practitioner I can explain that profession best. Nurse practitioners are registered nurses who go on to get a masters degree to become Advanced Registered Nurse Practitioners(APRN). APRN’s have experience in the medical field as an RN before being accepted into graduate school. All APRN’s have a bachelors degree and a masters degree in Nursing. In the state of Arkansas all APRN’s have passed “boards” which is a certifying exam. APRN’s can go through different tracks in school to chose a focus. Some of the different focuses include family, adult, gerontology, pediatric, women’s health and psychiatric practice. They can also get different certifications post graduation in almost any specialty. After graduation and after requirements are met, an APRN can practice independently in his/her scope of practice diagnosing and treating patients. He/she can only write prescriptions if he/she has a collaborating agreement with an MD. Collaborating agreements vary but you can see examples at www.arsbn.org. Nurse Practitioner licenses are regulated by the Arkansas State Board of Nursing.

Physician Assistants have a little different educational pathway. I hope I understand and explain it correctly. They go to undergraduate school and can have varying undergraduate degrees. They then apply for a physician assistant graduate school. Their schooling takes them through all the specialties. Looking at the UAMS website, for admitance they are also required 500 hours of clinical experience, this requirement varies from school to school. PA’s are also required to take national “boards” to get licensed. PA’s can also get post graduate certificates in almost any specialty. When they graduate they cannot practice independently. They have a supervising physician and their scope of practice is what their supervising physician and the Arkansas State Medical Board decide. They are governed by the State Medical Board.

In my opinion, PA’s and APRN’s travel two different roads to get to the same end point. I have worked beside PA’s and APRN’s in past and present jobs and we basically do the same thing. Of course, I have worked with lots of physicians too and sometimes we do the same duties. Here is what you should know about midlevels.

1. Just because we are called midlevels doesn’t mean the care we give is midlevel. I give my patients the kind of care that I want my family and loved ones to receive. If I think you have a problem out of my scope of practice then I will refer you to my collaborating physician. Just like a dermatologist physician refers someone with heart problems to a cardiologist. Not because the dermatologist is a bad doctor but because cardiac arrest is out of their scope of practice.

2. We aren’t training to be doctors. I constantly get asked if I’m going to “go on” to become a medical doctor. The answer is no. I would have to start from square one. It’s a different profession. I know it seems like a PA, APRN and MD are all the same profession but we are actually three different professions that might happen to do the same daily tasks in the eyes of the general public.

3. We don’t want to replace doctors. We need physicians to be able to practice at our highest level. Each practice uses physician extenders in different capacities. For example, in our clinic Dr. Sandy may be the provider that you are scheduled with and see that day but Honey or I may do your biopsy. Or you may just see Honey for your entire visit for psoriasis (she is our psoriasis expert). Or you may just see Dr. Brad for your entire visit (he is our MOHS surgeon).

4. We don’t like stereotypes. There are good doctors and bad doctors. There are good APRN’s and bad APRN’s. There are good PA’s and bad PA’s. Judge us after you meet us and see if you like the care we give. Don’t assume we are better or worse just because of the letters behind our name.

5. We improve healthcare. We can often shorten the time a patient waits for an appointment and give you more time during your visit. For example, in our practice Dr. Sandy manages the difficult medical issues and Honey and I are more expert with common dermatology issues such as acne or warts. By having us join the practice Dr. Sandy can spend more time with each individual that has complicated problems because we are seeing the wart and acne patients she would otherwise be seeing. Plus, we now have three appointments available at 11:00 instead of the one before Honey and I joined the practice. This results in people getting appointments quicker.

6. We are educated and licensed. We are prepared. When you have an appointment with a physician extender instead of a physician you aren’t getting “left overs” or “second choice” or less care than you would receive from a physician. Not at Johnson Dermatology anyways. I graduated top of my graduate class with a 4.0 GPA, could someone “sub-par” do that?

7. We are just part of a team. Midlevels NEED nurses, front office staff, physicians, lab technicians, radiology technicians, pharmacists, pharmacy technicians and even pharmaceutical sales reps to give you the best care. To get the best healthcare you deserve it literally takes a whole team. Realize that when you go to a healthcare appointment. Your healthcare provider is just a piece of the puzzle. You need the whole A-team to make it work the way you want.

8.We satisfy our patients. According to the AANP there are 916 million visits made to NPs each year and patients “report an extremely high level of satisfaction”. Maybe you should give us a try too?

9. We are experienced. When I was a travel nurse I would work in teaching hospitals and teach med students how to start IVs or how to read arterial blood gases and manage ventilators (patients on life support). At that time I had more experience in doing those tasks (I was an ICU nurse for 7 years). My point is that sometimes experience and repetition at tasks are as important as the letters behind your name.

10. Everyone has their strengths and roles. Dr. Brad is our MOHS surgeon. If you need a skin cancer removed then he is your guy, not Honey. But Honey is our psoriasis expert. If you need your severe psoriasis managed, she is your gal. Not because Dr. Brad couldn’t do it but she does it all the time and knows which insurances pay for which medications. Plus it’s what interests her. So on the weekend she is going to be the one more likely to read that new study that just came out on psoriasis while Dr. Brad is reading (maybe even dreaming) about surgery.

I’m guessing this post is longer than you cared to read. I hope I didn’t lose you because it was just too darn long! There is no simple answer to the role of midlevel providers but we are here to stay. Chances are you’re going to run into one of us. There are too many baby boomers and not enough doctors. There are too many health problems and not enough doctors. Heck, there are not enough midlevels. Lots of offices are booked three to six months out! I just hope whoever the midlevel is that treats you gives you a good experience that represents our profession well. I know that I promise to give you the best care at Johnson Dermatology. If I can’t answer something for you I will do everything in my power to find you an answer. Honey is as smart as the dermatology book we read front to back together. She can take care of my skin any day. She is literally one of the smartest women I know and I am honored to work beside her as the midlevels of Johnson Dermatology. Of course we are only as good as our team, which is the best.

Thank you to the physicians and nurses that made me the provider I am today,

Nina

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I love filler. I love it in my face and I love to inject it into others. It is immediate satisfaction and it looks so natural. My girlfriends and acquaintances often question me about filler and my love for the stuff. I thought maybe some of you might want to ask me the same questions but don’t feel comfortable enough to ask so today’s blog is my most FAQ’s with regards to filler (and my answers of course)!

Q: Aren’t you too young to have filler?

A: When is too young to have filler? Everyone ages and gets sagging lines and wrinkles at different numerical ages dependent on multiple factors including sun exposure, genetics and whether or not they smoke, just to name a few. If you have any “drooping” then you’re not too young. Plus some people want filler for bigger lips or to fill in a deep scar, not just for anti-aging.

Q:What should my goals be when getting injections?

A: I usually say “let’s get your skin to where it was about 10 years ago”. If you are 60 your skin isn’t going to look like it did when you were 20 with filler, not in a natural way anyways. Don’t expect the tightness of a facelift with filler. Expect to look refreshed.

Q: Why not save my money and get a facelift?

A: You have to go under anesthesia for a facelift which comes with a new set of risks and possible complications.  A facelift is more downtime and more recovery time. Some people can achieve a more subtle change with filler than the tight pull you get with a facelift. Some people need a facelift AND filler to fill volume loss and to pull skin taught. Some people might benefit from saving their money and getting a facelift. Ask this during your consultation.

Q: I only have X amount of money. Is it better to save until I get Y amount of money so I can do all the syringes I need at once or can I do a little at a time?

A: Either way works out in the end. I personally like doing a little at a time and adding on as you mature. This is a lifelong commitment, a commitment to anti-aging. You will probably always need more at some point. Some people do a higher number of syringes initially and then add on to that as they go which is another good way. A good injector will consider your budget and make a longterm plan with realistic goals just for you!

Q:How should I pick who injects me?

A: Pick someone who has more than a weekend class learning how to inject. Pick someone in the medical field that has resources to fix complications. Pick someone who enjoys injecting (ask them if they like to do it, or you probably should be able to see some enthusiasm). Pick someone who injects a LOT and often! A good place to start is with dermatologists or plastic surgeons. The best place to start is by picking me (hehe, kind of kidding).

Q: How often do I need to get filler?

A: That depends on you. Different types of fillers last different amounts of time, some about a year and some about 2 years. Some people metabolize filler faster, some slower. Some people age quicker than others and require more anti-aging tools. Some people require more filler and some people require more laser. Everyone’s anti-aging plan looks a little different. You should meet with your injector every 3-6 months to stay on track but you likely will not need filler at each visit.

Q:Why don’t you do Botox/Filler parties?

A: Every time I inject someone it’s a party. Seriously though, do you get your root canal on a couch? Your flu shot at a dinner table? No, of course not. In my opinion, Filler is a medical procedure and should be done in a clean, medical environment.

Q:Why don’t you offer the stuff cheap like I’ve seen elsewhere?

A:Because I’m an expert. I know I do the best job. You aren’t just paying for product when you come to me to be injected. You are paying for my expertise, my technique. I’ve spent many  hours at advanced trainings, many weeks at seminars away from my family, many years training with Dr. Sandy and that’s just since I finished 4 years of undergraduate education at the U of A and a masters degree in the Science of Nursing from UCA. Not to mention I have an eye and artistry that can’t be taught. Quality over quantity! When injected by an expert one syringe may look better than what someone less qualified does with 2 syringes.

Q: How do I pick which filler to use?

A:Don’t do it alone. Don’t pick based on what worked on someone else or what looked good in a commercial. If you have an expert injector they will help you pick the best product for you according to your budget and your skin.

What questions do you have that I didn’t answer here? Have you met our cosmetic concierge at Johnson Dermatology? Her name is Dani and she loves doing cosmetic consults and making long term anti-aging plans with you. Next time you are at the clinic you should ask to meet her, spend time with her and ask her any filler questions you still have. Hope to see you all at the clinic this week!

He who asks a question remains a fool for five minutes. He who does not ask remains a fool forever. -Chinese Proverb

Happy Week, Nina

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Sorry I missed a post last week. I was in NYC with family for a wedding all weekend. I remember when I was in college, I could have fun with friends until the wee hours of the morning and then wake up for class and just bee bop along like I’d had 12 hours of sleep the night before. Let’s just say in my thirties I require a little more rebound time. I know they say that 30 is the new 20 but when I was 20 I didn’t have a 2 year old and 3 month old who woke up at 6 AM no matter what time I  went to bed. Things change as we age and our skin isn’t exempt. As we age our skin becomes thinner, less fatty, drier, wrinkles, sags and has less bounce back and structure. We get brown spots and benign growths more commonly as our skin matures. Genetics play a part in how all these things happen to your skin but there are also extrinsic factors that age your skin prematurely. Here are some tips to prevent premature aging of your skin.

1. Sun protect- This had to be my number one. If you don’t want to avoid the sun for increased risk of skin cancer, then avoid it because it’s making your skin older quicker. Try self tanner instead of harmful rays from tanning beds or natural sunlight, wear your sunscreen where clothes don’t cover and you’re sure to save some skin.

2. Stop smoking- Smoking isn’t just harming your lungs. It’s making your skin look older quicker too.

3. Stop harsh skin care-If it burns and hurts when you put it on then your irritating your skin. Scrubbing with beads and other harsh products causes irritation that causes the skin to look older.

4. Stop facial expressions-okay that sounds crazy, I agree. What I’m trying to say is get Botox preventatively. When you look in the mirror and see crow’s feet it’s from years of squinting. Botox prevents lines in motion (lines when you make movements or expressions) which in turn will prevent lines at rest (those wrinkles you hate). Wear some good shades to prevent squinting.

5. Use Retinol- Retinol has been scientifically proven to reverse the changes of photoaging to the skin. We will all get some sun throughout our lives as we live. Try to repair that damage nightly with a good retinol. My favorite is SkinMedica Retinol. I use it every night. Not only do I think my skin looks younger using it but it’s keeping it young too!

I’m blessed with the gift of good health so I really can’t complain about this getting old thing, it’s so much better than the alternative. I am going to do what I can to stay healthy and that includes taking care of my skin. Hope you all join me in keeping your skin healthy…. and youthful. If you feel like your skin is looking tired come see us at Johnson Dermatology. We have lots of tricks to fight the aging fight. We use creams, lotions, potions, lasers and injections everyday. Thanks for trusting us as your skin experts in the River Valley.

XxXx, Nina

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Do you go to the doctor and ask for generic medications? Do you ask for medications off of the $4 list? Do you ask for the newest medicine? Do you ask for whatever will work the best? Do you even voice an opinion or do you just fill whatever prescription your health care provider hands you? Often times I think patients, pharmacists, nurses and healthcare providers think that generic medications are the same as their brand name counter parts. Often times they are similar but they aren’t the same. Simply said, generic medications are older medicines that have been around awhile and brand name medications are either a brand new medication altogether or a newer, supposedly improved older medication. Here are some reasons you might be prescribed brand name medications other than for you to spend a lot of money on medicine.

1. There isn’t a generic option. Some new medications don’t have a generic counter part. One of my favorite medications for Rosacea is called Soolantra and there isn’t a generic version. Sometimes if you want the latest and the greatest….. well what’s the saying? “You gotta pay to play”.

2. The brand name is cheaper for the patient. Weird right? Sometimes, for the patient, the generic version is more expensive than the brand name version with the coupon provided by the company. For example, a pill we use a lot in dermatology called Oracea has a generic option. The generic according to goodrx at Walgreens is $681 but the brand name, with a coupon, (with the right health insurance) is no more than $25. Weird huh?

3. The generic and the brand name are not created equal. For example, if you had stomach upset with generic doxycycline (an antibiotic known for stomach upset) then there is an alternative extended release doxycycline called Doryx or Acticlate that claims it doesn’t cause stomach upset. You may be able to take the brand name without any problems.

4. Samples. Have you ever been to the doctor and received a sample of a medication to use until you can get your prescription filled. Or maybe to try it out before you paid for a full prescription, make sure it did the job? Well that was always a brand name medication. Generic medications do not have samples given to health care providers. Brand name samples can be a blessing to a patient.

I’m all about saving a buck, I don’t want to spend money on my medications that could go towards my kids vacation or something way cooler. Sometimes we have to choose what medications we use based on price but more often than not, as healthcare providers, we are just choosing your medication based on what we think is best for your condition. The cost of healthcare is a hot topic and sensitive to some. We don’t live in a perfect world. As always, I want to work together with my patients for us to choose the best medication for your condition. I hope we achieve your skin goals cost effectively, together. It makes me smile when patients’ beautiful insides can shine through their skin!

“Perfection is not attainable, but if we chase perfection we can catch excellence.” -Vince Lombardi

Stay Skintastic, Hope to see you all at the clinic this amazing August, Nina

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