Burst Your Bubble: Growth Strategies for Dermatology NP/PAs

It's important to get out of your comfort zone, challenge yourself, and ask questions, says Alexa Hetzel, MS, PA-C. She shares her own experiences and describes the range of opportunities available to NP/PAs in dermatology. Plus, Sandri Johnson, MSN, FNP-BC provides an update on vitiligo.

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Transcript

This transcript is provided as a courtesy only and has not been edited for accuracy.

Welcome to the Dermalorian Podcast from the Dermatology Education Foundation. The Dermalorian Podcast is made possible with support from Johnson & Johnson.

As the number of NPs and PAs in dermatology continues to grow, so does the spectrum of opportunities for advancement and professional growth. DEF Advisory Council member and Dermatology Physician Assistant, Alexa Hetzel, shares some of her best advice for career growth.

We are here at Derm 2025 in the exhibit hall right outside of the general session where the incredible education is going on. And I'm here with DEF Advisory Council member and Derm faculty member, Alexa Hetzel. Alexa, why don't you tell everyone a little bit about yourself.

Alexa Hetzel:                      Hi, everybody. Like Paul said, my name is Alexa Hetzel. I'm a physician assistant. I've been in dermatology for just over 12 years. I practice in East Windsor, New Jersey, for Schweiger Dermatology.

 Excellent. So among the presentations that you did, you were part of the career development CME Symposium last night. Tell just a little bit about why you wanted to be a part of that program. Why is career development so important?

Alexa Hetzel:                      Well, I found that even in my own career development, there were so many people that I met and I could rely on to help get me where I needed to get. And I didn't realize there were things I didn't know until all of a sudden I didn't know them. And so there's so many small little tweaks that we can make that makes ourself more professional, makes us look better overall in terms of what we've done and our CVs and things like that.

  That definitely gives us the best foot forward, not only if we're trying to negotiate our contracts within our practice or switch practices or even do things like product theaters or speaking or advisory boards. I think it's important for us to be setting the best foot forward. And so I always want to pay that forward because I had help doing it, and so I want to help others reach that level as well.

Paul:                                      Awesome. So one of the things you talked about is the fact that you've been involved in a lot of research.

Alexa Hetzel:                      Mm-hmm.

Paul:                                      So obviously that goes hand in hand with clinical care, but it's not necessarily something that everyone does.

Alexa Hetzel:                      Yeah.

Paul:                                      Why did that interest you and how did you get involved to be able to really develop that part of your career?

Alexa Hetzel:                      Yeah. So I mentioned that I worked for Schweiger Dermatology, but two and a half years ago it was Windsor Dermatology. And so, I have always practiced at Windsor Dermatology. And even before I became a physician assistant, I actually was a clinical research coordinator and a medical assistant at that office. So I was getting my hours for PA school, they introduced me to it, and my very first study was Ixekizumab Phase III. So I fell in love with psoriasis and research from the get-go.

  And then as I realized there were so many ways that we could help so many people that were underserved or didn't have access to therapies or help develop new drugs that could help the masses. And then when we became Schweiger, my bubble was burst a little bit because my blinders were taken off that this is something that everybody does and I realized that this is something that nobody does.

It's really such a very niche thing for really hospital-based medicine. And so to be able to do that in private practice, it just becomes such a passion of mine.

Paul:                                      Excellent. Okay. And you just touched on something in the fact that your practice has changed a little bit.

Alexa Hetzel:                      Yeah.

Paul:                                      You are in a larger practice. You mentioned some of the benefits of that. But sometimes we don't always think about the fact that, yes, patient care, these amazing new drugs, it's so important to what dermatology MPs and PAs do, but the patients need to get the drugs.

  You're managing a staff. You are not just seeing patients, you are managing a care team. Can you talk a little bit about some of those skills and how folks can really develop them to get the best outcomes for their patients?

Alexa Hetzel:                      Yeah. I will say I am not very rigid except for when it comes to care of my patients. And so it starts when patients walk in the door. The front desk, my front desk is incredible. They know what I want, they know what to expect. They usually have a good idea of the pulse of things, but they'll come back and ask. And there's so much communication just from as soon as they walk in the door. But that's the patient's first experience.

  And then we move on to my medical staff. Same thing. They know the things that I'm looking for in terms of how long have they been here? Have they been here before? How long has this rash or this acne been there? The questions that I want them to ask, they know. And there's open communication with that. Is it okay if they don't get everything right? Of course, because I'm one of one. I'm in my own head, and so I don't expect them to read my mind, only occasionally.

 And then it comes down to me. So ultimately, making sure that everybody is communicating and everybody is happy. If my staff is also unhappy, then they're not going to do the prior authorizations and help me with those to get the patients the medications. They're not going to help me make phone calls for biopsy results and blood work. They're not going to help me with all of those little extra things that we have to do to make this seem like a seamless experience.

   And so we're very much a family because we spend so much time together. But it is really important to make sure that you say what you want, but don't be mean about it. Because if you're mean about it, you're not going to get anywhere.

Paul:                                      All right. One of the topics that came up last night was the merit-based incentive payment systems or MIPS. And you had, tying this back to staff, you talked about a direct way that you deal with MIPS in your practice. Can you tell us a little bit about that?

Alexa Hetzel:                      Yeah. So I looked up the measures for MIPS this year, because they do change occasionally. Not much, but they do change. And so I wrote them out and I printed them out for everybody. They have a little square of what the MIPS measures we have to achieve if we can achieve them within each patient. And so they know what questions to ask. Whether it's smoking cessation or if they are a current smoker. Whether it's what's their itch score for a new rash that they're coming in so we can document that and reevaluate it at their next visit.

                                                Or their psoriasis. If they're on a biologic, did they have their TB within the last six months? So there's a lot of questions that they're prepped to ask. And melanoma recalls, those are equally as important. So that way we are hopefully satisfying all of our MIPS measures.

Paul:                                      And these are natural things. You're going to want to know most of these things anyway, so it does make a lot of sense.

Alexa Hetzel:                      Exactly. Exactly.

Paul:                                      Okay. So another thing you talked about last night is the CV. It's something people take for granted. People might assume they know what their CV should look like, but it can be deceptive, right? Tell us a little bit about that.

Alexa Hetzel:                      So I think, even for myself, just starting off through this whole journey over the last 12 years, I thought CV and resume were the same. And they're not. And that's not a wrong thing. Nobody had taught me. And I eventually learned that a resume is definitely not a CV.

                                                And so then also developing my CV, in the beginning it started off very rough because there wasn't a lot for me to add, and I didn't know how to really organize it and put it together. But I think that's where a lot of our mentorship comes into, meeting other PAs and MPs in the field. Speaking to your pharmaceutical advisors, your thought leader liaisons, can help guide you in terms of how to make your CV look the best that it can look.

Paul:                                      Excellent. And for someone who is interested in doing more, especially beyond patient care, what are some of the tips you have? Talking to industry liaisons and things like that, but how can they do that, especially if maybe they're not as familiar, maybe they're a little timid?

Alexa Hetzel:                      I think talk to everybody. Talk to everybody that you can. You're going to learn good things from people, and you're going to learn bad things from people, but you're going to learn something from someone. And so having those conversations and relationships with your reps. If there's a drug that you like and you want to learn more on, speak to your MSL. Develop those relationships further. And then once you understand the science and you're like I really like this product... I've done it before where I've said something to one of our reps, and I was like, "I want to be a speaker for you guys. I really like your product. I'd really like to promote it."

                                                They're like, "Okay, well let's push that up."

                                                And that's how I became a speaker. And so if you don't ask, the answer is always no. And so continuing to advocate for yourself and just ask the questions are so helpful. Because you might not be a speaker right off the gate, but you could do an advisory board. And then the more advisory boards that you do, then maybe you'll be a little bit more slightly selected as a speaker, something like that.

                                                So it's baby steps. It doesn't happen overnight. It's been a process. And I'm still, I feel like, developing myself. And that's good because we're always ever-evolving and ever-changing. We don't want to be stagnant, but it doesn't happen overnight.

Paul:                                      I think that's really important. Speak up.

Alexa Hetzel:                      Yeah.

Paul:                                      It comes down to just putting yourself out there, right?

Alexa Hetzel:                      Yeah. Ask. It's always no unless you ask.

Paul:                                      Perfect. All right. And then another thing you talked about were some of your favorite resources. You were speaking with Matt Bruno about that. Are there any resources that you think are really essential or that you don't think people really know are out there that they really should?

Alexa Hetzel:                      Yeah. So one thing I didn't get to talk about was the programs that a lot of the pharmaceutical companies do have. So Sun and J&J both offer book programs, as well as Sanofi actually. So if you haven't gotten a book from one of your reps, ask them about their book program. You can select a book and they'll ship it to you. I love that feature because I like tangible things. I like to flip through pages and highlight stuff and write things in the margins. So I'm a book person. So I think those things are invaluable, and if we can get them for free, those books are so expensive.

                                                I use a lot of UpToDate. I think that's a great resource that I have just become familiar with. I can track also CMEs when I use it, so that's also nice when I'm looking at my continuing education credits.

                                                And there's this new app that I found called OpenEvidence. And it's a HIPPA-compliant app, but when you're looking in things, it's not just AI. It's not ChatGPT where they're going to spit out whatever they think they want, it might not be accurate. But it actually is based on real-life articles within JAD or different publications like that. So it'll spit out a real answer that is science-based.

Paul:                                      Excellent. That sounds fantastic.

Alexa Hetzel:                      Yeah, it's exciting.

Paul:                                      So pulling it all together, what would be your key piece of advice as a mentor to younger NPs or PAs just getting started in this field?

Alexa Hetzel:                      My biggest thing is know the field. So know your conditions, know why, know they're happening, why medications work for them. Know those mechanism of actions. It's a lot of back end, but it'll make it so much easier as we continue to get new medications to understand why they work differently or why they may work more effectively or why there may be side effects that to start to develop. And that baseline is so invaluable. It'll just help you progress further in your career.

                                                I would say talk to as many people as you can talk to, learn from as many people as you can learn from. Like I mentioned, there's good and bad to learn from everybody. And you can take the bad stuff and you can not implement that, and you can learn to avoid those things. And you can take the good and you can emanate those things. So there is always something to learn from everybody.

                                                And then burst your bubble a little bit. Get outside of your comfort zone and talk to people and figure out what else is out there. Because there are so many things that we can do as PAs and NPs in dermatology, and all you have to do is ask the questions.

Paul:                                      You're listening to the Dermalorian Podcast from the Dermatology Education Foundation. The Dermalorian Podcast is made possible with support from Johnson & Johnson. It's time for this episode's Dermalorian Derm Decoder.

                                                Dermatology nurse practitioner, Sandri Johnson, provides a practical update on the pathogenesis of vitiligo with an emphasis on clinically relevant considerations.

Sandri Johnson:                We know that vitiligo affects approximately 2% of the population, but that risk is much higher if you have a first degree relative that also has vitiligo. 95% of the condition or the patients that present have it before the age of 40. And about 20 to 25% of those patients also progress to other autoimmune disease or disorder. So make sure that you're getting your history and asking these questions that are very important. Probably go ahead and draw some labs, especially when it comes to thyroid tests. And always look for alopecia. We know how devastating that is.

                                                The interesting thing is that vitiligo, we always think of it in the darker skin tones because it's just that much more easy to recognize. But it actually affects the population of different skin tones the same. It just looks more distinguishable in darker skin tones.

                                                First, a little bit of information because it's not just an immunity issue. We have genetics. We have oxidative stress that are involved in the pathophysiology of vitiligo. We know that 20 to 40% of patients that have vitiligo have first and second degree relatives with it. There's a lot of genes that are really involved with the pathophysiology of vitiligo, both in the innate and in the adaptive immune pathway.

                                                We know oxidative stress is a major issue. Why? Because it creates defects in the endoplasmic reticulum of the melanocytes, and it decreases the production of glutathione. So we know that there's actually a pathway there that we can use for treatment. And in a nutshell, basically the autoimmunity of it is caused by an influx of reactive and activated CD8 T cells.

                                                So these CD8 T cells, they migrate into the skin. They release interfering gammas, and this interfering gamma binds to the keratinocyte receptor, and it activates the JAK/STAT pathway, which is producing all these inflammatory chemokines like CXL nine and 10. So they are the ones that basically go in and kill the melanocytes.

                                                From the vascularity and move into the skin and find the melanocytes, and they basically kill them. They make interfering gamma, and that in turns is turning on that CXL 10, which recruits more CDL. So you see all this recruitment coming down down here. And they come all the way in and kill your melanocytes.

                                                When vitiligo up there in the epidermis is killing these melanocytes, these stem cells can actually travel up the follicle and repopulate your melanocytes population. And this is why when you are seeing vitiligo getting better, you see these islands of repigmentation within the areas because it's actually coming through the follicle.

                                                So this is really interesting.

Paul:                                      Interesting indeed. For more interesting episodes of the Dermalorian Podcast, check out our website or your favorite podcast directory. The Dermalorian podcast is produced for the DEF by Physician Resources.

                                                Thanks for listening.