More than 2,500 years ago, the Greek philosopher Heraclitus wrote, "the only thing that is constant is change," apparently, we are not the first to face uncertainty.

With the healthcare environment rapidly changing, providers are experiencing new competitive pressures in the healthcare marketplace. The delivery of healthcare continues to be labor intensive and expensive. Demand to treat more patients increases, whereas the compensation for patient care is under constant downward pressure. Rising operating costs and disappointing reimbursement combine to keep the provision of quality care and management of costs difficult.

In some healthcare settings, it has already been necessary to provide demonstrations of the quality of patient care to payers, regulatory agencies, and managed care organizations. Registered and licensed practical nurses have already experienced the need for continuing nursing education to qualify for licensure, and the Joint Commission has established qualifications for both registered and licensed practical nurses to continue working in hospitals and some ambulatory clinics. No such regulations exist for medical assistants (MAs). Most of the Dermatology Nurses' Association (DNA) members continue to work with patients in private practice offices. In these offices, the need for Joint Commission accreditation has not been established. However, the desire and ethical responsibility to provide high-quality care are among the founding and continuing commitments of the DNA.

In the dermatology office, the hiring of MAs is increasing, and it is the dermatology MA who is likely to spend the most time with the patient. It is therefore critical that MAs have the opportunity for training, monitoring, and evaluation. Although there are a variety of education programs for MAs, currently, there are no curriculum or content standards in place for the education and training of MAs. In 2007, the National Council of State Boards of Nursing proposed a model curriculum for certified MAs; this proposal has yet to be adopted universally.

The DNA associate members, most of whom are MAs, have always expressed a desire for more integration and more opportunities within their workplace and the DNA. Establishing a curriculum for certification for dermatology MAs is difficult but not impossible. The discussion has always surrounded the diversity of education backgrounds. Some associate members have education beyond high school in a variety of disciplines, some associate members have nonnursing graduate degrees, and some associate members have long-standing relationships in dermatology practices that have spanned the years. However, the increased complexity of the dermatology practices, especially in dermatologic surgery and cosmetic dermatology, has added responsibilities for the MAs which must be met with an increase in opportunities for education or there will be not only regulatory and ethical but perhaps also liability issues to face.

Currently, offices would do well to establish their own standards, and these standards should include a practice manual with a list of duties and a description of how these duties should be carried out. The manual will change over time and should be updated as new duties are added at least annually. The Physicians' Alliance of America, Inc. (http://www.physiciansalliance.com) has copyrighted Suggestions for Medical Office Staff Quality Assurance and Oversight and outlines a useful starting place.

Establishing a manual with standards of care, reviewing expectations for the dermatology MAs, monitoring performance, and recognizing achievements will improve the quality of patient care. The result will be an increase in patient satisfaction and an increase in staff satisfaction.