The PA profession was created in the late 1960s as a response to a shortage of primary care physicians and a need to extend the availability of medical services for patients. Although the shortage of primary care persists, recent projections by the Association of American Medical Colleges (AAMC) projects even greater shortages in medical and surgical specialties.1
The initial idea for the PA profession was that physicians could delegate many routine tasks to PAs. PA training combined a didactic grounding in the basic sciences with a clinical apprenticeship model emphasizing general medical knowledge and its application in a primary care setting.2 The profession was originally designed to be physician-dependent. When in practice, PAs would form relationships with physicians who would take professional and legal responsibility for the PAs' work and expand their scope of practice as PAs demonstrated competency.3 This model has changed over time. In particular, PA-physician collaboration has been redefined in a way that has tended toward increasing levels of PA autonomy. The recently approved American Academy of PAs (AAPA) policy on optimal team practice (OTP) illustrates this continuing trend.4 OTP may ultimately result in a more fundamental restructuring of the original design of the PA-physician relationship. Regardless, the PA model has produced a flexible medical professional who can be trained quickly and deployed rapidly to address issues of patient access and provider shortages.
The flexibility of PAs to function in multiple venues is an attribute that is highly prized among physicians, the healthcare system, and PAs themselves.5 PAs are valuable to a healthcare system as they can be assigned to areas of need. PAs also take advantage of this professional mobility. An analysis of PAs between 1969 and 2008 found that 49% had changed specialties at least once in their career, 24% switched to another specialty class, and 11% reported practicing in at least three specialties over their careers.5 In a 2015 survey, 8.3% of PAs indicated that they changed specialties during 2014.6 The generalist training of PAs, coupled with a culture that emphasizes lifelong learning, has been credited as the key to this flexibility. As a result, specialty certification has been viewed by many members of the profession as a threat. AAPA has had a policy opposing specialty certification since 2002.4
At its founding, the PA model rested on two assumptions: that most PAs would enter the primary care workforce, and that physicians would be the primary employers of PAs.2 These assumptions are now challenged by the realities of contemporary PA practice. Healthcare systems, government agencies, and other institutions have emerged as direct employers of PAs, altering the paradigm of the PA working with a collaborating physician in a mentor role in these contexts.7 This has resulted in a fundamental change to the dyadic PA-physician model and the assumed apprenticeship-mentor relationship that would regulate PA practice.
Given the current nature of PA practice, what is the role of specialty certification? How does the profession preserve the flexibility that has created so much value for the healthcare system and patients while addressing healthcare systems' needs to assess PA competencies and experience? How does the profession accommodate the understandable desire of specialized PAs to be formally recognized for their expertise or to gain a credential that would facilitate their promotion in a healthcare system's defined structure for career advancement?
As part of AAPA's periodic policy review process, the AAPA Commission on Continuing Professional Development convened a Task Force on Flexibility and Specialty Certification composed of members representing a broad range of specialties, employment, and educational settings. The task force was appointed in December 2016 and concluded its work in March 2017 with a revised policy that was submitted to the AAPA House of Delegates in May 2017; the revised policy was approved.4
SPECIALTY PRACTICE IN THE PA PROFESSION
The trend toward specialty practice has been longstanding in the PA profession. In 1974, 68.8% of PAs were in primary care practice.2 According to 2016 National Commission on Certification of Physician Assistants (NCCPA) data, 73% of PAs report that they are in specialty practice.8 This creates a conundrum whereby a profession with generalist training and an assumed primary care trajectory is now dominated by specialty practice. NCCPA introduced certificates of added qualifications (CAQs) in 2011 as a means for PAs to show added knowledge in specific specialty areas.9,10 Participation in the CAQ program has been low (Table 1).
In 2016, NCCPA proposed a change to the recertification process: at the time of recertification, PAs would choose a specialty examination relevant to their practice. With achievement of an exceptional level of performance and, if they met additional requirements such as time spent practicing in the field, examinees would be eligible to be awarded a CAQ in addition to the renewal of the PA-C credential.11 After a spirited debate, this proposal was withdrawn. NCCPA has announced plans to focus the revision of the PA national recertification examination (PANRE) on core knowledge.12 NCCPA has published a new blueprint that will be used to develop a new PANRE and a pilot PANRE alternative.13
Healthcare systems and specialty organizations have responded to the need to prepare PAs for specialty practice by developing postgraduate programs. From 2007 to 2014, the Accreditation Review Commission on Education for the Physician Assistant (ARC-PA) offered voluntary accreditation for these programs.3 The process was held in abeyance after 2014 because of its high cost and intensity, and only eight clinical postgraduate training programs received accreditation. Overall, postgraduate programs range from well-structured and accredited programs to curricula that may be regarded as onboarding programs that train PAs for their roles within a specific healthcare system. Program capacity is low (often one to four per cohort) and therefore unlikely to have a dramatic effect on workforce needs.14 A recent review concluded that if these programs are to continue to exist, they should follow more consistent standards.15
ENVIRONMENTAL SCAN AND STAKEHOLDER CONSULTATION
A task force member conducted a review of literature related to PA specialty certification, PA roles and professional responsibility, PA workforce distribution among specialties, and factors influencing specialty choice. Although valuable data exist about clinical flexibility and specialty career selection, the literature addressing PA specialty certification is sparse, making it difficult to draw reliable conclusions. For this reason, the task force used a series of short surveys administered to various stakeholder groups to gather information about the role of PA specialty certification in contemporary PA practice.
A survey was sent to 35 PA specialty organizations and AAPA-affiliated special interest groups that focus on specialty practice. Responses were received from 24 organizations (69% response rate), including all organizations with a corresponding CAQ. To gain an employer perspective, a survey was sent to PAs who participate in the PAs in the Administration, Management, and Supervision group on the Huddle, AAPA's social networking site; 20 responses were received. Of these, four held titles indicating that they supervised a specialty service that included PAs alone or combined with NPs. The remaining 16 respondents held titles such as director of PA services or director of advanced practice providers. Additional stakeholder feedback was sought from physicians who work with PAs. A survey link was sent by members of the task force to physician colleagues. Twenty-seven responses were received from physicians in seven specialties, five of which have some form of specialty certification available to PAs. Because the sampling was neither complete nor systematic, conclusions cannot be drawn from this information; however, the physician data gave some indication of physician awareness of and attitudes toward PA specialty certification.
Questions posed to the specialty organizations focused on whether the organization had a formal position related to specialty certification and, if so, what that position was. Additional questions explored whether specialty certifications were available to PAs. Organizations were asked when specialty certification might be important to ensuring patient safety and under what circumstances consideration of specialty certification might not be appropriate. PAs involved in supervision and management were asked how specialty certification is used in their institutions for hiring and promotion. Questions for physicians focused on their relationship with the PAs with whom they interact (PAs employed directly by physician practice or through an affiliated organization), their awareness of specialty certification, and whether specialty certification was a consideration or requirement in hiring or promotion. The task force's surveys were conducted as part of an overall environmental scan rather than formal survey research and the discussion of the survey results should be understood in that context.
THE SCOPE OF SPECIALTY CERTIFICATION
The seven specialties for which NCCPA offers a CAQ were determined to be the most relevant to this discussion (Table 1). However, the task force uncovered numerous interprofessional certifications administered by other organizations that are open to PAs and other medical professionals. Another category of interprofessional certification includes various life-support certifications that may not be related to a specific specialty, but may be required for a PA to function in a specific role, such as on the code team in a medical facility. These non-NCCPA certifications are summarized in Table 2. For the purposes of this analysis, the task force considered information from each of these certifications; however, aside from the NCCPA CAQ process, no overarching governance structure regulates non-CAQ credentials for PAs.
SUMMARY OF STAKEHOLDER FEEDBACK
Of the 24 specialty organizations and special interest groups responding to the questionnaire, only 10 organizations had official positions on specialty certification. Of these organizations, eight were officially opposed. The Society of Emergency Medicine Physician Assistants and the Association of PAs in Psychiatry are the only AAPA-affiliated specialty organizations with a position endorsing the CAQ in their specialty. Unsurprisingly, the CAQ in emergency medicine is held by more PAs than any other CAQ and psychiatry has the highest percentage of PAs practicing in a specialty who hold the CAQ (Table 2). When asked about the role of voluntary certification in their specialty to ensuring quality of care and patient safety, constituent organization respondents expressed considerable skepticism, with many stating bluntly that they saw no relationship between certification and quality of care. Others stated that holding a certification did not demonstrate clinical competence. When asked about inappropriate use of specialty certification, respondents expressed similar concerns. Responding organizations generally are opposed to specialty certification in situations where it is used as a criterion for:
- entry into specialty practice
- third-party reimbursement.
Respondents expressed considerable skepticism for any additional requirement that would entail additional study time and expense unless it was accompanied by evidence that it positively affected practice by improving patient care and patient safety.
PA specialty organizations that saw a role for specialty certification indicated that added qualifications could let PAs identify a level of specialty knowledge beyond primary care. Others commented that it might be helpful in defining core competencies for a specialty and to enhance PAs' ability to compete for jobs with other providers, such as NPs, who have specialty training.
Of the 20 respondents to the survey sent to the members of the management and supervisory group on the Huddle, 19 indicated that specialty certification was never listed as a requirement in job postings in their organization. One lead PA for an emergency medicine service indicated that the CAQ is “sometimes” required, but candidates without the CAQ are put on a track to obtain it. Three organizations indicated that holding specialty certification was often listed as preferred. Two of these respondents represented emergency medicine services. The third respondent represented an oncology service and indicated that despite the expressed preference, the service rarely had applicants who met it. Four organizations indicated that specialty certification was used as a marker in the promotion process and that specialty-certified PAs were eligible for raises and bonuses. One organization reported that specialty certification was required for those seeking leadership roles. Although the sampling of this group was neither complete nor systematic, it appears that requiring or preferring specialty certification in hiring decisions is not widespread, with the exception of emergency medicine. However, these data indicate that specialty certification may play an important role for PAs seeking promotion, and may be especially important to those seeking leadership roles.
Of the 27 respondents to the physician survey, 15 responses were received from orthopedic surgery; five from psychiatry; two each from rheumatology and pediatrics; and one each from infectious disease, physical medicine and rehabilitation, and cardiovascular surgery. Most respondents worked for practices where PAs were directly employed by the practice rather than by an affiliated medical facility (20 of 27). Most (20 of 27) were unaware that specialty certification was available for PAs in their specialty despite the fact that all but two were from specialties with available CAQs. Twelve respondents indicated that they tended to hire PAs with documented work experience in the specialty. Fourteen respondents indicated that they sometimes hire PAs with experience in their area and sometimes hire new graduates and provide on-the-job training. Only two respondents indicated that they prefer to hire new graduates and train them specifically for their setting. Less than half (13 of 27) said they might consider specialty certification as a factor in a hiring decision and few (8 of 27) said they would consider specialty certification as a factor in promoting a PA.
Responses from the physician survey indicate that direct employment of PAs by medical groups is still important in some specialties. Although physician employers retain some willingness to train PAs, they prefer to hire PAs with experience in a given field. Specialty certification in addition to work experience can be a factor in hiring. However, physician groups seem less likely than healthcare systems to promote a PA, once employed, based on specialty certification.
Two organizations provide a structured curriculum of learning modules intended to prepare PAs who are entering the field. The Society of Dermatology Physician Assistants' diplomate fellowship program is a series of modules covering all aspects of dermatology through a structured curriculum of CME activities. The Association of Rheumatology Health Professionals, which includes PAs, has worked with the American College of Rheumatology to produce an online modular curriculum for PAs and NPs entering rheumatology practice. This program awards a certificate upon completion.16 These approaches differ from the CAQ in that they provide a PA entering a specialty field with a structured educational curriculum to prepare them for clinical practice, rather than relying on high-stakes testing that attempts to demonstrate qualification in that specialty.
Specialty certification has a number of potential advantages for PAs and other stakeholders in the healthcare system. First, it provides external validation of a PA's expertise. It also may be helpful to a PA seeking promotion in an established clinical ladder program in a healthcare system. In a clinical ladder, clinicians qualify for promotion based on defined criteria, which often include gaining advanced degrees or certifications. Holding a specialty certification also may enable a PA to compete more effectively for jobs in a specialty, provides employers with a tool for assessing applicants, and may provide patients with assurance about the qualifications of the PA caring for them.
The main concern PAs have about specialty certification is that its adoption will limit entry into specialty practice and limit mobility among specialties. The CAQ model requires experience in the field to establish eligibility to take the examination. Although this generally is compatible with the PA model, in which clinicians are trained as generalists and gain knowledge through work-related experience, if holding a specialty certification becomes an entry criterion, it will favor those already in the field while barring entry to other PAs. This could create shortages of PAs who are able to engage in the field. Limiting entry to those with certificates also could increase costs to the healthcare system because of higher starting salary requirements.
If specialty certification were to become a requirement for entry into PA practice in a specialty, a likely consequence would be the establishment of formal training programs, which would further reduce flexibility by restricting PA practice to the areas where one is trained and certified. PAs could find themselves living within the same rigid structures as physicians and NPs. Not only would PAs lose the ability to move from specialty to specialty, but healthcare systems would lose the ability to assign available PAs to areas with gaps, which could result in higher costs for the healthcare system and reduced access for patients.
When might specialty certification be appropriate?
The most compelling case for requiring specialty certification would be if a clear relationship between specialty certification and patient outcomes could be demonstrated. However, little such evidence exists for PA practice. In the physician literature, this link has been difficult to demonstrate. Sharp and colleagues reviewed the connection between certification and clinical outcomes, and out of 33 studies meeting the investigators' criteria, 16 demonstrated a positive relationship between certification status and desirable clinical outcomes.17 Fourteen showed no association and three showed a negative relationship, although the studies showing no association and negative relationships suffered from insufficient case mix.17 Research is needed to determine if any relationship between specialty certification and patient outcomes exists in the context of PA specialty practice because evidence to support this concept is lacking.
One specific circumstance in which specialty certification may play a helpful role in PA practice is in the promotion structures of a healthcare system. In this context, gaining specialty certification may let a PA meet a requirement to be promoted under a defined clinical ladder program. This seems appropriate because the certification's use is not to deny access to the ladder, but merely to meet a criterion for moving to a higher rung.
What uses of specialty certification would be inappropriate?
We conclude that any use of specialty certification is inappropriate if its use results in reduced flexibility for PAs to move among care settings to fill clinical gaps in the healthcare system, higher costs to the system, or reduced access to care, unless this is balanced by compelling evidence that specialty certification results in higher-quality and safer care. Until this evidence is available, we oppose the consideration of specialty certification in the following situations:
- As a criterion for entry into specialty practice employment settings
- As a criterion for credentialing
- As a criterion for reimbursement.
AN ALTERNATIVE PROPOSAL
A clinical portfolio approach that lets PAs provide a more rounded portrait of their clinical experiences and competencies might meet the needs of stakeholders who see specialty certification as a marker of competence. Portfolios have been used in the United Kingdom for trainees in the healthcare professions and for periodic revalidation of licensure.18-21 They are used by US medical students, residents, and fellows, and their potential for the PA profession is being explored.22 Unlike specialty certifications that document that a PA has passed a knowledge test, an electronic portfolio maintained by the PA with certain portions subject to external validation could let a PA display information related to formal and informal training, relevant CME, procedures performed and proficiency documentation, and relevant certificates or certifications. This information would be available to prospective employers, credentialing authorities, insurance companies, and other stakeholders.
Of particular interest would be the ability to document assessed proficiency with entrustable professional activities (EPAs) deemed important in a field.23 EPAs are activities that a medical professional can be trusted to perform with varying levels of supervision. Entrustability is assessed on a spectrum and as a clinician demonstrates competency in certain domains, the level of supervision changes. This model has been adopted in the United States for medical students, residents, and fellows. Standardized lists of EPAs are being developed along with methods for assessing them.24 This would let stakeholders make informed decisions about individual PAs based on a broad understanding of the PA's professional standing and experience, rather than relying on a solitary marker such as specialty certification. Although EPAs show great promise, they are not yet widely understood or used in the PA context.
The PA model adds value to the healthcare system by supplying medical professionals who can be trained rapidly and assigned throughout the healthcare system to address unmet needs. This flexibility should be fiercely protected in order to avoid losing a unique advantage enjoyed by the profession. As the model of PA practice evolves, employers and other stakeholders are looking for ways to assess PAs' qualifications and competencies. The profession should respond to these legitimate concerns but must do so in a way that demonstrates PA expertise without inhibiting the profession's flexibility.
Specialty certification could be problematic in that it may restrict PAs' ability to move throughout the healthcare system as needs arise. Certain concerns about specialty certification are already being realized because employers in some areas are already using it as a criterion for hiring.
Specialty certification may have an appropriate role in facilitating a PA's advancement in a healthcare system's promotion pathway or enhancing PAs' ability to compete with other clinicians for jobs. However, this must be balanced against the threat to flexibility that would affect PAs' ability to move within the healthcare system to meet gaps in patient care. Reducing this flexibility would harm the value of the profession to the healthcare system and to patients. Because the relationship between specialty certification and quality of care is unknown, research should be conducted to determine if such a relationship exists. The profession should take steps that will let PAs provide stakeholders with rich and nuanced information about a PA's background and experience rather than focusing on unidimensional credentials that rely solely on knowledge testing.
2. Larson EH, Hart LG. Growth and change in the physician assistant
workforce in the United States, 1967-2000. J Allied Health
3. Holt N. “Confusion's masterpiece”: the development of the physician assistant
profession. Bull Hist Med
5. Hooker RS, Cawley JF, Leinweber W. Career flexibility
of physician assistants and the potential for more primary care. Health Aff (Millwood)
9. Glicken AD, Miller AA. Physician assistants: from pipeline to practice. Acad Med
10. National Commission on Certification of Physician Assistants. No further changes to PANRE and the recertification process. http://www.nccpa.net/panre-model
. Accessed January 3, 2019.
15. Hussaini SS, Bushardt RL, Gonsalves WC, et al Accreditation and implications of clinical postgraduate PA training programs. JAAPA
16. Smith BJ, Bolster MB, Slusher B, et al Core curriculum to facilitate the expansion of a rheumatology practice to include nurse practitioners and physician assistants. Arthritis Care Res
17. Sharp LK, Bashook PG, Lipsky MS, et al Specialty board certification and clinical outcomes: the missing link. Acad Med
18. Buckley S, Coleman J, Davison I, et al The educational effects of portfolios on undergraduate student learning: a Best Evidence Medical Education (BEME) systematic review. BEME Guide No. 11. Med Teach
19. Vance G, Williamson A, Frearson R, et al Evaluation of an established learning portfolio
. Clin Teach
20. Haldane T. “Portfolios” as a method of assessment in medical education. Gastroenterol Hepatol Bed Bench
21. Ap Dafydd D, Williamson R, Blunt P, Blunt DM. Development of training-related health care software by a team of clinical educators: their experience, from conception to piloting. Adv Med Educ Pract
22. Neal JH, Neal LDM. Self-directed learning in physician assistant
education: learning portfolios in physician assistant
programs. J Physician Assist Educ
23. Lohenry KC, Brenneman A, Goldgar C, et al Entrustable professional activities: a new direction for PA education. J Physician Assist Educ