If you prefer to view this article in PDF form, click here.

Maintaining professional flexibility:

The case against accreditation of postgraduate physician assistant programs

The American Academy of Physician Assistants (AAPA) recognizes the value that voluntary participation in postgraduate clinical training programs may have for physician assistants (PAs) who seek additional knowledge and skills. However, the AAPA does not believe that there should be an accreditation system for these programs. This paper discusses why accreditation of postgraduate clinical training could jeopardize the role and mission of the PA profession and suggests other ways to promote quality and protect participants.

Postgraduate programs for PAs have existed since the early 1970s. Most of them offer an internship model of training. This type of program includes a modest didactic curriculum and intensive work in the clinical setting. The internship model programs are offered by hospitals, medical centers, and large group practices. They are typically 12 months in length, provide a stipend of $3,000 to $4000 per month, and enroll two participants per year.^1,2

These programs are primarily structured work experiences and the participants do not enjoy the unregulated status of students. Rather, they are licensed practitioners, subject to state PA practice acts. They enjoy the protections offered by the Fair Labor Standards Act and other laws designed to protect employees.

There are also postgraduate programs that follow a more academic model. These programs combine a highly structured didactic education (that is, courses taken for graduate credit) with clinical rotations. These programs, usually sponsored by accredited universities, award a master’s degree or credit towards a master’s degree.²

For the purposes of this discussion, degree completion programs, such as the one offered by the University of Nebraska, are not considered postgraduate programs.

The current capacity of the 28 programs that belong to the Association of Postgraduate PA Programs (APPAP) is approximately 100 PAs. Training is offered in dermatology, emergency medicine, family medicine, oncology, orthopedics, pediatrics, psychiatry, rural medicine, surgery, cardiovascular surgery, and urology.¹

The term “residency” is frequently used to describe PA postgraduate programs. However, unlike the compulsory residency training that physicians must have, postgraduate training for PAs is not a requirement. In fact, very few PAs have completed such programs. Postgraduate training is available to PAs at any point in their careers and is not a step currently required for licensure, practice, employment, or reimbursement.

This last point is important when considering whether postgraduate programs should be accredited. Accreditation is usually a good educational quality assurance tool. In this case, the proposed accreditation system is not very meaningful. Even if it were meaningful, a formal accreditation system could have many negative repercussions for the profession.

In 2003 the Accreditation Review Commission on Education for the Physician Assistant (ARC-PA) convened a task force to examine the feasibility of accrediting postgraduate programs. The task force did not look at other ways to achieve the goals of improving postgraduate programs and protecting the PAs who participate in them.

It has drafted a set of accreditation standards that focuses primarily on program operations and administration instead of content. A decision on whether to proceed with accreditation has not yet been made, but is expected in the near future.

Advocates of postgraduate program accreditation say that it would assure quality and increase consistency among programs. Accreditation would help applicants decide which program to attend because of the presumption that an accredited program is better than an unaccredited one. Another argument is that accreditation would strengthen the relationship between the faculty at PA programs and teaching clinicians, with the side effect of securing high quality clinical training sites for PA students. This, it is argued, would improve PA education in general and reflect positively on the entire profession.³

There are strong arguments, however, to be made against accreditation. A truly worthwhile accreditation system demands the development of accreditation standards that encompass not only the administrative aspects of the training, but also its educational content. Unfortunately, there is no agreement on what knowledge and skills should be taught⁴ and there is no movement toward the development of content-based standards. In truth, it would be difficult to develop specialty-specific educational standards because there are so few programs per specialty (only surgery has more than two programs). An accreditation system that checks only the fairness of administrative procedures and ignores educational content is of little value.

Another vital part of a credible accreditation system is careful and periodic evaluation of each program by qualified peer reviewers. The small number of postgraduate training programs per specialty will make it extremely difficult to find and maintain a core of experienced, knowledgeable, and unbiased site visitors. And if peer reviewers are not needed for on-site evaluation and the accreditation process is only a paper review of administrative procedures, one must ask, what is the point?

The potential cost of an accreditation system is another factor to be considered, both for the postgraduate programs and the accrediting agency. It is likely that the higher costs would be passed on to patients or to participants.

One of the strongest arguments against accreditation of postgraduate programs is that it is unenforceable. There is no way to require accreditation unless state laws were changed to require that all PAs have postgraduate clinical training before they could be licensed or employed. Without this requirement in law, it makes no difference whether individuals attend accredited or unaccredited programs.

The value of accreditation is that postgraduate programs could use it as a marketing tool. Yet anyone looking behind the facade of accreditation would see a meaningless system (verifying only fairness of administrative procedures) and no guarantee of constructive learning environments.

One may ask, if the accreditation system is voluntary, what is the harm? The answer is that the mere existence of a formal accreditation system would lend these training programs the appearance of an official status that could have serious unintended consequences for the entire PA profession. There is significant danger, particularly in states that are conservative or hostile to PAs, that regulators would mandate the completion of an accredited postgraduate program prior to approving the performance of specific technical procedures, overall job descriptions, or licensure applications. There is no guarantee that such requirements would exempt individuals who are already in practice, thus placing an extreme hardship on more than 55,000 practicing PAs, most of whom have not been through a postgraduate program. As mentioned earlier, existing postgraduate programs have limited capacity which, even if increased a hundredfold overnight, could not accommodate everyone who might need to participate.

There is also a danger that insurers could decide not to pay for services provided by PAs who lack postgraduate training or that employers would see accreditation of postgraduate training as a sign that they should begin to require completion of these programs by all PAs. While some PAs are advocates for postgraduate training, there is a distinct difference between PAs voluntarily choosing to attend a program and having the decision made for them by others.

But the greatest danger is that the ability of PAs to change from one specialty to another would be drastically reduced if postgraduate clinical training were to become mandatory. Data show that from year to year, about 20% of PAs change jobs. In recent years, changing jobs has become more associated with changing specialties.⁵

Decisions to require postgraduate training for licensure or employment could have a monumental effect on the profession. PAs would be forced permanently into specialties, limiting their ability to fill the employment voids and niches that make the PA profession useful and attractive. PAs are a valuable part of the U.S. health care system because of their flexibility.

Postgraduate training can continue successfully without accreditation. There is no need to run the risk of negatively altering the profession. The goals sought by proponents of accreditation can be achieved in other ways. For example, the Association of Postgraduate PA Programs could mandate adherence to certain educational criteria as a condition of membership in that organization. The member programs could use this in their marketing and recruitment efforts. This could lead to increased consistency among member programs. The overall impact on the PA profession would be beneficial. Entry-level PA programs could have more confidence in the training sites and establish closer ties.

Another option might be for the AAPA or another organization to provide substantially more information about postgraduate clinical training to those who were interested in attending a program. Materials could be developed and posted on the Web or distributed in other ways. This information could describe the quality of instructional resources and experiences available at the programs, the quality of the supervisory experiences, the programs’ adherence to the Fair Labor Standards Act, how frequently they assess and revise their content based on outcomes, first-hand reports from previous participants, and other useful information.

A third possibility would be for an independent group to operate a postgraduate program “recognition” system. This would not be accreditation, but programs would be evaluated and rated according to published criteria. The ratings would be made public.

There may be many other creative approaches to assuring the quality of postgraduate clinical training programs. It is imperative that options other than accreditation be explored before a formal accreditation process, and all its potentially negative side effects, becomes a reality. The AAPA believes that postgraduate clinical training should be available to those who want it. However, the AAPA strongly opposes accreditation of these postgraduate training programs because of the potential adverse impact on physician assistant employment, licensure, length and cost of training, career mobility, reimbursement, and professional flexibility.  

© 2007 Haymarket Media, Inc. and the American Academy of Physician Assistants. All rights reserved.
Use of jaapa.com subject to License agreement. Please read our Disclaimer and Privacy policy.