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Perspectives on the physician assistant specialty credentialing debate
 “Mountains Beyond Mountains”
Stephen C. Crane, PhD, MPH
The author is the executive vice president and CEO of the AAPA. In this editorial, Dr. Crane is speaking from his perspective as a health services researcher and a long-time health
policy analyst.
Some of you may know the book Mountains Beyond Mountains: The Quest of Dr. Paul Farmer, A Man Who Would Cure the World, by Tracy Kidder.1 This book recounts the story of how one physician worked on the problem of AIDS, first in Central America, then in the world. One commentator quoted on the book jacket says that Dr. Farmer accomplished all that he did “through a clear-eyed understanding of the interaction of politics, wealth, social systems, and disease.” Mountains Beyond Mountains is a great read for anyone involved in health care, particularly those of us who value prevention as well as curing.
The title of the book has a special application to the PA profession: Once one set of mountains is crossed or one set of challenges is overcome, there usually is another set of mountains or challenges to be met. This is the situation we—the profession and the Academy—are in now. While many mountains have been crossed since the PA profession emerged in the 1960s, many more mountains lie ahead. AAPA must maintain its own “clear-eyed understanding of the interaction of politics, wealth, social systems, and disease” if it is to continue to be successful on behalf of the PA profession and the patients it serves.
A vision for the PA profession
While clear-eyed understanding is necessary, it alone is not sufficient to get the profession where it wants to go. What motivates people like Paul Farmer, and indeed an entire profession like physician assistants, is a vision of the way things could and should be. Vision sets the direction that gets us over the right mountains. Without vision, as the cat would say in Alice in Wonderland, it doesn’t really matter which mountain you choose to climb. The vision for the PA profession is that “physician assistants will be worldwide leaders vital to providing and improving the medical care of all people.” The key part of this statement is the phrase “medical care of all people.” PAs are about providing care to people. This is the central mission and goal, and the profession must never forget this. PAs must always judge their actions and policies based on whether these actions and policies can potentially improve the delivery of health care services and advance health for individuals and communities.
The PA profession is so successful because of its founding principle, which is that an experienced individual educated in primary care medicine can work in a team relationship with a physician or surgeon to provide high-quality medical care to patients. This principle is at the core of the profession’s vision.
An invaluable model
This generalist model makes PAs the most flexible and adaptable of all medical professionals in terms of what they can do and where they can work. The generalist model contributes directly to the fact that 90% of PAs each year say they either definitely or probably would become a PA again if given the chance. Lifelong learning and periodic assessments of core knowledge ensure a strong, vibrant, dynamic profession that remains on the cutting edge of developments in medical science and technology. Physician delegation of scope of practice to PAs based on direct assessments of competence and capability ensure that PAs will deliver safe, high-quality care. As a result of the generalist model, PAs work in virtually every medical and surgical specialty, but they do not become “specialty PAs” in the sense that physicians become specialty physicians and practice in only one area of medicine or surgery. This difference allows PAs, immediately and virtually without additional cost to society, to address the rapidly changing needs of the health care system. This is and remains a sound model for the delivery of medical care, for patients and physicians alike. PAs should recognize the power of this model. They should not only be proud of it but also tout it as a model that is right and not wrong. Other medical professionals can learn as much from the PA model as PAs have learned from them.
Some people from outside the profession, and even from outside of medical care, now want to capitalize on what the profession and its supporters have created.2 They want to profit personally from the success of this model by controlling it and eventually changing it. The profession cannot allow that to happen because what is at risk is the ability of PAs to provide high-quality medical care to all people at a reasonable cost. The profession needs to control its own destiny.
At the same time, changes within health care also are prompting consideration of profound modifications in the structure of the PA profession. Increasingly, employers and others want some documentation of the skills and knowledge that individual PAs possess beyond their generalist knowledge to ensure the safe performance of specific acts, tasks, and functions. Others want to limit a PA’s ability to enter into a specialty area of medical or surgical practice until minimum requirements for education and experience are met. Proponents of the latter view would, in effect, recreate the restricted silos of medical and surgical practice that physicians are stuck in today and that contribute directly to higher medical care costs, reduced professional mobility for physicians, and generally decreased access to health care. As the nation faces an increasing shortage of critical physician services in all specialties, this is not the time to decrease the ability of any health professional to provide needed services.
Charting our own course
Those who advocate more restricted entry into practice suggest that the changes just mentioned are necessary to ensure the protection of the public. But where is the empirical evidence that the generalist model doesn’t work? If it is a flawed model, why has it had such success over the past 35 years? Why does the Bureau of Labor Statistics rank the PA profession, again, as one of the fastest-growing professions?3 Why does Money magazine rank the PA profession as the fifth best profession in the entire country?4 Why do so many people want to become PAs? Why is the demand for the profession so great? Why is satisfaction with the profession so high? Before the PA profession succumbs to simplistic arguments that the world is changing and thus the profession needs to fundamentally change its model, why don’t we ask tough questions about the limitations of the models that others would impose on us? Why don’t we suggest that some of the strengths of our model should be considered, and adopted, by others? Yes, it is absolutely important that patients, physicians, and employers know that a PA can practice safely and competently, and the profession can and should develop mechanisms to accomplish this. Yes, it is appropriate and fair to recognize the special and unique knowledge, skills, and abilities that individual PAs acquire over a lifetime of practice and learning, and again, the profession can find constructive ways to provide such recognition. But we must accomplish these goals without destroying the very PA model that has been so successful.
The vision for the PA profession is a good one. The mountains that lie ahead of the profession can and should be climbed with the ultimate goal of improving both the delivery of health care and the health of the public. The profession and the Academy must have the courage of their convictions in order to chart a course over the next set of mountains that is their own and not that of others.
REFERENCES
1. Kidder T. Mountains Beyond Mountains: The Quest of Dr. Paul Farmer, A Man Who Would Cure the World. New York, NY: Random House; 2003.
2. AAPA Board of Directors. Competing certification program proposed [letter]. Available at: http://www.aapa.org/members/competing-cert.html. Accessed June 27, 2006.
3. American Academy of Physician Assistants. Bureau of Labor Statistics issues projections. Available at: http://www.aapa.org/bls.html. Accessed July 21, 2006.
4. Kalwarski T, Mosher D, Paskin J, Rosato D. The best jobs in America: MONEY Magazine and Salary.com rate careers on salary and job prospects. Available at: http://money.cnn.com/magazines/moneymag/bestjobs/. Accessed July 21, 2006.
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