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Perspectives on the physician assistant specialty credentialing debate
 Education, not certification
David Carpenter, PA-C, MPAS
The author is immediate past president of the Colorado Academy of Physician Assistants and immediate past president of GIPA, the specialty organization for physician assistants in gastroenterology (www.gipas.org)
Bill Kohlhepp, chair of the National Commission on Certification of Physician Assistants (NCCPA), announced at the AAPA House of Delegates in San Francisco in May that NCCPA will begin looking at the needs of PAs practicing in specialties. With this announcement, the PA profession moved into uncharted territory. As we begin to explore this territory, we must not forget that the current challenges faced by PAs working in specialties must be addressed in a way that protects the profession as a whole.
The physician community has long had a history of specialization. In the 19th century, specializing involved doing an informal apprenticeship in an area of interest. In the early 20th century, the process was formalized, but a minority of physicians participated in it. In the 1960s, participation in formal programs became increasingly common, and now in the 21st century it is rare for a physician to enter practice without having completed a residency.
The PA profession followed the physician model, with an important exception. PAs receive a generalist medical education and for the most part undergo any additional training as part of an informal apprenticeship with their supervising physicians. While “residency” and surgical PA programs have existed, the vast majority of PAs have not participated in this type of training.
New demands
In the past 5 years, the PA profession has been increasingly pressured to adopt a system in which PAs working in specialties are “certified” to practice in that specialty. Proponents of “certification” for physician assistants cite a number of reasons for demanding it.
In the surgical arena, credentialing requirements have come from the hospital credentialing committees. As part of the credentialing process, these committees seek documentation of competence and training for PAs working in the OR. The demise of the NCCPA surgical certificate has made it increasingly difficult for PAs working in surgery to meet that demand.
Various hospital organizations have tried to tackle this problem. In Denver 3 years ago, the large hospital group HealthOne issued requirements for PAs to function as first assistants. Their guidelines were quickly copied throughout Colorado. The “HealthOne Physican Assistant Practice Prerogatives and Checklists” (May 2003) listed both nursing and surgical technology first-assist certifications as appropriate education for the PA in the operating room. These organizations are not good training grounds for PAs, however. Their approaches are inconsistent with PA training and do not adequately address PA scope of practice.
In addition, as part of the credentialing process, these hospitals require PAs working in nonsurgical specialties to document their training and experience. While credentialing has traditionally relied on office encounters to document proficiency in the specialty, this poses significant barriers to those PAs who care only for inpatients. Standards within a specialty would help satisfy these demands.
Finally, some physician specialty organizations, including those for physicians in emergency medicine and in cardiovascular surgery, have called for documentation of PA proficiency within the specialty. While the exact reasons for these requests remain unclear, their urgency has increased in the past few years. Both emergency medicine and cardiovascular surgery physician groups have begun to discuss whether they should develop their own certification tests for PAs.
It has become clear that development of specific documentation for PAs in surgical specialties will be critical to satisfy stakeholders. Additional documentation of proficiency in other areas will be needed to satisfy specialty organizations and hospital credentialing organizations.
Controlling our destiny
Any documentation of competence in a specialty must preserve two important PA ideals: commitment to the physician-PA practice model and mobility within the profession. The PANCE and PANRE set the standard of basic knowledge required of all PAs and should remain the touchstone of the profession. Beyond that, we should begin to consider other models for how competence in a specialty is attained and documented, and there are a number of models from which to choose. These include the residency-fellowship model, the outside certification model, and a relatively new concept, the certificate of additional qualification (CAQ).
The residency-fellowship model for physicians is well known. In it, the physician enters a residency or fellowship after graduating from medical school and undergoes didactic and clinical training in a specialty. This model is reinforced by limitations on residency and fellowship slots to control the number of specialists and is funded by Medicare in return for discounted resident services. While this model has advantages, for PAs it would force specialization, would delay entry into the workforce after graduation from PA school, and is probably unworkable without a Medicare subsidy.
The outside certification model is used in nursing to denote specialization within various nursing fields. This model has led to considerable and confusing fragmentation as multiple not-for-profit and for-profit agencies have stepped forward to administer these certifications. In this model, the provider works within an area for a number of years and then is tested on knowledge within that area. While this approach may work for other professions, any certification scheme that requires experience in the specialty prior to certification will discourage new PAs from entering the specialty.
A new standard that is evolving is the CAQ. In this model, providers who are interested in a specific area demonstrate through the use of learning modules and testing that they possess additional knowledge in the subject area. This approach would allow the PA not only to gain basic knowledge in a particular area of medicine but also to demonstrate this proficiency.
Any new standard must preserve mobility within the profession. Our current mobility allows PAs to follow their interests, and thus stay fresh and motivated, and to move to areas where they are needed the most, serving the needs of patients and the health care system. Any certification standard that forces a PA to spend time in a specialty fails the mobility test because it prevents the PA from entering the specialty in the first place. Similarly, a condition that requires a PA to complete a residency for certification imposes a high hurdle for the profession. The CAQ process allows seamless transition to a new specialty while answering the need of outside agencies for documentation.
A new framework
When we look at the demands increasingly being placed on PAs to demonstrate competence, it becomes clear that a new framework is needed to satisfy all stakeholders.
- The first part of this framework is use of the PANCE/
PANRE as the minimum qualification for a PA.
- The second part of this framework is surgical certification. Medicine has always been divided between the medical and surgical specialties, and now hospital credentialing committees have begun to demand additional documentation of surgical knowledge. The PA surgical community should decide whether it needs an additional formal certification or a certificate of surgical knowledge.
- The third part of this framework is the CAQ. Other medical specialties already use this term to denote additional qualifications or advanced knowledge. This certificate would show that the PA had demonstrated additional knowledge in the selected area. Ideally, it would be achieved via a distance-based, modular learning environment. For instance, a PA who wanted to switch from working in endocrinology to working in cardiology could log on, take a pretest, study a number of cardiology modules, and take a posttest. Passing would earn the PA a CAQ
in cardiology. This would satisfy the requirement of the specialty organizations while preserving PA mobility. It also would allow PAs in small specialties that cover multiple areas of medicine to take CAQs across those specialties. For example, a PA in reproductive endocrinology could take CAQs in both endocrinology and obstetrics and gynecology. This approach has the advantage of being uniquely responsive to the demands of the market and of the PA community.
Moving to a new paradigm
We stand at a crossroads. The danger is that an ill-considered change, whether voluntary or involuntary, could destroy the unique and uniquely valuable elements of the PA profession. As PAs, we are particularly qualified to direct the standards that govern our profession. We wish to retain the unique aspects while we ensure that PAs receive the training and documentation of competence that will make them valuable to medicine as part of the PA-physician team.
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