“Mountains Beyond Mountains”
Stephen C. Crane, PhD, MPH 
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.
JAAPAThe author is the former 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.
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.
Education, not certification
David Carpenter, PA-C, MPAS 
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.
JAAPAThe author is a 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).