NPs and PAs may be colleagues, but when it comes to licensure, certification, and regulation, the professions could not be more different. Nonetheless, practice in specialty areas—and recognition of advanced training and knowledge in those fields—has been an agenda item for both professions, particularly in recent years.
Rather than attempt to combine apples and oranges, Clinician Reviews decided to tackle this topic separately for each group. The PA discussion begins immediately below; if you wish to skip to the NP section, scroll down.
PAs: Specialty Certification?
In the PA world, specialty certification has been on the table for discussion for several decades. Yes, decades. When Janet Lathrop, MBA, President and CEO of the National Commission on Certification of Physician Assistants (NCCPA), speaks to her board of directors or makes a presentation to another organization about specialty certification, one of her slides contains the verbiage of a motion related to the topic. “Everyone thinks they’re minutes from a very recent meeting,” she says, “and they’re from 1978.”
That said, the subject has become a particularly hot one in the past few years. In May 2006, NCCPA “passed a motion to develop specialty recognition, including examinations,” Lathrop says. A subsequent motion, passed by the NCCPA board in August of this year, laid out an 18-month time frame to explore how specialty recognition might be handled.
“It could be that in the 18 months that the workgroup talks about a model, they’ll come back and say, ‘There is no model; we don’t want to do this,’” Lathrop says. “Or they potentially could come back and say, ‘We need to do specialty certification.’ All options remain open for discussion.”
Last month, during its final board meeting of the year, NCCPA updated its points of consensus regarding specialty recognition, which state that the board “will develop and administer specialty recognition according to the following principles:
“a. Specialty recognition will be voluntary and will be independent of NCCPA’s certification and recertification process.
“b. Specialty recognition will support and reinforce relationships between PAs and physicians.
“c. NCCPA will seek input and cooperation from appropriate stakeholders.
“d. Specialty recognition will support the credentialing process and not create barriers to licensure and practice.”
Point “c” is particularly salient, because there are divergent views within the profession as to what form specialty recognition should take.
Much has been made, in various channels, of the fact that NCCPA and the American Academy of Physician Assistants (AAPA) have opposing viewpoints when it comes to specialty certification. This is not entirely surprising, given the different missions that the organizations have. But Greg Thomas, PA, MPH, AAPA’s Senior Vice President for Education, Membership, and Resource Development, would like to dispel some myths.
“AAPA does in fact have policy in opposition to specialty certification, per se, that is based on examination,” he says. “But I think it’s very important to add that we are not only currently participating in, but encourage, the ongoing dialogue about this issue.”
Furthermore, Thomas points out that AAPA policy is not like a Supreme Court decision. “Policy is, by definition, a dynamic thing and can certainly, as times change and as circumstances change, be revisited and potentially changed,” he says. “I’m not saying that’s in the process of happening as we’re speaking. But I think that’s a misconception as well—that because something exists in policy, it cannot be changed.”
AAPA supports the concept of recognition of knowledge and skills in a specialty. “The terminology of certification is where there have been some differences of opinion,” Thomas says. “Our opposition is around certification, which could limit the potential mobility from one specialty to another. That may be a theoretical limitation, but that has been the basis of the opposition.”
Despite the differing perspectives, NCCPA and AAPA are keeping the lines of communication open. Thomas serves as an AAPA representative to the NCCPA, “so we’re not operating in a vacuum on this,” as Lathrop says.
“That doesn’t mean AAPA is supporting it—it means they’re being an appropriate, responsive business organization and saying, ‘OK, let us be in on this, let us hear what you have to say and let us have a voice at the table,’” she adds. “By participating, they’re not doing anything other than participating—finding out information, staying abreast. They don’t have to agree.
“But maybe,” she says, with a note of hope in her voice, “maybe we’ll come up with a model that serves the needs of everyone—most importantly, patients.”
Needs and Concerns
The logistics of what level of recognition is appropriate and acceptable for PAs practicing in specialties is the biggest piece of the puzzle. “In terms of what the specific mechanisms may be, I think it’s premature [to say],” Thomas explains. “That’s exactly the conversation that’s ongoing—not only within AAPA, but within PA specialty organizations, within the NCCPA, and frankly, even within some physician specialty organizations.”
Physician specialty and subspecialty groups have had a role to play in the latest go-round on this topic. PAs practicing in some specialty areas have approached NCCPA about specialty recognition, indicating that the physician organizations governing their specialty have requested some means of confirming that PAs have an appropriate level of training to perform relevant tasks or procedures.
“You can’t just walk out of PA school and put a Swan-Ganz catheter in somebody,” says Clinician Reviews PA Editor-in-Chief Randy D. Danielsen, PhD, PA-C, who is Immediate Past Chair of the NCCPA and current Chair of NCCPA’s Specialty Task Force. “You have to have some additional training, and then the question becomes, ‘How do we assure the public that the PA has the training?’”
The primary concern is that PAs might end up required to certify in order to practice in a specialty. Or, as Danielsen puts it, “The biggest fear is that PAs will not be able to cross between specialties without jumping through some hoops.”
That has been part of AAPA’s concern, since the PA profession was founded on a generalist medicine model. But members of NCCPA understand the potential limitations as well. “That’s the concern of the profession,” Lathrop acknowledges. “If we build it, will they come? Even if you develop this recognition through NCCPA and even if you don’t require it, if it’s voluntary, it could end up required by the states.”
Anything Is Possible, Nothing Is Definite
So what’s the solution? “If you could figure something out, let me know,” Lathrop says. She is reluctant to comment on what NCCPA’s model (if they develop one) might consist of, “because we don’t know.”
Danielsen is more willing to muse aloud, with the clear understanding that he’s tossing ideas out there and not representing NCCPA, or making suggestions, when he does so. If PAs “hang our hat on the star called ‘physician,’” as he puts it, “maybe we should have the initial certification exam be our licensing exam and then anything else we do be a voluntary board certification, where somebody chooses either formally or informally to go through an educational process and then take a specialty exam.”
Moving outside the realm of examinations, some PA specialty organizations that see the greatest need for this type of recognition have already taken matters into their own hands. “A few have established an advanced membership category for PAs within those specialties who meet certain criteria, such as number of years of practice in that specialty or advanced education or CME that is specifically related,” Thomas points out.
A good example is the distance-learning program that the Society of Dermatology PAs launched this summer through the University of Texas Southwestern. Experienced derm PAs are eligible to participate in Web-based educational modules, with diplomate membership status awarded to those who participate. Whether such programs will suffice to assure physicians—and patients—that PAs have adequate knowledge remains to be seen.
Working with specialty groups is an avenue that AAPA is exploring. “One of the things that AAPA is certainly looking at very seriously is trying to partner with other organizations, notably physician specialty organizations,” Thomas says, “to provide what we’re referring to as ‘intensive educational opportunities’ in a whole host of specialty and subspecialty areas.” He notes that some physician specialty groups already offer or are discussing the possibility of offering affiliate or associate membership to PAs who meet certain criteria.
How the matter of specialty recognition will play out is still anyone’s guess. Truly. “There are people who say we know what we’re going to do, that we’ve known it all along, and this is just smoke and mirrors,” Lathrop says. “But it’s really not. I can honestly say, with all sincerity, I have no idea. I just know that we’re going to work through this for the next 18 months, and hopefully come up with something.”
NPs: Nonregulated Specialties
It may have taken five years and the collaborative efforts of more than 50 organizations, but the nursing community has developed a Consensus Model for APRN Regulation: Licensure, Accreditation, Certification, and Education (available at the National Council of State Boards of Nursing [NCSBN] Web site, www.ncsbn.org). The model, as its subtitle indicates, outlines the role of an APRN (which includes certified registered nurse anesthetists, certified nurse-midwives, clinical nurse specialists, and certified nurse practitioners), as well as the six population foci in which an APRN may choose to be educated.
The NCSBN endorsed the model this summer, providing credibility at the national level, and now, much like the Nurse Licensure Compact, the model will be taken to the states for approval. If a state signs on to the consensus model and subsequently amends any relevant laws or regulations to conform with its principles, NPs and other APRNs would have a level of reciprocity, enabling them to relocate to any other states that have signed on without having to jump through regulatory hoops.
What is relevant to this particular article is that the consensus model expressly states, “Competence at the specialty level will not be assessed or regulated by boards of nursing but rather by the professional organizations.” In other words, as explained by Nancy Chornick, PhD, RN, CAE, Director of Practice for NCSBN, specialty recognition will be “out of the purview of legal recognition.”
Chornick goes on to say, “It’s important for NPs to understand that this is not a value issue. Certification is very valuable. It’s just that we’ve taken it out of the purview of licensure. In this way, we will assure that APRNs have a broad scope of practice, and then they’re free to specialize in whatever areas they want.”
While the nursing community has reached a consensus, that doesn’t mean there weren’t questions and concerns along the way. What may be interesting to some is that it was the regulatory bodies—the state boards of nursing—that were most concerned about the potential limitations of specialty certification.
As APRNs—particularly clinical nurse specialists and NPs—started to specialize more, they would go to the boards of nursing and indicate their desire to be licensed in their specialty. “From my point of view, this put those nurses at a disadvantage, because those nurses then must practice within that scope,” Chornick says. “For instance, if they’re specialized—just to carry it to an extreme—in conditions of the right thyroid lobe, then they have a lot of constraints.”
The pitfalls are twofold. Based on her experiences, Mary Smolenski, EdD, FNP, FAANP, CAE, Director of Certification for the American Nurses Credentialing Center (ANCC), says, “NPs aren’t opposed to recognizing the certification in a particular area. But when it gets down to the fact that, gee, now you can’t work in derm unless you go off and get another certification, that’s where the problem arises.”
A narrow scope of practice could mean a decreased number of job opportunities, if an opening in the particular specialty is not readily available. But an even greater concern on the part of the NCSBN is that “individuals who have a very narrow scope of practice then don’t have the education or evaluation for a broader area,” Chornick says. “So it’s really a patient safety issue. You need to be educated and evaluated and work within a certain scope.”
That said, NPs’ primary education, licensure, and certification provide a platform that can be expanded at the practitioner’s choice. “Anything you can add to your basic licensure that ... shows you met a certain standard in a particular area adds to your recognition in that specialty,” Smolenski says. “You don’t want to be mandated to have that level of certification. But the fact that you have it, and you can say, ‘I do have this specialty knowledge,’ to me is a plus, not a minus.”
Looking Beyond Examination
While stating that “preparation in a specialty area of practice is optional,” the consensus model does “strongly recommend” certification in a specialty, if one is chosen. The model also provides a certain amount of leeway in how this additional knowledge and training are acquired and assessed:
“Competency in the specialty areas could be acquired either by educational preparation or experience and assessed in a variety of ways through professional credentialing mechanisms (eg, portfolios, examinations, etc).”
Since professional organizations would monitor specialty practice under the model, Chornick explains, “the profession would establish standards and decide what type of marker, so to speak, or designation would be appropriate for that person.”
Obviously, as a representative of ANCC, Smolenski appreciates the value of examination. But there are practical limitations to how many exams can be offered.
“Theoretically, you can develop an exam for anything,” she observes. “But from a business standpoint and a psychometric standpoint, you can’t—because if you’re trying to develop an exam that means anything, that the public can have faith in, you have to have certain numbers of people [to take it].”
Chornick also cites the expense of certification as a rationale for looking at other methods. “Licensure requires examination, so by allowing the specialties to have the profession in charge, they don’t need the examination,” she says. “A lot of specialties were unable to afford the development of a certification exam, so this will allow for alternative methods.”
For example, ANCC has started looking at portfolios for specialty recognition. Smolenski is already working with some nursing specialty groups to create online portfolios. The advantage is the breadth of information that can be made available to review boards or employers: Individuals might include case studies, articles, and presentations they have authored; a list of committees they’ve participated in; a complete history of work experience; and even a list of procedures they’ve learned, as well as how many times they’ve performed them and who supervised them.
“Portfolios give you a different picture of somebody,” Smolenski notes. “You can see the experiences that people have had and what else they bring to the table that is more broad-based than just passing an exam.”
Methods of specialty recognition beyond examination may also level the playing field for those who freeze up at the very idea of being tested. “A lot of people cannot take tests,” Smolenski points out. “They just don’t do well. And then other people are really good test-takers.
“Exams validate that you’ve met a certain standard—but the issue is, just because you passed the test, does that mean you’re competent?” she adds. “You can’t really equate the two. There’s a lot more to competency than a test.”