This past month, the National Commission on Certification of Physician Assistants (NCCPA) notified all its stakeholders of a new voluntary specialty certification program for PAs in emergency medicine, orthopedic surgery, cardiovascular surgery, nephrology, and psychiatry to be launched in 2011—with the expectation that other specialties will follow. Many PAs have applauded this event; others have been critical of its potential effect on the profession.
Since I am the chair of the NCCPA’s workgroup on specialty certification and have been intimately involved for the past 3+ years with this topic, this editorial is written from that experience. As with most editorials, it is biased. A further disclaimer: These are my thoughts and experiences and should not be construed to be the policy of the NCCPA. I speak only for myself and offer my apologies to my NP colleagues for focusing on a PA-specific topic this month.
The starting place for our discussion at the NCCPA centered on acknowledging significant changes in the past decade within our health care system, coinciding with the growing clinical diversity of PA practice. Both of these issues indicated to the NCCPA that—after three decades of debate and discussion about the complexities and potential risks and rewards of certifying PAs in specialties—now is the appropriate time to do it.
Why? Simply put, NCCPA understands patients’ need for access to affordable, high-quality health care and believes passionately that certified PAs are integral to meeting that need. NCCPA’s responsibility in that equation is ensuring that certified PAs have the knowledge and skills to deliver the care and the documentation of their training, experience, and expertise needed to achieve and maintain their rightful place on the health care delivery team.
Of course, other environmental factors brought the issue to the forefront. It is a well-known fact that there has been a significant increase in the number of PAs practicing in specialty areas rather than primary care. At the same time, employers and governmental agencies (eg, AHRQ, NIH, IOM) are placing heightened emphasis on patient safety and risk management. State regulatory boards are taking a closer look at supervising responsibilities of physicians and the education of their PA partners. It is also clear that the complexities and increased demands of current health care practice place constraints and increased burden on supervision and other time-consuming aspects of the physician-PA relationship.
Even more compelling than those generalities, PAs in different parts of the country, in various specialties and practice settings, are increasingly facing real and significant challenges. Have you talked to many PAs practicing in psychiatry lately? If so, chances are you’ve heard about some real challenges to reimbursement. Practicing in a surgical specialty? If you haven’t been challenged to provide documentation of surgical training or expertise yourself, you probably know someone who has.
Based on the direction of health care and the rest of the world around us, there’s no good reason to think those issues are going to go away on their own. In fact, it looks more like the beginning of a new trend. Witness, for example, the significant changes that have taken place in physician certification over the past few years, as the process for maintaining certification was intensified and broadened to include a much larger spectrum of competencies and activities. This kind of trend is not something we can just continue to duck if we want to stay relevant—especially in the face of health care reform.
With all of those issues in the background, the NCCPA created four foundational thoughts for the discussion on specialty certification. It was clear from the beginning to all parties discussing this concept that specialty recognition of any kind should be voluntary and independent of the existing generalist certification/recertification process. It was also critical that any certification program support and reinforce the relationship between PAs and their supervising physicians.
From the beginning of the discussion, NCCPA also felt it important to seek input and cooperation from all the appropriate stakeholders, particularly the AAPA and PA specialty professional organizations. (That’s why more than three years passed between NCCPA’s 2006 announcement that the organization would develop some form of specialty recognition and last month’s more detailed announcement about how the new process will work.) Lastly, and perhaps most importantly, specialty recognition must support the credentialing process while not creating barriers to licensure and practice.
By far the last issue was the most difficult to address. Opponents of specialty certification are concerned that any additional certification will create a barrier to mobility. There are also concerns that PAs who choose not to participate may find their résumés are sent to the bottom of the applicant pile. Sympathetic to these concerns, NCCPA committed to doing its part to maintain and promote the PA-C designation and state licensure as the sole “tickets” to practice by making both of those items prerequisites for the new specialty certification program.
Many stakeholder interests were considered in the discussion, with particular focus on the public and PAs. At the core of the discussion, it was clear that it is reasonable that the public—our patients—should expect that PAs working in specialty areas have been appropriately trained and evaluated in their chosen area of practice. The assumption here is that PAs, graduating from programs with a generalist curriculum, do not enter the workforce with the body of knowledge and experience needed in many of the non–primary care specialties. This is especially true in the specialties that are procedure-intensive or deal with the most critically ill or injured patients. At the same time, patients benefit from the presence of PAs in specialty practice, and in the interest of protecting or improving access to and affordability of care, NCCPA needs to be certain that PAs are equipped with the credentials they need to be there for those patients.
From the perspective of the average PA, the principal concern during discussions about specialty certification is the very strong desire to maintain the potential for interspecialty mobility. The most recent AAPA survey shows that 65% of PAs work in specialties or subspecialties.1 Those PAs deserve and should have a mechanism for documentation of their education and abilities in their areas of practice, and everyone benefits when that documentation comes from a credible source through an appropriately rigorous process.
At the same time, PAs must remain cost-effective team members with the ability to move between specialties. Current data indicate that recently certified PAs are choosing specialty areas at a higher rate than those of us from earlier cohorts, and most PAs will work in two or more specialties during their career.2 In a longitudinal cohort analysis from the AAPA, 57% of respondents reported changing specialties at least once, and 49% changed specialties within their first two years of practice.3
For those unfamiliar with the new specialty certification model, here is a recap.
To qualify for specialty certification, under this new voluntary system, PAs will be required to hold the PA-C designation, the generalist certification already awarded by the NCCPA. In addition, applicants will be required to have either an unencumbered state PA license or comparable authorization to practice from a federal agency.
Once PAs meet these prerequisites, the specialty certification pro-cess will include four requirements: specialty continuing medical education (CME), procedures and patient case logging, experience in the specialty, and a proctored specialty exam. In an effort to prevent the specialty certification program from becoming a barrier to entry to specialty practice, those four requirements may be completed in any order. After completing one component, PAs will be officially designated as candidates for specialty certification and may identify themselves that way to current or potential employers, credentialing boards, and others while in the process of completing the remaining requirements.
Then, just like the PA-C certification process, specialty certification will be time limited. PAs will complete maintenance of certification process and periodically take and pass the specialty exam again to maintain their voluntary specialty certification. At this writing, the details of the maintenance process are still being developed.
There are many other details to work through, and NCCPA is inviting appropriate physician and PA organizations to appoint members to specialty advisory committees that will help shape those details in a way that makes the most sense for each specialty included in the new certification program. These committees will consider, for their respective specialty, whether there are any specific CME topics or activities that should be required as part of the 25-hour CME requirement. The committees will discuss whether there should be exemptions to the experience requirement for specific educational experiences. They’ll also consider what procedures or types of cases should be logged, how many should be required, and whether there should be more than one menu of required procedures for subsets within a specialty to reflect the variability of PA practice, even within specific specialty areas.
Since NCCPA announced the new specialty certification model last month, the most frequently asked question has been, “Have you considered (my specialty)?” One of the most difficult decisions the workgroup faced was deciding which specialties should be included in the program’s initial launch. That decision would have been easy if NCCPA were—as some have suggested—introducing specialty certification to fill up its coffers. If this were about money, the NCCPA would have simply chosen the largest specialties and been done with it.
However, since this process was never about increasing revenues, the equation was much more complex. NCCPA considered many factors. Yes, population size was one of them. But we also considered what we’d been hearing from PAs in the various specialties about their need for some kind of specialty credential or documentation of qualifications; the support of the PA and physician specialty organizations; PA mobility trends; and the criticality of patients served, just to name a few. This was certainly not an easy task, but we knew we had to start somewhere, and the “somewhere” we ultimately chose includes a mix of large and small surgical and medical specialties and subspecialties.
The significance of introducing specialty certification for PAs is not lost on anyone involved with the NCCPA decision. The workgroup and the board of directors felt a great weight of responsibility to the organization, to PAs, and to the patients about whom we all care most deeply. This will change things. Some believe specialty certification will be the undoing of the PA profession. Others are grateful that someone has finally recognized that specialists within the profession need more recognition and documentation of qualifications in their area of practice. Time will be the judge, but from where I sit, the future of the PA profession has never looked brighter.
Some of my colleagues advised me against writing this editorial. They said it was akin to stepping on a beehive. I disagree. I have more faith and respect for my PA colleagues than that. As always, I appreciate professional and thoughtful dialogue. You can reach me at PAEditor@qhc.com.