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PHYSICIAN ASSISTANT CERTIFICATION

There are currently 70,000 physician assistants practicing in every areas of medicine, the majority of them practicing specialties and subspecialties. Many specialty organizations are asking PAs to show competency in their field of practice and many PA organizations agree that changes are needed in the current certification process. If certification for specialty practice becomes mandatory, PAs may lose their unique ability to move among various practice specialties. You are listening to ReachMD XM 157, the channel for medical professionals. Welcome to the clinician’s roundtable. I am Lisa D'Andrea your host and with me today is Jim Cawley, Professor of Healthcare Science, and the Director of the PA/MPH Program in the School of Medicine and Health Science at the George Washington University. Jim has published extensively on aspects of the healthcare work force and is currently completing work on Physician Assistant’s Practice and Policy to be published in 2009. Today, we are discussing physician assistant’s specialty recognition and specialty certification.

LISA D’ANDREA:

Hi, Jim, welcome to the show.

JIM CAWLEY:

Thank you Lisa.

LISA D’ANDREA:

Jim, a broad-based general medicine education has been core of the PA profession for 40 years. In 1975, The National Commission on Certification Of Physician Assistance and NCCPA was established to assure the public that certified physician assistance, which is the PA-C had met the established standard to practice medicine. Now, the NCCPA is considering methods of specialty recognition, which could include specialty certification exams. What happened? (01:30)

JIM CAWLEY:

We live in a specialized world and medicine has become increasingly specialized in the last several decades to the degree that 70% or more physicians are in specialties and subspecialties and PAs are not far behind at about 65% or 66% and increasingly the specialties draw PAs, which has setup a circumstance where we have significant subsets of PAs who indeed want to have systems that recognize their expertise, and we see these trends in medical profession as well as in the PA profession and it is top to turn back.

LISA D’ANDREA:

If I am a PA, I am scarred right now. So, let's make sure people understand that there is an enormous difference between certification and recognition. Could you explain the difference?

JIM CAWLEY:

Certification would imply that a PA who lets say for example worked in a specialty such as emergency medicine would at some point after they have graduated as a PA and worked in the field of the emergency medicine for several years, would at some point need to take another examination that would certify or somehow verify their knowledge in the field of emergency medicine and then the next step would be that that particular passage of that exam would somehow be a credential or be required for that PA to work in the field of emergency medicine. (03:00) The scenario that many fear would occur if systems of specialty certification would emerge in essence what we will be talking about would be creating barriers or limitations to the entry of physician assistance into certain specialty area. Recognition to note a slightly lesser set of qualifications or slightly less level of attainment in terms of entering a given specialty that it would be a process that would be short of a formal examination in a given specialty area. For example, to become recognized as an emergency medicine physician assistant what might be required would be proof that an individual work in the field for 5 to 7 years and that there would be other processes like attainment of continuing education in the emergency medicine, physician attestation of competency in emergency medicine, and similar times of continued professional development achievements that would result in an individual being recognized as proficient in emergency medicine.

LISA D’ANDREA:

Many PA <_____> are also in hospital settings and PAs are being scrutinized the same as MDs. They are also requesting privileges in hospitals just like MDs and the credentialing bodies use the same standards and they want documented evidence of training the expertise (04:30) in the field. What is wrong with raising the bar?

JIM CAWLEY:

You made very good point, and indeed, credentialing agencies and hospital departments are indeed increasingly demanding proof of expertise and competency in specialty areas and this is a phenomenon that we see across the board. The dilemma for the PA profession is to on one hand to meet those requirements and to indeed show that we do have competencies in a variety of specialty areas, but at the same time try to preserve this wonderful feature of our profession that is called “clinical flexibility” which allows the PA to be able to work in one area for a number of years for example and then move to another area of medicine. This is a highly unique and very desirable feature of our profession and majority actually of the individuals that we interview for entry into our physician system of educational program indicate that this feature that leaves them or tracts them to the PA profession. So, this is something that we do not want to lose, but at the same time, we do recognize these increasingly credential and qualification pressures that you describe.

LISA D’ANDREA:

If you are just joining us, you are listening to the clinician’s roundtable on ReachMD XM 157, the channel for medical professionals. I am Lisa D'Andrea and I am speaking with Jim Cawley, a Professor of Healthcare Science and the Director of The PA/MPH Program in the School of Medicine and Health Science at the George Washington University. (06:00) We are discussing physician assistant’s specialty recognition and specialty certification.

Jim, several PA specialty groups such as cardiovascular PAs have a very different position. They have been under considerable pressure by the State Regulatory Agencies and hospitals to prove their competency in the field. Emergency medicine, dermatologic PAs are also looking for help to continue to progress in their field. This is a problem that is different from what was encountered in primary care, but these PAs are also pioneers and they are just wearing a different hat and they are asking for help. What advice do you have for them?

JIM CAWLEY:

Well, I think that these groups and these PAs are taking the position that they would be expected to take. They are highly skilled professionals. They have developed a lot of proficiency in a given area and it is not unusual or unreasonable for them to want to have their own examination, their own setup recognition processes that would confer on them the expertise that they have earned. This is the way that physicians also have achieved expertise in their various specialty areas as well. See, you cannot blame the groups and what we have to try to do is to find a balance between allowing this sort of phenomena of specialization and specialty recognition/certification to occur, but at the same time not partition the profession excessively and to not develop barriers to entry into different specialties that would damage this feature (07:30) of clinical flexibility. It is a dilemma for the profession and I think that I see a willingness on both sides to at least discuss what ways we might develop that can permit both to occur.

LISA D’ANDREA:

What is the role of the medical market place in all this?

JIM CAWLEY:

Well the medical market place clearly is driving not only specialization and subspecialization, but the circumstances that you describe increasing recognition, increased qualifications, increased demonstration of competency before an individual can enter a given practice areas. This is also the role of medical boards and medical regulatory agencies to ensure the safety of the public by assessing and verifying that an individual is safe to practice in a given specialty or a subspecialty area.

LISA D’ANDREA:

May be, its time to start talking about some more postgraduate programs.

JIM CAWLEY:

They have become increasingly popular as I am sure you are aware there are about 45 of them at the moment and they are very popular among graduating physician assistance and I think increasingly we will see more residency programs develop.

LISA D’ANDREA:

So, PAs used to graduate and go to work the next day and that was in a time when they worked in primarily in primary care. Do you think that PAs are qualified to graduate today and scrub into a hard case tomorrow.

JIM CAWLEY:

Well, increasingly that is one area and there are probably several others where the consensus is that a physician assistant (09:00) will require some additional formal training. Hence, the popularity of residency programs, and I think medical boards in areas for example, such as cardiothoracic surgery are starting to increase their requirements for experience and formal training such that there are persons that do not enter a specialty unless they have these kinds of advanced training.

LISA D’ANDREA:

Could this possibly help PAs by better preparing them for their specialty, increasing their knowledge, and then their flexibility?

JIM CAWLEY:

I think without question and I think that that level of skill is appreciated by the physicians and the hospitals that employ PAs with those skills.

LISA D’ANDREA:

So, who is pushing the change? Is it PAs, the public, the hospitals, the physicians, everyone?

JIM CAWLEY:

Well, it is the mixture of all of the above. They are certainly desire on the part of PAs, themselves, and specialties to advance their own profile and level of recognition. We spoke of the pressures that are coming forth from medical board, hospitals, and credentialing agencies and then there is also I think pressure on the other side primarily coming from the AAPA that wants to maintain this element of clinical flexibility.

LISA D’ANDREA:

What about the PA curriculum? Do you think that we need to take another look at this and change it to reflect the specialties?

JIM CAWLEY:

Well, there is a lot of latitude that currently exist in the PA accreditation requirements and I believe that there are different philosophies that different educational programs have that (10:30) we might see a trend of increasing levels of specialization in PA programs, particularly some of those that might be set in medical schools where their graduates might have a more likelihood of entering into hospital medicine or critical care medicine or taking resident substitute kinds of positions, but I think that there is a great deal of latitude that exist and those essentials and there are number of programs who are on the opposite end of that spectrum who maintain a great deal of emphasis in primary care.

LISA D’ANDREA:

So, it sounds like specialty recognition appears to be the middle ground. Do you think that that will be acceptable to the medical world?

JIM CAWLEY:

I do. I think that that can be presented to medical groups and boards that does indicate PA proficiency in those areas that sort of stop short formal examination in those specialty areas.

LISA D’ANDREA:

Tell me some of the pros of specialty certification.

JIM CAWLEY:

It meets the demands of regulatory agencies, hospital credentialing agencies, medical specialty board. It provides convincing case to physician employers that a PA is, indeed, proficient in a given specialty and it confers sort of a good health keeping seal of approval on that PA in terms of that expertise in that specialty.

LISA D’ANDREA:

If specialty certification or recognition comes about, what would be the consequences for the PA profession?

JIM CAWLEY:

Impairment of the clinical flexibility, (12:00) option, limitation of PA entry into given specialties and that individuals would be locked in so to speak the specialty areas and the element of flexibility lost.

LISA D’ANDREA:

And if people want to get more information, where do you think just they go?

JIM CAWLEY:

Well, I think that the NCCPA web site has some very good balanced material on this particular issue. The PA has also put out specialty position papers. I think that both organizations are very involved in dealing with this issue. I would refer the listener to the web sites of both the AAPA as well as the NCCPA.

LISA D’ANDREA:

Thank you Jim for coming on a show.

JIM CAWLEY:

Thank you Lisa.

I am Lisa D'Andrea and you have been listening to the clinician’s roundtable on ReachMD XM 157, the channel for medical professionals. Please visit our web site at www.reachmd.com which features our entire library through on-demand podcast or call us toll free with your comments and suggestions at 888-MDXM-157 and thanks for listening.