Things have been quiet lately on the front lines of the PA specialty certification issue. This may be a lull, however, since the issue continues to vex the PA profession and present challenges to its organizations.

The issue of specialty certification/recognition is complex and presents a dilemma for the PA profession. Over the past several decades, the forces of medical specialization have had a profound influence on the medical profession, which in turn has affected PA utilization and practice.

PAs, Primary Care and Specialty Practice

Among the 70,000 or so PAs in clinical practice in 2008, more than 65% are in specialties.¹ The American Academy of Physician Assistants estimates that PAs practice in more than 60 different specialty fields, and the percentage of PAs in primary care continues to fall. In 2007, about 34% of practicing PAs reported that their specialty was in the primary care fields of family/general medicine (24.9%), general internal medicine (6.9%) or general pediatrics (2.4%).¹ The percentage of PAs working in these primary care fields was 50% in 1997² and 43.1% in 2002.³

Conversely, the number and proportions of PAs in specialties has grown rapidly. Popular and growing specialties for PAs include the surgical subspecialties, now at 22.2% in 2008,¹ up from 15.7% in 1997.² More than 10% today work in orthopedics alone. Other growing specialties include emergency medicine at 10%, the subspecialties of internal medicine at 11% and dermatology at 4%.1

There is no sign on the horizon that the percentages of PAs in specialties will go down. In fact, given the assortment of jobs commonly seen in PA employment listings, it is likely that these percentages will go higher.

The trend of PA specialization has created pressures for clinicians practicing in these areas to seek recognition of their proficiency, quite a natural phenomenon. PAs in the fields of cardiovascular surgery, dermatology, gastroenterology, nephrology and emergency medicine are among those who have expressed a desire for a certifying examination and/or some form of recognition of their clinical expertise.

PA organizations in these specialties have held discussions with the National Commission on Certification of Physician Assistants (NCCPA) regarding specialty recognition, and some reportedly are in the process of developing their own specialty certifying examinations. This, some fear, eventually will lead to restrictions on the entry of PAs into certain specialties, which could compromise the highly valued component of the profession-clinical flexibility.

PA Career Mobility

While some PAs may not change specialties over the course of their careers, a sizable proportion will. The AAPA estimates that about 20% of PAs change their specialty annually.⁴ Many PAs highly prize their profession for the opportunities it provides related to lifestyle factors and the ability to practice in different medical disciplines over the course of a career. Applicants to PA programs also appreciate this flexibility and often select the profession over others for this specific reason.

The AAPA has appropriately defended the component of clinical flexibility in the PA profession and has opposed the development of specialty certifying exams on the basis that they would present barriers to the entry of PAs in to these specialties and restrict the career mobility of PAs. The AAPA has advocated the notion of specialty recognition as a middle ground plan to accommodate the needs of PAs in specialties.

Specialty Certification Examinations

The NCCPA, which correctly sees itself as the organization best prepared to develop PA certifying examinations, continues to wrestle with this issue. For the past 30 years, the NCCPA has discussed and considered the question of PA specialty certification and its implications. At a recent meeting of its board, the NCCPA agreed to express the position that there is currently not a solution, certainly not an easy solution, to the dilemma presented to the PA profession on specialty certification.⁵

That said, the NCCPA also stated that it will not "close the door" on the notion of specialty certification and decided to move ahead to develop test items in specialty areas so as to build up an examination item bank. This move signals that, in the event that specialty certification becomes a reality for PAs, the NCCPA is prepared to enter the area of specialty examination.

It is wise for the NCCPA to take the step to develop test items for possible future PA specialty examinations, lest other less-qualified organizations attempt to enter into this endeavor. The NCCPA has a strong track record of developing widely utilized and accepted standardized examinations for the PA profession. It would be the appropriate organization to develop and administer PA certification examinations should the day arrive that they are perceived as necessary. As the PA profession continues to become increasingly specialized, that day may be coming closer.

The dilemma posed by increasing PA specialization defies a simple solution and certainly will continue to be debated for years in the PA profession. It is likely that we will inch toward specialty certification examinations, a step that will prompt a storm of criticism regarding the threat to clinical flexibility. It's a specialty world, and in the end, the inexorable forces of specialization probably will prevail.

The challenge to the PA profession will be to find a way to safeguard clinical flexibility, which is a unique feature among the health professions.

References

1. American Academy of Physician Assistants. Number and percent distribution of clinically practicing respondents by general specialty practiced for primary employer. 2007 AAPA Physician Assistant Census Report. http://www.aapa.org/research/07census-content.html#3.6. Accessed September 22, 2008.

2. American Academy of Physician Assistants. Distribution of clinically practicing respondents by general specialty practiced for primary employer. http://www.aapa.org/research/tables-1997.pdf. Accessed September 22, 2008.

3. American Academy of Physician Assistants. Distribution of clinically practicing respondents by general specialty practiced for primary employer. http://www.aapa.org/research/02census-content.html#tab20. Accessed September 22, 2008.

4. American Academy of Physician Assistants. Maintaining professional flexibility: the case against accreditation of postgraduate physician assistant programs. http://www.aapa.org/manual/03-MaintainProfession.pdf. Accessed September 22, 2008.

5. Lathrop J. Report of NCCPA's exploration of the needs of PAs in specialty practice. Presented at: Insights, Ideas, and Answers. National Commission on Certification of Physician Assistants; September 18, 2008; Johns Creek, GA.

James F. Cawley is professor and director of the PA/MPH program at the School of Medicine and Health Sciences at The George Washington University in Washington.