The tidal wave of specialization that has swept over the medical profession over the past 50 years is exerting its effects on the PA profession. Specialization, seemingly an inexorable phenomenon, has influenced the practice of medicine in profound ways, from the demise of the American general practitioner to the rise of a Byzantine world of specialty and subspecialty societies, examination processes, certification systems and credentialing arrangements.¹

Some would observe that it was only a matter of time before specialization would transform the PA profession just as it has that of physicians. In 1972, Ann A. Bliss wrote that "immediately upon graduation, the physician's assistant (sic) is in considerable danger of being swallowed whole by the whale that is our present entrepreneurial subspecialty medical practice system. The likely co-option of the newly-minted physician's assistant by subspecialty medicine is one of the most serious issues confronting the PA."² While Bliss believed that this "danger" would occur much sooner than it has, it appears that the time of reckoning with specialization has finally arrived.

ARC-PA, NCCPA and a 'Perfect Storm'

After several decades during which the status quo for the PA profession was generalist and primary care practice based upon a general medicine entry exam and a similar recertifying exam, issues related to specialization have surfaced in a big way. Two recent decisions made by our professional organizations, coupled with the growing trend of more PAs entering specialty practice (in 2005, 59% of all clinically active PAs), have converged in a "perfect storm" that threatens one of the most valued components of the profession: career flexibility. The American Academy of Physician Assistants is appropriately concerned about the threat to career flexibility and has taken official policy positions seeking to protect the abilities of PAs to enter specialties as they progress through their careers.

The first action in this trend was the decision of the Accreditation Review Commission on Education for the Physician Assistant to develop a system of accreditation for PA postgraduate programs, a seemingly logical and positive development from the point of view of PAs seeking advanced clinical training. However, the fear is that once residency programs gain accreditation, graduation from such programs will become an entry requirement, inhibiting the ability of PAs to enter certain specialties. ARC-PA asserts that it is its responsibility to insure the quality of PA educational offerings and that accreditation is a form of quality assurance.

The second action was the recent announcement of the National Commission on Certification of Physician Assistants of its intention to develop a process of specialty recognition/certification. Spurring this decision appeared to be the announcement by a group headed by a Utah dermatologist whose stated intention is to develop a system of specialty certification examinations for PAs.³

While the chair of the NCCPA described the motivation for this decision as one having "historical roots," he went on to state that, in this initiative, "other factors played a role in the decision." The NCCPA stressed that "the public, including our patients, have an expectation about the care being delivered by PAs practicing in specialty settings. Patients have a right to expect that their PA has the training, knowledge and skills to deliver the specialty care they are receiving. Unfortunately, at this point, no set standard exists for PAs practicing in specialty areas."⁴

The NCCPA's move to develop some system of specialty recognition may or may not include specialty examinations. There are multiple issues to consider in the creation of nationally standardized examinations, not the least of which is cost. In the past, NCCPA-offered specialty examinations, such as the surgical examination, have been dropped due to lack of participation and consequent financial losses. Historically, the NCCPA has considered the prospect of developing specialty examinations, but as late as 2001, has deferred to the wishes of the AAPA, which remains concerned about the direction that specialty examination/recognition would take the profession.

'The Passing of the Generalist'

The AAPA's opposing position is summarized in the statement that "commitment and recommitment to documentation of a generalist fund of knowledge is good for PAs (it allows access to a wide variety of practice opportunities and at least in theory the flexibility to change our specialty at any time in our clinical careers) and good for patients (it allows PAs to quickly fill health care service needs gaps.)"⁵ The first point, the ability to have career flexibility, is a fair and convincing argument, and this principle has served the profession well for more than three decades. The latter point, that it is good for patients, is increasingly open to question, since many patients would agree with those who support specialty certification that PAs working in specialty practices should possess sufficient well-defined standards of training and qualification in a given specialty.

At the moment, we do not know if the specialty-changing PA is prepared to assume the range of responsibilities to assure safety and competence in his or her new specialty. Employers and regulatory boards, mindful of maintaining high standards for entry into clinical specialty practice, may at some point demand some form of advanced training and/or a specialty examination system.

With nearly two-thirds of the profession now in specialty practice, it is not surprising that the present forces have finally surfaced. Dialogue among the organizations is now occurring that will result in some form of acceptable process that recognizes the needs of this segment of the profession. Many will lament the passing of the generalist nature of PA practice and the loss of career flexibility.

Given the larger historical trends in medicine, and the changing demands of modern practice, increasing specialization and systems of specialty recognition are likely realities for the PA profession.

James F. Cawley is director of the PA/MPH program and professor and vice chair of the Department of Prevention and Community Health, School of Public Health and Health Services at The George Washington University in Washington.

References

1. Stevens R. American Medicine and the Public Interest. New Haven, Conn: Yale University Press; 1971.

2. Sadler AM, Sadler BL, Bliss AA. The Physician AssistantToday and Tomorrow: Issues Confronting New Health Practitioners. 2nd ed. Cambridge, Mass: Ballinger; 1975:1.

3. Cornell S. Generalists no more? ADVANCE for Physician Assistants Web site. Available at: http://www.physician-assistant.advanceweb.com/Editorial/Content/Editorial.aspx?CC=73667. Accessed July 5, 2006.

4. Chairman's Speech at the House of Delegates, Monday, May 29, 2006. National Commission on Certification of Physician Assistants Web site. Available at: https://www.nccpa.net/News_06AAPAConfAnnouncement.aspx. Accessed July 5, 2006.

5. Davis A. Red alert. Legislative Watch. Alexandria, Va: American Academy of Physician Assistants; June 16, 2006.