The buzz these days inside the PA profession is all about the NCCPA's recently announced intention to consider the possible development of specialty-specific examinations for practicing PAs. This development appears to be prompted at least in part by the interest of a Utah-based physician and his colleagues to develop a process whereby a series of PA specialty certifying examinations would be established.

The NCCPA, the only national organization that has experience and expertise in PA testing, has issued a statement about its plan to consider methods of specialty recognition, which could include the development of specialty certification examinations. In June, the NCCPA held an open forum on this topic, at which a number of representatives of various PA specialty organizations weighed in on the topic of specialty certification or some alternative such as specialty recognition.

The AAPA is appropriately concerned by this development, fearing that a pathway of specialty certification ultimately would result in a narrowing of the career entry opportunities that PAs now enjoy. Certification, particularly if it is determined by examination, could place barriers to PAs seeking entry into particular specialties, thus adversely altering a long cherished component of the PA profession and its employment pathways.

Certification vs. Recognition

Relevant to this discussion is the importance to distinguish between specialty certification, which is the term used by the NCCPA, and specialty recognition, which is a term that is preferred by the AAPA.

The term specialty certification connotes the establishment of a formal, nationally standardized examination administered to all PAs in a given clinical specialty through a process that would be expensive to develop and administer. The use of specialty-specific examinations also would require that there be a critical mass of persons in a particular specialty-that is, a minimum number of individuals eligible and willing to take the examination in order to make it economically feasible.

Specialty recognition, on the other hand, is a concept that defines a process or series of achievements whereby a PA, who has worked for some period of years in a given specialty, and after fulfilling a series of qualifying steps (for example, membership and fellow status in a AAPA-affiliated PA specialty group, documentation by a supervising physician of clinical proficiency in that specialty, and the attainment of other designated professional accomplishments in that clinical specialty), would be qualified for a privileged status in the academy. That status, which in some medial professional organizations is known as diplomate status, in turn would be recognized by the national certifying agency, the NCCPA, and on that basis and possibly other qualifiers (perhaps some form of take-home examination), would award the PA specialty recognition as a PA with expertise in the relevant clinical specialty area.

The key here in the distinction between specialty recognition and certification is the utilization of a formal examination as part of the process. As noted, the employment of a standardized examination makes the process much more expensive, complex and pressurized for the eligible candidates.

Another Examination?

Advocates of specialty certification using an examination should be reminded of the history of PAs' antipathy toward formal examinations. Many veteran PAs will recall the heated debates in the AAPA House of Delegates related to recertification, where PAs loudly decried the use of formal examinations to test clinical competency. The argument put forth was that it was impossible for performance on a multiple-choice examination to accurately indicate clinical competence.

If PAs still hold this view, it raises the question of the desirability of NCCPA-administered specialty testing as a means to certify that a PA is an expert in a given clinical specialty.

Specialty recognition would appear to be a middle-ground approach, one that would avoid the cost and intensity of administering specialty certifying examinations. The recognition process would offer PAs who seek particular designation in a given specialty the public distinction that they seek for their accomplishments, but would avoid the costly pressurized approach of formal examination. Whether the recognition process would be sufficient in their minds or in the minds of employing physicians, hospitals or regulatory agencies is unknown.

While declaring that it intends to take the tack of special certifying examinations, the NCCPA has made an effort to listen to the PA profession and its various specialty representative groups. Clearly, if the route taken were to be examinations, having the NCCPA develop and administer the process would be far preferable than to leave it to outsiders who have virtually no experience or apparent expertise in this endeavor, and for whom the motivation seems to be more entrepreneurial than anything else. It is also true that the NCCPA is still considering the various options and has not yet made any final decision on a process of either recognition or certification through examination.

Regardless of the outcome, the die is cast for the profession: There will be some form of formalized recognition of PAs who work in specialties. We are in a period in which the conceptualization of that process is taking place. Ideas are welcome.

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. He also is professor of health care sciences at the university's School of Medicine and Health Science.