One of the bigger issues of the day in the PA profession is the debate-more accurately, the conundrum-of specialty recognition and certification. In this matter, the PA profession faces a difficult choice between, on one hand, acceding to what some refer to as the "natural progression" of medical specialization, ¹ and on the other, preserving a unique and cherished element of the PA career, the ability to move among various practice specialties.

Recognition vs. Certification

"Recognition" in this discussion connotes a process involving the demonstration of proficiency in a clinical area that may be attained through a variety of methods, including continuing medical education, additional formal training, programs of proscribed study, physician attestation and time in practice, among others. "Certification" is similar in that the methods of attaining clinical proficiency may be those used in the recognition process, but in addition a formal examination usually is included in the process.

The tide of specialization that has swept over medicine and, more recently the PA profession, began in the 1940s and continues to have profound effects. ² While the original concept of the PA model was to help alleviate the shortage of primary care clinicians in medically underserved communities, in reality the patterns of PA distribution have been more of a microcosm of physician distribution.

The distribution of PAs in the primary care settings of family medicine, general internal medicine and general pediatrics was 50.8% in 1996. By 2006, only 36.1% of PAs were practicing in these settings. Jones comments that "although a higher proportion of PAs than physicians continue to work in primary care practice settings, the data suggest that PAs also tend to follow the specialization trends of the supervising physician employment pool." ³

Why the Call for Recognition?

PA specialty groups, such as those in cardiovascular surgery and emergency medicine, have been pressing the case for their own certifying examinations that ostensibly would verify their proficiency in these fields.

Pressure for specialty recognition and certification also emanates from the health care system. Employers and health systems are placing increased emphasis on policies that stress patient safety and risk management, and these include credentialing processes that require demonstration of advanced qualifications.

The National Commission on Certification of Physician Assistants, in acknowledging the forces of specialization in the PA profession, has noted that new PA graduates have less experience than those who graduated in the profession's formative years, and that the profession's growth and increasing visibility has resulted in the need for greater accountability. ⁴ In addition, some feel that PAs are emerging from their formal programs less prepared for the scope of practice required, particularly in the surgical subspecialties and emergency medicine.

On the other side of the issue lie well-justified concerns about moving down the path of either specialty recognition or certification. The American Academy of Physician Assistants has been outspoken in defending the tenets of preserving PA clinical flexibility. The AAPA's opposition to PA specialty recognition was manifested in 2005 with its position on the move by the Accreditation Review Commission on Education for the Physician Assistant to accredit PA postgraduate programs. The academy's concern then was that accreditation would confer legitimacy on these programs such that it would lead to the development of barriers to entry to clinical practice in various specialty areas. This concern is the basis of the AAPA's continuing skepticism about PA specialty certification examinations.

The Generalist Education

The AAPA is appropriately defending a component of the profession that is highly valued by members and has been a remarkable feature. Their broad-based general medical education has allowed PAs to be, in the words of one advocate, medical "stem cells," moving successfully into practice areas defined by their supervising physicians and having that ability over the course of a career. Generations of PAs have benefited from the ability to move among the medical practice specialties.

The AAPA maintains that policies that would place barriers to PA entry into specialty practice should be resisted. The ability to move among the specialties is one that is unique among the health professions and is a reason why many are attracted to the PA profession.

The NCCPA has stated that changes in the health care system, changes in the pipeline of PA education and changes in PA practice indicate that now is the appropriate time to pursue specialty recognition while preserving the "generalist" examination. The NCCPA states that it will adhere to what appear to be sensible principles in the development of specialty recognition?for example, seeking input from key stakeholders (which it has already done in meetings in 2006 and 2007) and stating that participation in specialty recognition will be voluntary. The commission also mentions that specialty recognition will support the credentialing process and not create barriers to licensure. ⁴

The issue of specialty recognition or certification is a difficult one for the profession. In terms of dealing with the forces of specialization, a sports analogy is apt: It's said of dominant athletes, "You can't stop them, you can only hope to contain them." How the PA profession deals with specialization will be critical for its future and will test the ability of the profession's organizations to seek compromise in working for the best interests of its members and the public (our patients).

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.

References

1. Sawyer NA. Specialization: 'Natural Progression' [letter]. ADVANCE for Physician Assistants . 2007;15(4):21.

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

3. Jones PE. Physician assistant education. Acad Med. In press.

4. National Commission on Certification of Physician Assistants. Points of Consensus as of November 13, 2006. Available at: http://www.nccpa.net/News_06PointsofConsensus.aspx . Accessed April 16, 2007.