In the early part of November 2015, the National Commission on Certification of Physician Assistants (NCCPA) selected a new Physician Assistant National Recertifying Exam (PANRE) model for further exploration and public comment. The NCCPA believes that the new “two-component” model, consisting of the usual secure exam plus a new series of at-home generalist assessments, would better assess PAs’ maintenance of the skills and knowledge that are needed in a rapidly changing field. They further state that, for PAs whose test performance scores are deficient but fall within a defined performance range, the new model would allow PAs to undergo remediation through CME to benefit from additional focused study rather than face retesting or the loss of certification.
The American Academy of PAs (AAPA), which advocates for the more than 104,000 certified PAs in the United States, remains unconvinced about the need for the new model. They believe that the proposed exams will place additional and unnecessary burdens on PAs, employers, and the health care system overall and that competency is better judged at the practice level. We summarize the differences between the current PANRE and the proposed new exam model in the following table:
|Current and PROPOSED PANRE models|
|Current PANRE||Proposed PANRE|
|Certification Maintenance Cycle||10 years||10 years|
|Credential Awarded on Successful Completion of the Exam||PAs are awarded a generalist PA-C credential||PAs are awarded a generalist PA-C credential|
|Type of Assessment||Proctored, timed, secure exam||A proctored, timed, secure specialty-focused exam, in combination with periodic take-at-home, open-book generalist exams|
|Exam Content||Broad-based general medicine exam covering all organ systems and the patient lifespan||A specialty-focused exam on the knowledge needed to practice in a safe and effective manner in the PA’s area of practice and broader-based core knowledge exams|
|Scoring System||Pass/fail system based on number of questions answered correctly according to a passing standard recommended by a representative panel of certified PAs||Performance assessed based on number of questions answered correctly according to passing standards recommended by representative panels of PAs; rather than a single pass/fail standard, test includes opportunities for remediation to established levels of performance|
|Relationship to NCCPA’s Certificate of Added Qualifications (CAQ) Program||None||The specialty-focused exam would also satisfy the exam component of the CAQ program requirements for those scoring above an established performance level; PAs would still have to fulfill the program’s other requirements if they desire a CAQ|
The Current PANRE Process
The four-hour (PANRE) includes 240 multiple-choice questions that are administered in four blocks of 60 questions, with 60 minutes to complete each block and with a 15-minute break after each of the first three blocks. The exam covers a breadth of medical and surgical conditions across all organ systems and throughout the human lifespan. The entire exam consists of general medical and surgical questions, but PAs can focus 40% of those questions in one of three areas of their choice: primary care, adult medicine, or surgery.
For decades, certified PAs have been required to take the PANRE in the fifth or sixth year of a six-year certification maintenance cycle. However, in 2014, PAs started transitioning to a ten-year certification maintenance cycle, with the PANRE taken in the ninth or tenth year of each cycle. PAs have up to four opportunities to pass the PANRE in the final two years of each cycle.
Proposed New Recertification Exam Model
The recertification exam in the proposed new model would be made up of two separate components. The first component would be a proctored, timed, secure exam (similar in format to the current PANRE, which is administered at Pearson VUE test centers). The second component would include periodic take-at-home exams to test PAs on the broad base of core knowledge that they should have as generalist-educated providers who are able to change specialties.
The proctored exam would assess PAs’ grasp of the knowledge needed to practice in a safe and effective manner in their specialty area of practice. The NCCPA anticipates that this new test would be shorter in duration than the current four-hour proctored test. Performance on the proctored, specialty-focused exam will fall into several scoring bands: (1) a minimum level below which examinees would be required to retest; (2) a remedial level of performance in which examinees would not retest but would be required to complete continuing medical education (CME) activities related to areas of suggested knowledge deficiency; (3) an intermediate-to-high range in which no remediation would be required; and (4) an exceptional level of performance at which examinees would be eligible for a Certificate of Added Qualification (CAQ) in that specialty, should they desire to pursue one and if they meet related CME and experiential requirements.
During the take-at-home exams, PAs would be allowed to consult resources (i.e., colleagues or medical textbooks and/or journals) to help determine the correct answers on topics they may not encounter every day in their specialty, just as they do in practice. The NCCPA anticipates that PAs would be given somewhere between three and six weeks to complete a take-at-home exam.
Because of the time it would take to develop these new exams, it would be several years before the new PANRE model would be implemented, if the NCCPA does in fact decide to pursue it.
PAs Concerns and NCCPA Reasoning
It is understandable that some PAs may be feeling uneasy about the newly proposed changes as well as about the rules for certification maintenance in the new ten-year certification maintenance cycle. However, according to NCCPA President and CEO Dawn Morton-Rias, Ed.D., PA-C, the recently announced new PANRE model is necessary because it addresses the significant shift in practice that has taken place throughout the spectrum of health care.
“Our challenge,” says Morton-Rias, “is to reconcile two divergent interests: (1) a desire to preserve the generalist nature of the PA-C credential (which is fundamental to the profession) and the flexibility PAs have to change specialties during their career, and (2) a call from PAs for exams that are more relevant to their current practice. We believe that the model that we are exploring balances those two important concerns.”
The AAPA, however, is not convinced that the new PANRE model would accurately demonstrate competence and expertise in specialties, or that any one test can or should be used as the sole measure of PA expertise. According to AAPA President Jeffrey A. Katz, PA-C, DFAAPA, there is no research that demonstrates that PA recertification exams have a positive impact on patient safety, outcomes, or satisfaction.
“The AAPA wants to ensure that the NCCPA’s proposed specialty exam requirements do not become a de facto threshold for practice or employment,” says Katz. “The AAPA is committed to preserving multiple pathways to demonstrate competence and expertise in specialties. It is well-documented that provider competency is established at the practice level, which is one of the best ways for practitioners to build and maintain expertise in today’s constantly evolving healthcare landscape. For example, in hospitals and other licensed facilities, physicians, PAs, and other providers of medical care are required to undergo a focused, professional performance evaluation to be granted privileges to practice. Such an evaluation may include observation, proctoring, and simulation.”
PAs often state that the ability to move from specialty to specialty is one of the most treasured aspects of their profession. Indeed, according to the NCCPA 2014 Statistical Profile of Certified Physician Assistants, more than 70% of certified PAs practice in specialties other than primary care, and the generalist PA-C credential supports PAs’ flexibility to change specialties during their career. Morton-Rias says that the proctored exam in the new model would provide flexibility to PAs in this regard, allowing them to select an area (from several common specialty areas) that reflects their practice area on this high-stakes exam. Katz, however, believes that it would be difficult, if not impossible, to establish practice-specific proctored exams that are relevant to PA practice across all specialties, subspecialties, and settings because the PA scope of practice in any given specialty or environment varies.
“For example,” says Katz, “it would not be appropriate to test a PA in orthopaedics on all aspects of orthopaedics if that PA focuses exclusively on hip replacement. The process would require an infinitely diverse set of specialty exam options. This is why competency is best assessed at the practice level.”
In choosing the new model, the NCCPA Board was looking for a recertification method that would reflect the consideration that PAs and the NCCPA both desire a recertification exam process that is relevant and meaningful to current and emerging PA practice. In their daily practice, PAs are constantly called upon to recall knowledge, but they also have the opportunity to consult other resources when necessary, and, according to the NCCPA, that fact is reflected in the nature of the proposed new PANRE model. The new model also provides feedback, especially to PAs who test at the marginal level of proficiency, and permits them to complete activities to improve their knowledge base going forward. According to Morton-Rias, this type of learning method tends to be very useful for adult learners who may test at the borderline level.
As the United States’ only certifying organization for PAs, the NCCPA is serious about its obligation to develop PA certification programs and assessment strategies that are aimed at serving the best interests of the public.
“It is reasonable for the public and other key NCCPA stakeholders to expect that PAs are assessed across general or core medical content and within their area of current practice,” says Morton-Rias. “Healthcare continues to become more complex and PAs are becoming increasingly visible and critical to successful delivery of care in every clinical setting and specialty. Modernizing the recertification exam process to reflect the current and future state of practice is an obligation we have to PAs and to all who rely on the certification we confer.”
Katz is in agreement that there is need for PA assessment, but he disagrees with the type of assessment proposed by the NCCPA.
“It is interesting to note that, currently, PAs are the only medical profession that requires an individual to periodically take and pass a high-stakes comprehensive exam to remain certified,” says Katz. “In 24 states, PAs would lose their license to practice medicine or retain prescriptive authority if they did not pass the exam to maintain their certification.”
“What we hear most from PAs is their commitment to practice medicine and provide valued, safe, and quality patient care,” states Katz, “but some PAs who have practiced for 20 years and passed certification twice are talking about retiring simply due to the burden of the exams. In the face of a looming provider shortage, our healthcare system and, more importantly, our patients, cannot afford to lose highly experienced medical practitioners.”
Next Steps in the NCCPA Process
The final decision to adopt the new model is still months away, however, and would only occur after the NCCPA gathers comments from the public.
“We are preparing for a public comment period of several months before the Board makes its final decision, which will be sometime within the second quarter of 2016,” says Morton-Rias. “If the model is approved by the NCCPA Board, it would take a minimum of three to five years to begin to implement changes, giving us all time to adjust and plan.”
The public comment period will officially launch later this month with the publication of a white paper that addresses the year-long process to inform the development of this model and the rationale for the various attributes of this potential new PA recertification exam process.
The exploration of this new model is an ongoing process, and, according to Morton-Rias, the NCCPA wants and needs to hear from PAs and those who rely on the certification that the NCCPA confers on PAs.
For information about the need to take a PANRE review course, see the NEJM Knowledge+ blog article “Why and When to Consider Taking a PANRE Review Course”. Many online review courses are available, including the NEJM Knowledge+ Family Medicine Board Review.