Spend even a short amount of time surfing blogs and online forums for Physician Assistants (PAs) and you will quickly encounter anxiety around the Physician Assistant National Recertifying Examination (PANRE). There appears to be a growing sense among PAs that, within the past few years — and with the NCCPA’s elimination of the take-at-home version of the recertification exam and move to more-clinical vignette-based question types — the difficulty of the PANRE has increased dramatically. Even seasoned PAs, claiming to have studied assiduously for their exams, report leaving the PANRE fearing failure or having — at best — no sense for how they might have fared on the exam.

Here are just a few examples of comments appearing in PA online forums:

“I just finished taking the PANRE about an hour ago and all I have to say is ‘wow’. I found it to be much more confusing and trickier than anticipated…Not sure what more/how much harder I can study if I have to retake it….”

“I just took my PANRE for the first time and felt like I guessed a lot on the exam. Anyone out there who took the primary care exam this month who felt like it was hard too?”

“I found the exam difficult. Of the four sections, one was particularly more difficult than the other three. I walked out of there feeling happy it was over, but scared I might have to take it again in 3 months.”

“…I just recently took my PANRE (5th year) and I share the horrendous feeling that others have experienced…Furthermore, I’m slightly upset since I poured a lot of time into studying.”

Responses to those experiencing severe post-PANRE anxiety are generally soothing, pointing out, for example, that:

  • Pass rates for the PANRE typically run in the 95 to 96% range.
  • The NCCPA often tests new questions on the PANRE, but does not count them toward one’s pass/fail score. (To the test-taker, those questions are indistinguishable from scored questions during the exam.)
  • The PANRE is designed statistically and scientifically to test knowledge across a broad array of medical areas with a primary focus on isolating PAs either hovering very near to or falling clearly below the pass/fail cut score for general medical knowledge.

In other words, if you have been practicing successfully as a PA, keeping pace with required CME activities, pursuing lifelong medical learning outside of CME, and actively studying for the PANRE, the likelihood of passing is quite high even if you leave the exam feeling otherwise. Of note is that anxious forum posters often return to report that they did indeed pass their exams.

Preparing for the PANRE

The perception of increasing difficulty on the high-stakes PANRE has generated plenty of debate around the exam itself and the NCCPA’s overall approaches to knowledge assessment and PA recertification. While the debates are certainly healthy for the profession, their influence on changing the PANRE in material ways is slow at best. So what can PAs do in the meantime to alleviate severe pre- and post-PANRE anxiety?

To maximize confidence both leading up to and during the PANRE, PAs are first advised to time their self-scheduled exams carefully, leaving plenty of room in recertification cycles for retakes if needed. The PANRE can be taken up to four times within the final 2 years leading up to certification expiration, but only two times in each year and only once every 90 days.

“We recognize that facing the recertification exam is a stressful event. That’s why we strongly encourage PAs to take full advantage of the opportunity to test a year early, before the pressure of the certification expiration deadline begins to add to the understandable test anxiety that drives many to overspend as they prepare,” says Dawn Morton-Rias, Ed.D, PA-C, who is also president and CEO of the NCCPA.

Christie J. Lucente — Physician Assistant Reviewer for NEJM Knowledge+ Family Medicine Board Review, a practicing PA-C since 2004 who has passed one PANRE, one specialty Certificate of Added Qualifications (CAQ) in Emergency Medicine, and is now preparing for her second PANRE — suggests a large portion of PANRE-related anxiety can be attributed to specialization.

“There are PAs in practice who have become extremely specialized. For example, there may be a PA who has focused exclusively on skin biopsies for the past five or ten years. The PANRE is designed to test a much broader base of medical knowledge. And, while that makes the test more challenging for those who are specialized, it’s also what distinguishes our profession from MDs and nurse practitioners (NPs). In fact, most choose the PA profession because we want the flexibility to practice in different areas of medicine throughout our careers. However, the price of that flexibility is to maintain a broad base of general medical knowledge, which is tested periodically through the PANRE.”

If you have never yet taken a PANRE, it is important also to understand that exam questions differ in style from the initial Physician Assistant National Certification Exam (the PANCE). Lucente describes the key difference:

“The PANCE and PANRE cover the same subject matter, so being mindful of topics included in the NCCPA’s Content Blueprint is important for both exams. As for the types of questions you might see on each exam, the NCCPA states that, in general, questions on the PANCE are more specific in nature. The PANRE, by contrast, focuses on how we apply broader medical principles.”

Especially for first-time PANRE takers, Lucente advises gaining plenty of practice answering more clinically focused questions, which require individuals to perform higher-level cognitive tasks — application, analysis, and strategy vs. just definition and understanding, for example. There are many options for doing so, beginning with the NCCPA’s own practice exams, which are also assured to reflect the exam’s content blueprint as well as the style and pacing of the actual PANRE exam. The NCCPA offers two PANRE practice exams, which can be taken an unlimited number of times. While not intended to predict performance on the PANRE, the low-cost practice exams do provide clear indicators of how much studying and advance preparation might be needed in various topic areas for each individual PA.

The NCCPA provides practice-exam reporting broken down according to the exam blueprint. If a test taker performs poorly across many or most subcategories, a broad PANRE review course might be indicated as a strong point of departure for refreshing core medical knowledge, building test-taking confidence and directing subsequent independent study. If, on the other hand, you are weak in only a few specific areas of the NCCPA practice test, your study time and CME budget might be better spent in more focused ways. As Lucente describes:

“Most PAs have a certain annual budget allocated for continuing medical education (CME). A PANRE review course — especially a multiday course involving travel — can consume a large portion or even all of that budget, leaving little for CME that might be more relevant to one’s specialty and/or specific PA career path. While I have taken PANRE review courses in the past and believe they can be quite effective, each PA needs to make an assessment of how to spend his or her limited CME dollars each year.”

When to Consider Taking a PANRE Review Course

A review of materials set forth by course providers — including location-based, CD/DVD, and online-only types — suggests that broad PANRE review courses may be best suited for PAs who:

  • Have left exam prep until very late in their recertification cycles
  • Are not especially disciplined about studying independently
  • Are not typically strong test takers
  • Have yet to experience computer-based versions of the PANRE
  • Do not make a regular habit of keeping current with general medical knowledge via journals, conferences, peer networking, question banks, self-assessment tools, and so forth
  • Have daily distractions, such as child or elder care that can make it difficult to carve out focused time for self-directed study
  • Have been narrowly specialized over a long duration (some 60% of PANRE questions test general/primary care medical knowledge while 40% can, by test taker’s choice, be more specialized, focusing either on adult medicine or surgical practice)
  • Show downwardly trending PANRE scores over time (a function of distance from academic settings and regular study)
  • Have taken NCCPA practice tests and performed poorly across the board (versus in just a few specific areas)

Choose Wisely

In 2012, the American Academy of Physician Assistants (AAPA) surveyed more than 2,800 certified PAs to gain insights on perceived usefulness of specific PANCE/PANRE preparation options. While the AAPA poll looked at specific resource titles, each mode of study showed similar ranges in terms of perceived usefulness among PAs:

  • Review books: 53% to 73%
  • Practice exams: 48% to 77%
  • Online or self-study review courses: 45% to 80%

The key takeaway here is that each PANRE prep category has both weak and strong contenders, so careful research is needed in deciding how to invest one’s time and CME money on specific board-review offerings.

Many PANRE review courses and other resources can be purchased conveniently online, but checking original publication dates for content as well as content-revision frequencies is a must to ensure it is both up to date with advances in medical knowledge and with changes in how the NCCPA structures the PANRE to assesses that knowledge.

While it is a reasonable assumption that PANRE review courses have been developed using the NCCPA exam blueprint — meaning they portion course content appropriately across the breadth of subject areas covered in the exam — this is not a given and should always be verified when weighing PANRE review course options.

A big positive for many PANRE review courses, according to Lucente, is that — in addition to medical knowledge — they teach specific test-taking strategies, including how to rapidly deconstruct and decode exam questions. PANRE review courses also provide key insights into how questions are developed for the exam, how the exam is structured and scored, why it is important to answer every question (even by guessing), and specific strategies for making best-possible guesses.

PANRE review courses, Lucente notes, may also highlight how to work more effectively in both timed and computer-based testing environments. When taking the actual PANRE, you have approximately 60 seconds to read, digest and answer each question; due to exam scoring methods, it is always best to answer every question. Practicing questions repeatedly within realistic time constraints can go a long way to relieving test-takers’ anxiety, Lucente says.

While many PANRE review courses offer money-back guarantees, they are not failsafe as online forums reveal plenty of examples of PAs who have failed the PANRE even after taking reputable and popular PANRE review courses. At the end of the day, says Lucente, each PA must make a clear and honest assessment of his or her own learning styles, capacities for retaining information and testing, and career-path priorities.

“It is always going to come down to what is right for each individual PA, their lifelong learning and study habits, where they are in their careers and specialties, how much experience they have with taking these sorts of exams, and how they want to spend their CME money. If there is an effective way to prepare for the PANRE that delivers the same benefits of a PANRE review course — and there is no other reason to travel to a specific destination — I believe many would choose to spend their CME money in ways that add to their core clinical and specialty knowledge.”

More from NEJM Knowledge+ on PANCE and PANRE:
Physician Assistant Certification
Taking the PANCE/PANRE Exam

Please join our ongoing conversation about best practices for PANRE review by sharing your own experiences with PANRE review courses in the comments below.