Maintaining Professional Flexibility: Issues Related to Accreditation of Postgraduate (Adopted 2005 and amended 2010) Executive Summary of Policy Contained in this Paper Summaries will lack rationale and background information, and may lose nuance of policy. You are highly encouraged to read the entire paper. The AAPA believes that postgraduate clinical training should be available to those who want it. Due to the possibility of the establishment of barriers to the free entry of PAs into clinical specialties and the ability of PAs to change specialties over the course of their clinical careers, the AAPA continues to have concerns about the accreditation of PA postgraduate training programs. Background The American Academy of Physician Assistants (AAPA) recognizes the value of lifelong learning, and that voluntary participation in postgraduate clinical training programs may benefit physician assistants (PAs) who seek additional knowledge and skills. In the past, the AAPA has raised objections to the development of an accreditation system for these programs. This position was based on the belief that accreditation of postgraduate clinical training could compromise a key tenet of the PA profession, namely clinical flexibility and adaptability. Since 2007, however, the Accreditation Review Commission on Education for the Physician Assistant (ARC-PA) has instituted an accreditation system for PA postgraduate programs. This position paper discusses the potential impact of such accreditation on the role and mission of the PA profession and suggests ways to promote quality and maintain flexibility. Postgraduate programs for PAs have existed since the early 1970s. Most of them offer an internship model of training that comprises a modest didactic curriculum and intensive work in the clinical setting. The internship model programs are offered by - 1
hospitals, medical centers, and large group practices. Programs are typically 12 months in length, provide a stipend of $3000-$4000 per month, and enroll small numbers of participants per year. 1, 2 These programs are essentially structured work experiences and the participants do not enjoy the unregulated status of students. Rather, they are licensed practitioners, and are therefore subject to state PA practice acts. Participants are afforded the protections offered by the Fair Labor Standards Act and other laws designed to protect employees. There are also postgraduate programs that follow a more academic model. These programs combine a highly structured didactic education (that is, courses taken for graduate credit) with clinical rotations. These programs, usually sponsored by accredited universities, award a master s degree or credit towards a master s degree. 2 For the purposes of this discussion, programs that lead to the awarding of an academic degree unrelated to a specific area of clinical practice are not considered postgraduate programs. Current Status There are currently 48 programs that are members of the Association of Postgraduate PA Programs (APPAP); there are approximately 200 graduates of such programs annually. Training is offered in dermatology, emergency medicine, critical care medicine, family medicine, oncology, orthopedics, pediatrics, psychiatry, rural medicine, surgery, cardiovascular surgery, and urology. 1 The term residency is frequently used to describe PA postgraduate programs. Unlike physician residency training, postgraduate training for PAs is entirely a voluntary option, is open to PAs at any point in their careers, and is not a requirement for licensure, employment, reimbursement or certification. The term postgraduate program is preferred over residency program by the profession s organizations in referring to such programs. The ARC-PA defines clinical postgraduate programs as formal educational programs that offer structured curricula, including didactic and clinical components, to educate NCCPA eligible or certified PA's for a defined period of time in preparation for practice in a medical or surgical specialty. Programs typically involve full time study of 12-24 months duration and follow several models including fellowships, graduate degree - 2 -
programs, and residency programs. The ARC-PA accreditation standards for postgraduate programs focus on administrative issues rather than content; as of October 2009, approximately 10% of existing programs were accredited. Concerns Regarding Accreditation Since the ARC-PA initially proposed the inclusion of PA postgraduate programs as educational experiences eligible for accreditation, the AAPA has expressed concerns regarding such a move. One concern held by the AAPA is that the development of accreditation standards would necessarily encompass educational content in addition to the administrative aspects of training. At present however, there is no agreement on what knowledge and skills should be taught 4 and there is no movement toward the development of content-based standards. In truth, it would be difficult to develop specialty-specific educational standards because there are so few programs per specialty (only surgery has more than two programs). With increasing numbers of PAs who have completed postgraduate programs, and ARC-PA accreditation of these programs, awareness of the programs has increased. With such awareness, the possibility of credentialing bodies preferring or requiring postgraduate training may become more of a reality. The additional proposal by the National Commission on Certification of Physician Assistants (NCCPA) to offer specialty certifications in 2011 provides additional concerns regarding possible requirements for postgraduate training in the future. 8 Advocates of postgraduate program accreditation assert that accreditation provides assurance of quality and consistency among programs. Accreditation status may guide applicants in decisions to attend an accredited program based on the assumption that an accredited program may be superior to an unaccredited one. Accreditation also may serve to strengthen the relationship between the faculty at PA programs and teaching clinicians, with the additional benefit of securing high quality clinical training sites for PA students. This, it is argued, would improve PA education in general and reflect positively on the entire profession. 3 On the other hand, adding postgraduate training for the individual PA creates a longer training period and a higher financial burden. And, some postgraduate programs may use accreditation purely as a marketing tool. - 3 -
A significant argument against accreditation of postgraduate programs is that it is voluntary and unenforceable. There is no way to require accreditation unless state laws change to require that all PAs have postgraduate clinical training before they could be licensed or employed. Without this requirement in law, it makes little difference whether individuals attend accredited or unaccredited programs, or indeed, any postgraduate program. The AAPA does not advocate statutory requirements for postgraduate education, nor have there yet been prominent discussions of the idea at the level of state organizations or legislative bodies. So, what is the harm of a voluntary accreditation system? The answer is that the mere existence of a formal accreditation system may lend these training programs the appearance of an official status that could have unintended consequences for the PA profession. There is concern, particularly in states that are conservative or less friendly to PAs, that regulators would mandate the completion of an accredited postgraduate program prior to approving the performance of specific technical procedures, overall job descriptions, or licensure applications. There is no guarantee that such requirements would exempt individuals who are already in practice, thus placing a considerable hardship on more than 75,000 practicing PAs, most of whom have not attended a postgraduate program. Existing postgraduate programs have limited capacity which could not accommodate mandated postgraduate training, with or without ARC-PA accreditation. There is also a possibility that insurers may limit or deny reimbursement for services provided by PAs who lack postgraduate training or that employers would see accreditation of postgraduate training as a sign that they should require postgraduate training for all PAs. While many extol the virtues of postgraduate training, there is a distinct difference between PAs voluntarily choosing to obtain advanced training and having the decision made for them by others. Perhaps the greatest danger is to PA flexibility and adaptability. The ability of PAs to change from one specialty to another would be drastically reduced if postgraduate clinical training were to become mandatory. PAs generally possess a high degree of specialty mobility and career flexibility. They are decidedly adaptable, with at least half changing specialty at least once. More than a quarter will practice at least two specialties, - 4 -
and at least 11% of PAs will work in three or more distinct specialties over the course of their careers. Hospitals, large managed care organizations, the Department of Defense, the Veterans Health Administration, and other institutions have taken advantage of the career flexibility characteristics of PAs for decades. 5 Decisions to require postgraduate training for licensure or employment could have a significant effect on the profession. PAs could be locked into specialties, limiting their ability to fill the employment voids and niches that historically have made the PA profession useful and attractive. PAs are a valuable part of the U.S. health care system precisely because of their flexibility. Conclusions The AAPA believes that postgraduate clinical training should be available to those who want it. Due to the possibility of the establishment of barriers to the free entry of PAs into clinical specialties and the ability of PAs to change specialties over the course of their clinical careers, the AAPA continues to have concerns about the accreditation of PA postgraduate training programs. The basis of the AAPA s concern is the potential adverse impact on physician assistant employment, licensure, length and cost of training, career mobility, reimbursement, and professional flexibility. The number of PA postgraduate programs continues to grow, driven by the combination of the desire of some PAs to obtain advanced education in inpatient medicine and surgery, as well as the reality of an ongoing demand for clinical staff in large teaching hospital settings. Thus far, no adverse affects on PA employment have been observed or described related to the existence of accredited PA postgraduate programs, but the profession should remain vigilant for negative ramifications from increasing emphasis on postgraduate training. References 1. Association of Postgraduate. Available at: http://www.appap.org. Accessed October 17, 2009. 2. Accreditation Review Commission for Physician Assistants. Available at: http://www.arc-pa.org/acc_programs/acc_programspostgrad.htm. Accessed on March 15, 2010. - 5 -
3. Asprey D, Helms L. A description of physician assistant postgraduate residency training: the director s perspective. Perspectives on Physician Assistant Education. Summer 1999; 10:124-131. 4. Dehn R. Editorial: PA residency accreditation: why we need it now. JAAPA, 2003; 16:9-10. 5. Timmer S. Call for uniform guidelines for postgraduate surgical residency programs. JAAPA, 1991; 4:453-454. 6. American Academy of Physician Assistants. Information Update. Physician assistant income: changes in inflation-adjusted total annual income from primary employer 2002-2003 and 2003-2004. Alexandria, VA. October 2004. 7. Hooker, R.S., Cawley, J.F., Leinweber, W. Physician Assistant Career Flexibilty. Health Affaits 2010, in press. 8. NCCPA. Specialty Certification: Coming in 2011. Available at: http://www.nccpa.net/newsarticles/newsarticlesspecialtycertification.aspx. Accessed on March 15, 2010. - 6 -