Randy D. Danielsen, PhD, PA-C, DFAAPA, PA

Recently I drove to Flagstaff, Arizona, to enjoy the cool mountain air and to attend a continuing medical education (CME) seminar sponsored by the Arizona State Association of Physician Assistants. I didn’t particularly need any CME credits, since I had previously attained the requisite number of hours to maintain my license and certification. I must admit the real reason for my trip was the opportunity to rub shoulders with old friends and new leaders in my profession.

At the conclusion of this well-planned and well-implemented CME event, I completed a short survey. I was asked the usual questions regarding my decision to attend this seminar: location, acquisition of CME credits, an opportunity to network, etc. The next question related to whether the lectures I attended would change the way I practice—a question that was difficult for me to answer, although I knew what the politically correct answer would be.

The American Medical Association presently defines CME as “educational activities that serve to maintain, develop, or increase the knowledge, skills, and professional performance and relationships a physician uses to provide services for patients, the public, or the profession.”¹ I am sure that the national PA and NP associations have similar definitions.

CME, or continuing education (CE), has been widely discussed and criticized for decades. Much of the discussion centers on the contention that listening to lectures that review or introduce new medical information is sufficient to change clinician performance. Regulatory boards and certification bodies continue to require clinicians to complete a certain number of formal hours of education each year to retain licensure or certification. In fact, almost every professional association provides CME/CE; it is often an important part of the organization’s revenue. Many national associations continue to sponsor large educational opportunities each year.

Most continuing education for clinicians is aimed at improving performance and/or optimizing patient outcomes. These efforts are patterned after undergraduate medical education and consist of variable formats, from large-group presentations to interactive small-group discussions and even individual one-on-one sessions. In recent times, formal CME/CEs have become available via the Internet with written and/or video/audio lectures, including posttests. With the advent of the Blackberry^® and the iPhone^®, clinicians can now receive formal offerings through these devices as well.

Despite the variety of available CME/CE offerings, questions remain about what effect they have on clinicians’ performance in current practice. The Agency for Healthcare Research and Quality concluded, “Despite the low quality of the evidence, CME appears to be effective at the acquisition and retention of knowledge, attitudes, skills, behaviors, and clinical outcomes.” But is this true?

Research has shown that clinicians continue to misuse therapeutic and diagnostic interventions in practice.² The Johns Hopkins University Evidence-Based Practice Center prepared a report that suggested more research is needed to determine what types of media, techniques, and exposures are most associated with improved outcomes.³ After reading these and other studies, I think there is actually quite a bit of doubt as to whether CME/CE has any measurable effect.

So how do we close the educational gap between evidence and practice? Is formal CME/CE effective? If so, what is the best method for changing clinician performance to effect positive health care outcomes—and to meet the growing need for specialty-specific CME/CE?

In the last decade, there has been research documenting the utility of simulation technology for clinician education. Simulation, however, has not been widely endorsed or used for CME/CE. Anecdotal evidence suggests that it is effective, especially for psychomotor and communication skills, but evidence remains scant.⁴ Even so, we know that clinicians learn better if they are educated in the context of where they practice.

There has also, in recent years, been ongoing discussion regarding deliberate practice, which is defined as an educational variable associated with delivery of strong and consistent educational objectives as part of a mastery-learning model. This process is quite demanding, since it is deliberately grounded in information processing and behavioral theories of skill acquisition and maintenance.⁵ The end point of deliberate practice in a CME mastery-learning context is to require constant improvement of skill and knowledge in clinical practice rather than maintenance at a minimal level.

Based on this information and personal experience, I have several suggestions to make CME/CE more effective. Clinicians should:

• Be highly motivated, with good concentration.

• Be engaged in a process that is based on well-defined educational learning objectives.

• Be challenged with an appropriate level of difficulty.

• Be focused on material that promotes repetitive practice.

• Be evaluated through rigorous, precise measurements of outcomes.

• Receive informative feedback from valid educational sources (eg, simulators, instructors, or educational instruments).

• Be encouraged to reach a mastery standard.

• Have an opportunity for advancement to other, higher-level tasks.

There is one other component that requires mention whenever current CME/CE practices are considered. We cannot underestimate the importance of camaraderie and networking at CME/CE functions and the importance of opportunities for clinicians to just “get away.” I’d love to hear from you regarding CME/CE events that you have attended that met or exceeded your expectations and what made them worthwhile. You can reach me at [email protected].

Recently I drove to Flagstaff, Arizona, to enjoy the cool mountain air and to attend a continuing medical education (CME) seminar sponsored by the Arizona State Association of Physician Assistants. I didn’t particularly need any CME credits, since I had previously attained the requisite number of hours to maintain my license and certification. I must admit the real reason for my trip was the opportunity to rub shoulders with old friends and new leaders in my profession.

At the conclusion of this well-planned and well-implemented CME event, I completed a short survey. I was asked the usual questions regarding my decision to attend this seminar: location, acquisition of CME credits, an opportunity to network, etc. The next question related to whether the lectures I attended would change the way I practice—a question that was difficult for me to answer, although I knew what the politically correct answer would be.

The American Medical Association presently defines CME as “educational activities that serve to maintain, develop, or increase the knowledge, skills, and professional performance and relationships a physician uses to provide services for patients, the public, or the profession.”¹ I am sure that the national PA and NP associations have similar definitions.

CME, or continuing education (CE), has been widely discussed and criticized for decades. Much of the discussion centers on the contention that listening to lectures that review or introduce new medical information is sufficient to change clinician performance. Regulatory boards and certification bodies continue to require clinicians to complete a certain number of formal hours of education each year to retain licensure or certification. In fact, almost every professional association provides CME/CE; it is often an important part of the organization’s revenue. Many national associations continue to sponsor large educational opportunities each year.

Most continuing education for clinicians is aimed at improving performance and/or optimizing patient outcomes. These efforts are patterned after undergraduate medical education and consist of variable formats, from large-group presentations to interactive small-group discussions and even individual one-on-one sessions. In recent times, formal CME/CEs have become available via the Internet with written and/or video/audio lectures, including posttests. With the advent of the Blackberry^® and the iPhone^®, clinicians can now receive formal offerings through these devices as well.

Despite the variety of available CME/CE offerings, questions remain about what effect they have on clinicians’ performance in current practice. The Agency for Healthcare Research and Quality concluded, “Despite the low quality of the evidence, CME appears to be effective at the acquisition and retention of knowledge, attitudes, skills, behaviors, and clinical outcomes.” But is this true?

Research has shown that clinicians continue to misuse therapeutic and diagnostic interventions in practice.² The Johns Hopkins University Evidence-Based Practice Center prepared a report that suggested more research is needed to determine what types of media, techniques, and exposures are most associated with improved outcomes.³ After reading these and other studies, I think there is actually quite a bit of doubt as to whether CME/CE has any measurable effect.

So how do we close the educational gap between evidence and practice? Is formal CME/CE effective? If so, what is the best method for changing clinician performance to effect positive health care outcomes—and to meet the growing need for specialty-specific CME/CE?

In the last decade, there has been research documenting the utility of simulation technology for clinician education. Simulation, however, has not been widely endorsed or used for CME/CE. Anecdotal evidence suggests that it is effective, especially for psychomotor and communication skills, but evidence remains scant.⁴ Even so, we know that clinicians learn better if they are educated in the context of where they practice.

There has also, in recent years, been ongoing discussion regarding deliberate practice, which is defined as an educational variable associated with delivery of strong and consistent educational objectives as part of a mastery-learning model. This process is quite demanding, since it is deliberately grounded in information processing and behavioral theories of skill acquisition and maintenance.⁵ The end point of deliberate practice in a CME mastery-learning context is to require constant improvement of skill and knowledge in clinical practice rather than maintenance at a minimal level.

Based on this information and personal experience, I have several suggestions to make CME/CE more effective. Clinicians should:

• Be highly motivated, with good concentration.

• Be engaged in a process that is based on well-defined educational learning objectives.

• Be challenged with an appropriate level of difficulty.

• Be focused on material that promotes repetitive practice.

• Be evaluated through rigorous, precise measurements of outcomes.

• Receive informative feedback from valid educational sources (eg, simulators, instructors, or educational instruments).

• Be encouraged to reach a mastery standard.

• Have an opportunity for advancement to other, higher-level tasks.

There is one other component that requires mention whenever current CME/CE practices are considered. We cannot underestimate the importance of camaraderie and networking at CME/CE functions and the importance of opportunities for clinicians to just “get away.” I’d love to hear from you regarding CME/CE events that you have attended that met or exceeded your expectations and what made them worthwhile. You can reach me at [email protected].

Recently I drove to Flagstaff, Arizona, to enjoy the cool mountain air and to attend a continuing medical education (CME) seminar sponsored by the Arizona State Association of Physician Assistants. I didn’t particularly need any CME credits, since I had previously attained the requisite number of hours to maintain my license and certification. I must admit the real reason for my trip was the opportunity to rub shoulders with old friends and new leaders in my profession.

At the conclusion of this well-planned and well-implemented CME event, I completed a short survey. I was asked the usual questions regarding my decision to attend this seminar: location, acquisition of CME credits, an opportunity to network, etc. The next question related to whether the lectures I attended would change the way I practice—a question that was difficult for me to answer, although I knew what the politically correct answer would be.

The American Medical Association presently defines CME as “educational activities that serve to maintain, develop, or increase the knowledge, skills, and professional performance and relationships a physician uses to provide services for patients, the public, or the profession.”¹ I am sure that the national PA and NP associations have similar definitions.

CME, or continuing education (CE), has been widely discussed and criticized for decades. Much of the discussion centers on the contention that listening to lectures that review or introduce new medical information is sufficient to change clinician performance. Regulatory boards and certification bodies continue to require clinicians to complete a certain number of formal hours of education each year to retain licensure or certification. In fact, almost every professional association provides CME/CE; it is often an important part of the organization’s revenue. Many national associations continue to sponsor large educational opportunities each year.

Most continuing education for clinicians is aimed at improving performance and/or optimizing patient outcomes. These efforts are patterned after undergraduate medical education and consist of variable formats, from large-group presentations to interactive small-group discussions and even individual one-on-one sessions. In recent times, formal CME/CEs have become available via the Internet with written and/or video/audio lectures, including posttests. With the advent of the Blackberry^® and the iPhone^®, clinicians can now receive formal offerings through these devices as well.

Despite the variety of available CME/CE offerings, questions remain about what effect they have on clinicians’ performance in current practice. The Agency for Healthcare Research and Quality concluded, “Despite the low quality of the evidence, CME appears to be effective at the acquisition and retention of knowledge, attitudes, skills, behaviors, and clinical outcomes.” But is this true?

Research has shown that clinicians continue to misuse therapeutic and diagnostic interventions in practice.² The Johns Hopkins University Evidence-Based Practice Center prepared a report that suggested more research is needed to determine what types of media, techniques, and exposures are most associated with improved outcomes.³ After reading these and other studies, I think there is actually quite a bit of doubt as to whether CME/CE has any measurable effect.

So how do we close the educational gap between evidence and practice? Is formal CME/CE effective? If so, what is the best method for changing clinician performance to effect positive health care outcomes—and to meet the growing need for specialty-specific CME/CE?

In the last decade, there has been research documenting the utility of simulation technology for clinician education. Simulation, however, has not been widely endorsed or used for CME/CE. Anecdotal evidence suggests that it is effective, especially for psychomotor and communication skills, but evidence remains scant.⁴ Even so, we know that clinicians learn better if they are educated in the context of where they practice.

There has also, in recent years, been ongoing discussion regarding deliberate practice, which is defined as an educational variable associated with delivery of strong and consistent educational objectives as part of a mastery-learning model. This process is quite demanding, since it is deliberately grounded in information processing and behavioral theories of skill acquisition and maintenance.⁵ The end point of deliberate practice in a CME mastery-learning context is to require constant improvement of skill and knowledge in clinical practice rather than maintenance at a minimal level.

Based on this information and personal experience, I have several suggestions to make CME/CE more effective. Clinicians should:

• Be highly motivated, with good concentration.

• Be engaged in a process that is based on well-defined educational learning objectives.

• Be challenged with an appropriate level of difficulty.

• Be focused on material that promotes repetitive practice.

• Be evaluated through rigorous, precise measurements of outcomes.

• Receive informative feedback from valid educational sources (eg, simulators, instructors, or educational instruments).

• Be encouraged to reach a mastery standard.

• Have an opportunity for advancement to other, higher-level tasks.

There is one other component that requires mention whenever current CME/CE practices are considered. We cannot underestimate the importance of camaraderie and networking at CME/CE functions and the importance of opportunities for clinicians to just “get away.” I’d love to hear from you regarding CME/CE events that you have attended that met or exceeded your expectations and what made them worthwhile. You can reach me at [email protected].

This past month, the National Commission on Certification of Physician Assistants (NCCPA) notified all its stakeholders of a new voluntary specialty certification program for PAs in emergency medicine, orthopedic surgery, cardiovascular surgery, nephrology, and psychiatry to be launched in 2011—with the expectation that other specialties will follow. Many PAs have applauded this event; others have been critical of its potential effect on the profession.

Since I am the chair of the NCCPA’s workgroup on specialty certification and have been intimately involved for the past 3+ years with this topic, this editorial is written from that experience. As with most editorials, it is biased. A further disclaimer: These are my thoughts and experiences and should not be construed to be the policy of the NCCPA. I speak only for myself and offer my apologies to my NP colleagues for focusing on a PA-specific topic this month.

The Rationale
The starting place for our discussion at the NCCPA centered on acknowledging significant changes in the past decade within our health care system, coinciding with the growing clinical diversity of PA practice. Both of these issues indicated to the NCCPA that—after three decades of debate and discussion about the complexities and potential risks and rewards of certifying PAs in specialties—now is the appropriate time to do it.

Why? Simply put, NCCPA understands patients’ need for access to affordable, high-quality health care and believes passionately that certified PAs are integral to meeting that need. NCCPA’s responsibility in that equation is ensuring that certified PAs have the knowledge and skills to deliver the care and the documentation of their training, experience, and expertise needed to achieve and maintain their rightful place on the health care delivery team.

Of course, other environmental factors brought the issue to the forefront. It is a well-known fact that there has been a significant increase in the number of PAs practicing in specialty areas rather than primary care. At the same time, employers and governmental agencies (eg, AHRQ, NIH, IOM) are placing heightened emphasis on patient safety and risk management. State regulatory boards are taking a closer look at supervising responsibilities of physicians and the education of their PA partners. It is also clear that the complexities and increased demands of current health care practice place constraints and increased burden on supervision and other time-consuming aspects of the physician-PA relationship.

Even more compelling than those generalities, PAs in different parts of the country, in various specialties and practice settings, are increasingly facing real and significant challenges. Have you talked to many PAs practicing in psychiatry lately? If so, chances are you’ve heard about some real challenges to reimbursement. Practicing in a surgical specialty? If you haven’t been challenged to provide documentation of surgical training or expertise yourself, you probably know someone who has.

Based on the direction of health care and the rest of the world around us, there’s no good reason to think those issues are going to go away on their own. In fact, it looks more like the beginning of a new trend. Witness, for example, the significant changes that have taken place in physician certification over the past few years, as the process for maintaining certification was intensified and broadened to include a much larger spectrum of competencies and activities. This kind of trend is not something we can just continue to duck if we want to stay relevant—especially in the face of health care reform.

Decision-Making Process
With all of those issues in the background, the NCCPA created four foundational thoughts for the discussion on specialty certification. It was clear from the beginning to all parties discussing this concept that specialty recognition of any kind should be voluntary and independent of the existing generalist certification/recertification process. It was also critical that any certification program support and reinforce the relationship between PAs and their supervising physicians.

From the beginning of the discussion, NCCPA also felt it important to seek input and cooperation from all the appropriate stakeholders, particularly the AAPA and PA specialty professional organizations. (That’s why more than three years passed between NCCPA’s 2006 announcement that the organization would develop some form of specialty recognition and last month’s more detailed announcement about how the new process will work.) Lastly, and perhaps most importantly, specialty recognition must support the credentialing process while not creating barriers to licensure and practice.

By far the last issue was the most difficult to address. Opponents of specialty certification are concerned that any additional certification will create a barrier to mobility. There are also concerns that PAs who choose not to participate may find their résumés are sent to the bottom of the applicant pile. Sympathetic to these concerns, NCCPA committed to doing its part to maintain and promote the PA-C designation and state licensure as the sole “tickets” to practice by making both of those items prerequisites for the new specialty certification program.

Many stakeholder interests were considered in the discussion, with particular focus on the public and PAs. At the core of the discussion, it was clear that it is reasonable that the public—our patients—should expect that PAs working in specialty areas have been appropriately trained and evaluated in their chosen area of practice. The assumption here is that PAs, graduating from programs with a generalist curriculum, do not enter the workforce with the body of knowledge and experience needed in many of the non–primary care specialties. This is especially true in the specialties that are procedure-intensive or deal with the most critically ill or injured patients. At the same time, patients benefit from the presence of PAs in specialty practice, and in the interest of protecting or improving access to and affordability of care, NCCPA needs to be certain that PAs are equipped with the credentials they need to be there for those patients.

From the perspective of the average PA, the principal concern during discussions about specialty certification is the very strong desire to maintain the potential for interspecialty mobility. The most recent AAPA survey shows that 65% of PAs work in specialties or subspecialties.¹ Those PAs deserve and should have a mechanism for documentation of their education and abilities in their areas of practice, and everyone benefits when that documentation comes from a credible source through an appropriately rigorous process.

At the same time, PAs must remain cost-effective team members with the ability to move between specialties. Current data indicate that recently certified PAs are choosing specialty areas at a higher rate than those of us from earlier cohorts, and most PAs will work in two or more specialties during their career.² In a longitudinal cohort analysis from the AAPA, 57% of respondents reported changing specialties at least once, and 49% changed specialties within their first two years of practice.³

Specialty Certification
For those unfamiliar with the new specialty certification model, here is a recap.

To qualify for specialty certification, under this new voluntary system, PAs will be required to hold the PA-C designation, the generalist certification already awarded by the NCCPA. In addition, applicants will be required to have either an unencumbered state PA license or comparable authorization to practice from a federal agency.

Once PAs meet these prerequisites, the specialty certification pro-cess will include four requirements: specialty continuing medical education (CME), procedures and patient case logging, experience in the specialty, and a proctored specialty exam. In an effort to prevent the specialty certification program from becoming a barrier to entry to specialty practice, those four requirements may be completed in any order. After completing one component, PAs will be officially designated as candidates for specialty certification and may identify themselves that way to current or potential employers, credentialing boards, and others while in the process of completing the remaining requirements. 

Then, just like the PA-C certification process, specialty certification will be time limited. PAs will complete maintenance of certification process and periodically take and pass the specialty exam again to maintain their voluntary specialty certification. At this writing, the details of the maintenance process are still being developed.

What’s Next?
There are many other details to work through, and NCCPA is inviting appropriate physician and PA organizations to appoint members to specialty advisory committees that will help shape those details in a way that makes the most sense for each specialty included in the new certification program. These committees will consider, for their respective specialty, whether there are any specific CME topics or activities that should be required as part of the 25-hour CME requirement. The committees will discuss whether there should be exemptions to the experience requirement for specific educational experiences. They’ll also consider what procedures or types of cases should be logged, how many should be required, and whether there should be more than one menu of required procedures for subsets within a specialty to reflect the variability of PA practice, even within specific specialty areas.

Since NCCPA announced the new specialty certification model last month, the most frequently asked question has been, “Have you considered (my specialty)?” One of the most difficult decisions the workgroup faced was deciding which specialties should be included in the program’s initial launch. That decision would have been easy if NCCPA were—as some have suggested—introducing specialty certification to fill up its coffers. If this were about money, the NCCPA would have simply chosen the largest specialties and been done with it.

However, since this process was never about increasing revenues, the equation was much more complex. NCCPA considered many factors. Yes, population size was one of them. But we also considered what we’d been hearing from PAs in the various specialties about their need for some kind of specialty credential or documentation of qualifications; the support of the PA and physician specialty organizations; PA mobility trends; and the criticality of patients served, just to name a few. This was certainly not an easy task, but we knew we had to start somewhere, and the “somewhere” we ultimately chose includes a mix of large and small surgical and medical specialties and subspecialties.

The significance of introducing specialty certification for PAs is not lost on anyone involved with the NCCPA decision. The workgroup and the board of directors felt a great weight of responsibility to the organization, to PAs, and to the patients about whom we all care most deeply. This will change things. Some believe specialty certification will be the undoing of the PA profession. Others are grateful that someone has finally recognized that specialists within the profession need more recognition and documentation of qualifications in their area of practice. Time will be the judge, but from where I sit, the future of the PA profession has never looked brighter.

Some of my colleagues advised me against writing this editorial. They said it was akin to stepping on a beehive. I disagree. I have more faith and respect for my PA colleagues than that. As always, I appreciate professional and thoughtful dialogue. You can reach me at [email protected].  

This past month, the National Commission on Certification of Physician Assistants (NCCPA) notified all its stakeholders of a new voluntary specialty certification program for PAs in emergency medicine, orthopedic surgery, cardiovascular surgery, nephrology, and psychiatry to be launched in 2011—with the expectation that other specialties will follow. Many PAs have applauded this event; others have been critical of its potential effect on the profession.

Since I am the chair of the NCCPA’s workgroup on specialty certification and have been intimately involved for the past 3+ years with this topic, this editorial is written from that experience. As with most editorials, it is biased. A further disclaimer: These are my thoughts and experiences and should not be construed to be the policy of the NCCPA. I speak only for myself and offer my apologies to my NP colleagues for focusing on a PA-specific topic this month.

The Rationale
The starting place for our discussion at the NCCPA centered on acknowledging significant changes in the past decade within our health care system, coinciding with the growing clinical diversity of PA practice. Both of these issues indicated to the NCCPA that—after three decades of debate and discussion about the complexities and potential risks and rewards of certifying PAs in specialties—now is the appropriate time to do it.

Why? Simply put, NCCPA understands patients’ need for access to affordable, high-quality health care and believes passionately that certified PAs are integral to meeting that need. NCCPA’s responsibility in that equation is ensuring that certified PAs have the knowledge and skills to deliver the care and the documentation of their training, experience, and expertise needed to achieve and maintain their rightful place on the health care delivery team.

Of course, other environmental factors brought the issue to the forefront. It is a well-known fact that there has been a significant increase in the number of PAs practicing in specialty areas rather than primary care. At the same time, employers and governmental agencies (eg, AHRQ, NIH, IOM) are placing heightened emphasis on patient safety and risk management. State regulatory boards are taking a closer look at supervising responsibilities of physicians and the education of their PA partners. It is also clear that the complexities and increased demands of current health care practice place constraints and increased burden on supervision and other time-consuming aspects of the physician-PA relationship.

Even more compelling than those generalities, PAs in different parts of the country, in various specialties and practice settings, are increasingly facing real and significant challenges. Have you talked to many PAs practicing in psychiatry lately? If so, chances are you’ve heard about some real challenges to reimbursement. Practicing in a surgical specialty? If you haven’t been challenged to provide documentation of surgical training or expertise yourself, you probably know someone who has.

Based on the direction of health care and the rest of the world around us, there’s no good reason to think those issues are going to go away on their own. In fact, it looks more like the beginning of a new trend. Witness, for example, the significant changes that have taken place in physician certification over the past few years, as the process for maintaining certification was intensified and broadened to include a much larger spectrum of competencies and activities. This kind of trend is not something we can just continue to duck if we want to stay relevant—especially in the face of health care reform.

Decision-Making Process
With all of those issues in the background, the NCCPA created four foundational thoughts for the discussion on specialty certification. It was clear from the beginning to all parties discussing this concept that specialty recognition of any kind should be voluntary and independent of the existing generalist certification/recertification process. It was also critical that any certification program support and reinforce the relationship between PAs and their supervising physicians.

From the beginning of the discussion, NCCPA also felt it important to seek input and cooperation from all the appropriate stakeholders, particularly the AAPA and PA specialty professional organizations. (That’s why more than three years passed between NCCPA’s 2006 announcement that the organization would develop some form of specialty recognition and last month’s more detailed announcement about how the new process will work.) Lastly, and perhaps most importantly, specialty recognition must support the credentialing process while not creating barriers to licensure and practice.

By far the last issue was the most difficult to address. Opponents of specialty certification are concerned that any additional certification will create a barrier to mobility. There are also concerns that PAs who choose not to participate may find their résumés are sent to the bottom of the applicant pile. Sympathetic to these concerns, NCCPA committed to doing its part to maintain and promote the PA-C designation and state licensure as the sole “tickets” to practice by making both of those items prerequisites for the new specialty certification program.

Many stakeholder interests were considered in the discussion, with particular focus on the public and PAs. At the core of the discussion, it was clear that it is reasonable that the public—our patients—should expect that PAs working in specialty areas have been appropriately trained and evaluated in their chosen area of practice. The assumption here is that PAs, graduating from programs with a generalist curriculum, do not enter the workforce with the body of knowledge and experience needed in many of the non–primary care specialties. This is especially true in the specialties that are procedure-intensive or deal with the most critically ill or injured patients. At the same time, patients benefit from the presence of PAs in specialty practice, and in the interest of protecting or improving access to and affordability of care, NCCPA needs to be certain that PAs are equipped with the credentials they need to be there for those patients.

From the perspective of the average PA, the principal concern during discussions about specialty certification is the very strong desire to maintain the potential for interspecialty mobility. The most recent AAPA survey shows that 65% of PAs work in specialties or subspecialties.¹ Those PAs deserve and should have a mechanism for documentation of their education and abilities in their areas of practice, and everyone benefits when that documentation comes from a credible source through an appropriately rigorous process.

At the same time, PAs must remain cost-effective team members with the ability to move between specialties. Current data indicate that recently certified PAs are choosing specialty areas at a higher rate than those of us from earlier cohorts, and most PAs will work in two or more specialties during their career.² In a longitudinal cohort analysis from the AAPA, 57% of respondents reported changing specialties at least once, and 49% changed specialties within their first two years of practice.³

Specialty Certification
For those unfamiliar with the new specialty certification model, here is a recap.

To qualify for specialty certification, under this new voluntary system, PAs will be required to hold the PA-C designation, the generalist certification already awarded by the NCCPA. In addition, applicants will be required to have either an unencumbered state PA license or comparable authorization to practice from a federal agency.

Once PAs meet these prerequisites, the specialty certification pro-cess will include four requirements: specialty continuing medical education (CME), procedures and patient case logging, experience in the specialty, and a proctored specialty exam. In an effort to prevent the specialty certification program from becoming a barrier to entry to specialty practice, those four requirements may be completed in any order. After completing one component, PAs will be officially designated as candidates for specialty certification and may identify themselves that way to current or potential employers, credentialing boards, and others while in the process of completing the remaining requirements. 

Then, just like the PA-C certification process, specialty certification will be time limited. PAs will complete maintenance of certification process and periodically take and pass the specialty exam again to maintain their voluntary specialty certification. At this writing, the details of the maintenance process are still being developed.

What’s Next?
There are many other details to work through, and NCCPA is inviting appropriate physician and PA organizations to appoint members to specialty advisory committees that will help shape those details in a way that makes the most sense for each specialty included in the new certification program. These committees will consider, for their respective specialty, whether there are any specific CME topics or activities that should be required as part of the 25-hour CME requirement. The committees will discuss whether there should be exemptions to the experience requirement for specific educational experiences. They’ll also consider what procedures or types of cases should be logged, how many should be required, and whether there should be more than one menu of required procedures for subsets within a specialty to reflect the variability of PA practice, even within specific specialty areas.

Since NCCPA announced the new specialty certification model last month, the most frequently asked question has been, “Have you considered (my specialty)?” One of the most difficult decisions the workgroup faced was deciding which specialties should be included in the program’s initial launch. That decision would have been easy if NCCPA were—as some have suggested—introducing specialty certification to fill up its coffers. If this were about money, the NCCPA would have simply chosen the largest specialties and been done with it.

However, since this process was never about increasing revenues, the equation was much more complex. NCCPA considered many factors. Yes, population size was one of them. But we also considered what we’d been hearing from PAs in the various specialties about their need for some kind of specialty credential or documentation of qualifications; the support of the PA and physician specialty organizations; PA mobility trends; and the criticality of patients served, just to name a few. This was certainly not an easy task, but we knew we had to start somewhere, and the “somewhere” we ultimately chose includes a mix of large and small surgical and medical specialties and subspecialties.

The significance of introducing specialty certification for PAs is not lost on anyone involved with the NCCPA decision. The workgroup and the board of directors felt a great weight of responsibility to the organization, to PAs, and to the patients about whom we all care most deeply. This will change things. Some believe specialty certification will be the undoing of the PA profession. Others are grateful that someone has finally recognized that specialists within the profession need more recognition and documentation of qualifications in their area of practice. Time will be the judge, but from where I sit, the future of the PA profession has never looked brighter.

Some of my colleagues advised me against writing this editorial. They said it was akin to stepping on a beehive. I disagree. I have more faith and respect for my PA colleagues than that. As always, I appreciate professional and thoughtful dialogue. You can reach me at [email protected].  

This past month, the National Commission on Certification of Physician Assistants (NCCPA) notified all its stakeholders of a new voluntary specialty certification program for PAs in emergency medicine, orthopedic surgery, cardiovascular surgery, nephrology, and psychiatry to be launched in 2011—with the expectation that other specialties will follow. Many PAs have applauded this event; others have been critical of its potential effect on the profession.

Since I am the chair of the NCCPA’s workgroup on specialty certification and have been intimately involved for the past 3+ years with this topic, this editorial is written from that experience. As with most editorials, it is biased. A further disclaimer: These are my thoughts and experiences and should not be construed to be the policy of the NCCPA. I speak only for myself and offer my apologies to my NP colleagues for focusing on a PA-specific topic this month.

The Rationale
The starting place for our discussion at the NCCPA centered on acknowledging significant changes in the past decade within our health care system, coinciding with the growing clinical diversity of PA practice. Both of these issues indicated to the NCCPA that—after three decades of debate and discussion about the complexities and potential risks and rewards of certifying PAs in specialties—now is the appropriate time to do it.

Why? Simply put, NCCPA understands patients’ need for access to affordable, high-quality health care and believes passionately that certified PAs are integral to meeting that need. NCCPA’s responsibility in that equation is ensuring that certified PAs have the knowledge and skills to deliver the care and the documentation of their training, experience, and expertise needed to achieve and maintain their rightful place on the health care delivery team.

Of course, other environmental factors brought the issue to the forefront. It is a well-known fact that there has been a significant increase in the number of PAs practicing in specialty areas rather than primary care. At the same time, employers and governmental agencies (eg, AHRQ, NIH, IOM) are placing heightened emphasis on patient safety and risk management. State regulatory boards are taking a closer look at supervising responsibilities of physicians and the education of their PA partners. It is also clear that the complexities and increased demands of current health care practice place constraints and increased burden on supervision and other time-consuming aspects of the physician-PA relationship.

Even more compelling than those generalities, PAs in different parts of the country, in various specialties and practice settings, are increasingly facing real and significant challenges. Have you talked to many PAs practicing in psychiatry lately? If so, chances are you’ve heard about some real challenges to reimbursement. Practicing in a surgical specialty? If you haven’t been challenged to provide documentation of surgical training or expertise yourself, you probably know someone who has.

Based on the direction of health care and the rest of the world around us, there’s no good reason to think those issues are going to go away on their own. In fact, it looks more like the beginning of a new trend. Witness, for example, the significant changes that have taken place in physician certification over the past few years, as the process for maintaining certification was intensified and broadened to include a much larger spectrum of competencies and activities. This kind of trend is not something we can just continue to duck if we want to stay relevant—especially in the face of health care reform.

Decision-Making Process
With all of those issues in the background, the NCCPA created four foundational thoughts for the discussion on specialty certification. It was clear from the beginning to all parties discussing this concept that specialty recognition of any kind should be voluntary and independent of the existing generalist certification/recertification process. It was also critical that any certification program support and reinforce the relationship between PAs and their supervising physicians.

From the beginning of the discussion, NCCPA also felt it important to seek input and cooperation from all the appropriate stakeholders, particularly the AAPA and PA specialty professional organizations. (That’s why more than three years passed between NCCPA’s 2006 announcement that the organization would develop some form of specialty recognition and last month’s more detailed announcement about how the new process will work.) Lastly, and perhaps most importantly, specialty recognition must support the credentialing process while not creating barriers to licensure and practice.

By far the last issue was the most difficult to address. Opponents of specialty certification are concerned that any additional certification will create a barrier to mobility. There are also concerns that PAs who choose not to participate may find their résumés are sent to the bottom of the applicant pile. Sympathetic to these concerns, NCCPA committed to doing its part to maintain and promote the PA-C designation and state licensure as the sole “tickets” to practice by making both of those items prerequisites for the new specialty certification program.

Many stakeholder interests were considered in the discussion, with particular focus on the public and PAs. At the core of the discussion, it was clear that it is reasonable that the public—our patients—should expect that PAs working in specialty areas have been appropriately trained and evaluated in their chosen area of practice. The assumption here is that PAs, graduating from programs with a generalist curriculum, do not enter the workforce with the body of knowledge and experience needed in many of the non–primary care specialties. This is especially true in the specialties that are procedure-intensive or deal with the most critically ill or injured patients. At the same time, patients benefit from the presence of PAs in specialty practice, and in the interest of protecting or improving access to and affordability of care, NCCPA needs to be certain that PAs are equipped with the credentials they need to be there for those patients.

From the perspective of the average PA, the principal concern during discussions about specialty certification is the very strong desire to maintain the potential for interspecialty mobility. The most recent AAPA survey shows that 65% of PAs work in specialties or subspecialties.¹ Those PAs deserve and should have a mechanism for documentation of their education and abilities in their areas of practice, and everyone benefits when that documentation comes from a credible source through an appropriately rigorous process.

At the same time, PAs must remain cost-effective team members with the ability to move between specialties. Current data indicate that recently certified PAs are choosing specialty areas at a higher rate than those of us from earlier cohorts, and most PAs will work in two or more specialties during their career.² In a longitudinal cohort analysis from the AAPA, 57% of respondents reported changing specialties at least once, and 49% changed specialties within their first two years of practice.³

Specialty Certification
For those unfamiliar with the new specialty certification model, here is a recap.

To qualify for specialty certification, under this new voluntary system, PAs will be required to hold the PA-C designation, the generalist certification already awarded by the NCCPA. In addition, applicants will be required to have either an unencumbered state PA license or comparable authorization to practice from a federal agency.

Once PAs meet these prerequisites, the specialty certification pro-cess will include four requirements: specialty continuing medical education (CME), procedures and patient case logging, experience in the specialty, and a proctored specialty exam. In an effort to prevent the specialty certification program from becoming a barrier to entry to specialty practice, those four requirements may be completed in any order. After completing one component, PAs will be officially designated as candidates for specialty certification and may identify themselves that way to current or potential employers, credentialing boards, and others while in the process of completing the remaining requirements. 

Then, just like the PA-C certification process, specialty certification will be time limited. PAs will complete maintenance of certification process and periodically take and pass the specialty exam again to maintain their voluntary specialty certification. At this writing, the details of the maintenance process are still being developed.

What’s Next?
There are many other details to work through, and NCCPA is inviting appropriate physician and PA organizations to appoint members to specialty advisory committees that will help shape those details in a way that makes the most sense for each specialty included in the new certification program. These committees will consider, for their respective specialty, whether there are any specific CME topics or activities that should be required as part of the 25-hour CME requirement. The committees will discuss whether there should be exemptions to the experience requirement for specific educational experiences. They’ll also consider what procedures or types of cases should be logged, how many should be required, and whether there should be more than one menu of required procedures for subsets within a specialty to reflect the variability of PA practice, even within specific specialty areas.

Since NCCPA announced the new specialty certification model last month, the most frequently asked question has been, “Have you considered (my specialty)?” One of the most difficult decisions the workgroup faced was deciding which specialties should be included in the program’s initial launch. That decision would have been easy if NCCPA were—as some have suggested—introducing specialty certification to fill up its coffers. If this were about money, the NCCPA would have simply chosen the largest specialties and been done with it.

However, since this process was never about increasing revenues, the equation was much more complex. NCCPA considered many factors. Yes, population size was one of them. But we also considered what we’d been hearing from PAs in the various specialties about their need for some kind of specialty credential or documentation of qualifications; the support of the PA and physician specialty organizations; PA mobility trends; and the criticality of patients served, just to name a few. This was certainly not an easy task, but we knew we had to start somewhere, and the “somewhere” we ultimately chose includes a mix of large and small surgical and medical specialties and subspecialties.

The significance of introducing specialty certification for PAs is not lost on anyone involved with the NCCPA decision. The workgroup and the board of directors felt a great weight of responsibility to the organization, to PAs, and to the patients about whom we all care most deeply. This will change things. Some believe specialty certification will be the undoing of the PA profession. Others are grateful that someone has finally recognized that specialists within the profession need more recognition and documentation of qualifications in their area of practice. Time will be the judge, but from where I sit, the future of the PA profession has never looked brighter.

Some of my colleagues advised me against writing this editorial. They said it was akin to stepping on a beehive. I disagree. I have more faith and respect for my PA colleagues than that. As always, I appreciate professional and thoughtful dialogue. You can reach me at [email protected].  

This year, President Obama and Congress will attempt health care reform, giving particular attention to the issues of affordability, quality, and access to care. Another area that I have been concerned about—one that is certainly linked to quality—is compassionate care.

Let me share an example: A few weeks ago, while assisting my granddaughter in putting a bed frame together, my wife fell and struck her face on an end table. We took her directly to the local emergency center. After about an hour, she was ushered into the exam room, where the physician, without ever actually speaking to her, made a quick examination and dictated orders for CT of the head and face to the nurse. He said the PA would be in to suture up my wife’s lacerations. He showed about as much compassion to her plight as the end table did.

Now, there is some good news in this story. After the CT scan (which was negative) and another three-hour wait, the PA entered the room. What a contrast! He was appropriately concerned and spoke directly to my wife while he examined her. He spoke to me to let me know what he recommended. He took an appropriate history, talked to my wife about safety at home, and also appropriately interjected some humor. His demeanor (and compassion) significantly calmed my wife (and me), and further distress from this otherwise frightful situation was averted.

Now, I am about to go out on a limb: How often have you heard stories about physicians showing a lack of compassion? I have heard such stories many times. In fairness, I have known many physicians who were very caring and compassionate. But unfortunately, in my experience, this has been the exception rather than the rule. Some say that medical school and residency tend to knock the compassion out of people.

Now, if I turn the question around and ask how often you’ve heard about PAs or NPs showing a lack of compassion, the answer changes. It is not uncommon to hear that the PA or NP went above and beyond and was very compassionate in taking care of patients. This seems to be the rule rather than the exception. (OK, I admit that I am biased.) The question “Are PAs and NPs more or less compassionate than physicians?” would be the basis of a great study. My editorial comments are purely anecdotal and may inadvertently perpetuate a myth.

From the time of the Flexner report,1 medical educators have been criticized by foundations, educational institutions, and professional task forces for emphasizing scientific knowledge over many other skills, including compassion. When it comes to compassion, will we know it when we see it? It is true that there is no shortage of books and articles on the subject of compassion; however, there is little consistency. According to Purtilo,2 “There are three powerful components of compassion: (1) The character trait or virtue of sympathetic understanding recognized as a virtue, (2) Willingness to carry out your professional responsibilities toward the patient, recognized as moral duty, and (3) Readiness to go beyond the call of duty.” The word compassion comes from the Latin passio (“suffering”) and con (“with”), a concept that encourages the desire to treat others with sympathy and understanding.

As we evaluate health care reform this year, we must revisit how best to assess and promote compassion. It is clear to me that an effective method must be multifaceted. The success of any clinician is based in part on professional and interpersonal skills—including compassion—developed before, during, and after the process of formal education. Some would argue that compassion cannot be taught: Either it’s there or it’s not.

I am calling on all educational programs to reevaluate their selection process and to give greater attention to professionalism, particularly as it relates to compassion. Recognizing that current interviewing processes are not suited to evaluate an applicant’s professionalism, I suggest they be redesigned to have applicants write reflective papers examining ethical situations. Alternatively, applicants might be required to participate in group problem-solving exercises during the interview process.

A crucial aspect of any professional educational curriculum is the development or enhancement of professional behaviors and role identity. There is evidence that unprofessional behavior exhibited during the educational process is a predictor of future problems with regulatory boards. Both subjective and objective measures should occur during the educational process to assess compassion. Some of the best ways to assess this component of professionalism are through faculty and preceptor modeling, strong professional expectations, reflective papers, peer evaluations, standardized patients, and objective structured clinical examinations.

There are some objective assessment tools that look at emotional and cognitive intelligence; however, they are expensive and require certified evaluators. Assessing actual student attitudes and behavior during the educational process is arguably a better way of ensuring that graduates are competent in these areas. Judgments about attitudinal and behavioral competencies are legitimate and no more arbitrary than those made about scientific or clinical knowledge. Therefore, teachers and mentors must demand appropriate behaviors when they interact with students in clinical teaching environments.

According to Punkett,3 “If ethical, professional, and interpersonal skills are important to the profession and should be taught in professional programs, then students need structured feedback on these behaviors, just as they receive feedback on their medical knowledge and clinical skills.” Institutions can begin (or enhance) development of these skills by publishing standards that address professional behaviors in addition to the academic and technical standards that are the mainstay of curricula.

We cannot overestimate the importance of modeling and the role that peers and preceptors play in the process of fostering compassion in clinicians. According to Cooke et al,4 “Cognitive psychology has demonstrated that facts and concepts are best recalled and put into service when they are taught, practiced, and assessed in the context in which they will be used.”

PAs, NPs, and physicians are expected by our society to meet the highest professional and ethical standards. I started this editorial by illustrating where one physician did not meet this standard and where one PA did. The title is a little misleading (purposefully), since I think we (PAs and NPs) are leading the way in compassionate health care. We must continue that leadership and model that behavior to our peers and colleagues who are physicians and avert the demise of compassion in our health care system.

I would love to hear your examples of situations when one of your peers met and actually exceeded your expectations of compassionate health care. Please send your responses to this editorial to [email protected].

This year, President Obama and Congress will attempt health care reform, giving particular attention to the issues of affordability, quality, and access to care. Another area that I have been concerned about—one that is certainly linked to quality—is compassionate care.

Let me share an example: A few weeks ago, while assisting my granddaughter in putting a bed frame together, my wife fell and struck her face on an end table. We took her directly to the local emergency center. After about an hour, she was ushered into the exam room, where the physician, without ever actually speaking to her, made a quick examination and dictated orders for CT of the head and face to the nurse. He said the PA would be in to suture up my wife’s lacerations. He showed about as much compassion to her plight as the end table did.

Now, there is some good news in this story. After the CT scan (which was negative) and another three-hour wait, the PA entered the room. What a contrast! He was appropriately concerned and spoke directly to my wife while he examined her. He spoke to me to let me know what he recommended. He took an appropriate history, talked to my wife about safety at home, and also appropriately interjected some humor. His demeanor (and compassion) significantly calmed my wife (and me), and further distress from this otherwise frightful situation was averted.

Now, I am about to go out on a limb: How often have you heard stories about physicians showing a lack of compassion? I have heard such stories many times. In fairness, I have known many physicians who were very caring and compassionate. But unfortunately, in my experience, this has been the exception rather than the rule. Some say that medical school and residency tend to knock the compassion out of people.

Now, if I turn the question around and ask how often you’ve heard about PAs or NPs showing a lack of compassion, the answer changes. It is not uncommon to hear that the PA or NP went above and beyond and was very compassionate in taking care of patients. This seems to be the rule rather than the exception. (OK, I admit that I am biased.) The question “Are PAs and NPs more or less compassionate than physicians?” would be the basis of a great study. My editorial comments are purely anecdotal and may inadvertently perpetuate a myth.

From the time of the Flexner report,1 medical educators have been criticized by foundations, educational institutions, and professional task forces for emphasizing scientific knowledge over many other skills, including compassion. When it comes to compassion, will we know it when we see it? It is true that there is no shortage of books and articles on the subject of compassion; however, there is little consistency. According to Purtilo,2 “There are three powerful components of compassion: (1) The character trait or virtue of sympathetic understanding recognized as a virtue, (2) Willingness to carry out your professional responsibilities toward the patient, recognized as moral duty, and (3) Readiness to go beyond the call of duty.” The word compassion comes from the Latin passio (“suffering”) and con (“with”), a concept that encourages the desire to treat others with sympathy and understanding.

As we evaluate health care reform this year, we must revisit how best to assess and promote compassion. It is clear to me that an effective method must be multifaceted. The success of any clinician is based in part on professional and interpersonal skills—including compassion—developed before, during, and after the process of formal education. Some would argue that compassion cannot be taught: Either it’s there or it’s not.

I am calling on all educational programs to reevaluate their selection process and to give greater attention to professionalism, particularly as it relates to compassion. Recognizing that current interviewing processes are not suited to evaluate an applicant’s professionalism, I suggest they be redesigned to have applicants write reflective papers examining ethical situations. Alternatively, applicants might be required to participate in group problem-solving exercises during the interview process.

A crucial aspect of any professional educational curriculum is the development or enhancement of professional behaviors and role identity. There is evidence that unprofessional behavior exhibited during the educational process is a predictor of future problems with regulatory boards. Both subjective and objective measures should occur during the educational process to assess compassion. Some of the best ways to assess this component of professionalism are through faculty and preceptor modeling, strong professional expectations, reflective papers, peer evaluations, standardized patients, and objective structured clinical examinations.

There are some objective assessment tools that look at emotional and cognitive intelligence; however, they are expensive and require certified evaluators. Assessing actual student attitudes and behavior during the educational process is arguably a better way of ensuring that graduates are competent in these areas. Judgments about attitudinal and behavioral competencies are legitimate and no more arbitrary than those made about scientific or clinical knowledge. Therefore, teachers and mentors must demand appropriate behaviors when they interact with students in clinical teaching environments.

According to Punkett,3 “If ethical, professional, and interpersonal skills are important to the profession and should be taught in professional programs, then students need structured feedback on these behaviors, just as they receive feedback on their medical knowledge and clinical skills.” Institutions can begin (or enhance) development of these skills by publishing standards that address professional behaviors in addition to the academic and technical standards that are the mainstay of curricula.

We cannot overestimate the importance of modeling and the role that peers and preceptors play in the process of fostering compassion in clinicians. According to Cooke et al,4 “Cognitive psychology has demonstrated that facts and concepts are best recalled and put into service when they are taught, practiced, and assessed in the context in which they will be used.”

PAs, NPs, and physicians are expected by our society to meet the highest professional and ethical standards. I started this editorial by illustrating where one physician did not meet this standard and where one PA did. The title is a little misleading (purposefully), since I think we (PAs and NPs) are leading the way in compassionate health care. We must continue that leadership and model that behavior to our peers and colleagues who are physicians and avert the demise of compassion in our health care system.

I would love to hear your examples of situations when one of your peers met and actually exceeded your expectations of compassionate health care. Please send your responses to this editorial to [email protected].

This year, President Obama and Congress will attempt health care reform, giving particular attention to the issues of affordability, quality, and access to care. Another area that I have been concerned about—one that is certainly linked to quality—is compassionate care.

Let me share an example: A few weeks ago, while assisting my granddaughter in putting a bed frame together, my wife fell and struck her face on an end table. We took her directly to the local emergency center. After about an hour, she was ushered into the exam room, where the physician, without ever actually speaking to her, made a quick examination and dictated orders for CT of the head and face to the nurse. He said the PA would be in to suture up my wife’s lacerations. He showed about as much compassion to her plight as the end table did.

Now, there is some good news in this story. After the CT scan (which was negative) and another three-hour wait, the PA entered the room. What a contrast! He was appropriately concerned and spoke directly to my wife while he examined her. He spoke to me to let me know what he recommended. He took an appropriate history, talked to my wife about safety at home, and also appropriately interjected some humor. His demeanor (and compassion) significantly calmed my wife (and me), and further distress from this otherwise frightful situation was averted.

Now, I am about to go out on a limb: How often have you heard stories about physicians showing a lack of compassion? I have heard such stories many times. In fairness, I have known many physicians who were very caring and compassionate. But unfortunately, in my experience, this has been the exception rather than the rule. Some say that medical school and residency tend to knock the compassion out of people.

Now, if I turn the question around and ask how often you’ve heard about PAs or NPs showing a lack of compassion, the answer changes. It is not uncommon to hear that the PA or NP went above and beyond and was very compassionate in taking care of patients. This seems to be the rule rather than the exception. (OK, I admit that I am biased.) The question “Are PAs and NPs more or less compassionate than physicians?” would be the basis of a great study. My editorial comments are purely anecdotal and may inadvertently perpetuate a myth.

From the time of the Flexner report,1 medical educators have been criticized by foundations, educational institutions, and professional task forces for emphasizing scientific knowledge over many other skills, including compassion. When it comes to compassion, will we know it when we see it? It is true that there is no shortage of books and articles on the subject of compassion; however, there is little consistency. According to Purtilo,2 “There are three powerful components of compassion: (1) The character trait or virtue of sympathetic understanding recognized as a virtue, (2) Willingness to carry out your professional responsibilities toward the patient, recognized as moral duty, and (3) Readiness to go beyond the call of duty.” The word compassion comes from the Latin passio (“suffering”) and con (“with”), a concept that encourages the desire to treat others with sympathy and understanding.

As we evaluate health care reform this year, we must revisit how best to assess and promote compassion. It is clear to me that an effective method must be multifaceted. The success of any clinician is based in part on professional and interpersonal skills—including compassion—developed before, during, and after the process of formal education. Some would argue that compassion cannot be taught: Either it’s there or it’s not.

I am calling on all educational programs to reevaluate their selection process and to give greater attention to professionalism, particularly as it relates to compassion. Recognizing that current interviewing processes are not suited to evaluate an applicant’s professionalism, I suggest they be redesigned to have applicants write reflective papers examining ethical situations. Alternatively, applicants might be required to participate in group problem-solving exercises during the interview process.

A crucial aspect of any professional educational curriculum is the development or enhancement of professional behaviors and role identity. There is evidence that unprofessional behavior exhibited during the educational process is a predictor of future problems with regulatory boards. Both subjective and objective measures should occur during the educational process to assess compassion. Some of the best ways to assess this component of professionalism are through faculty and preceptor modeling, strong professional expectations, reflective papers, peer evaluations, standardized patients, and objective structured clinical examinations.

There are some objective assessment tools that look at emotional and cognitive intelligence; however, they are expensive and require certified evaluators. Assessing actual student attitudes and behavior during the educational process is arguably a better way of ensuring that graduates are competent in these areas. Judgments about attitudinal and behavioral competencies are legitimate and no more arbitrary than those made about scientific or clinical knowledge. Therefore, teachers and mentors must demand appropriate behaviors when they interact with students in clinical teaching environments.

According to Punkett,3 “If ethical, professional, and interpersonal skills are important to the profession and should be taught in professional programs, then students need structured feedback on these behaviors, just as they receive feedback on their medical knowledge and clinical skills.” Institutions can begin (or enhance) development of these skills by publishing standards that address professional behaviors in addition to the academic and technical standards that are the mainstay of curricula.

We cannot overestimate the importance of modeling and the role that peers and preceptors play in the process of fostering compassion in clinicians. According to Cooke et al,4 “Cognitive psychology has demonstrated that facts and concepts are best recalled and put into service when they are taught, practiced, and assessed in the context in which they will be used.”

PAs, NPs, and physicians are expected by our society to meet the highest professional and ethical standards. I started this editorial by illustrating where one physician did not meet this standard and where one PA did. The title is a little misleading (purposefully), since I think we (PAs and NPs) are leading the way in compassionate health care. We must continue that leadership and model that behavior to our peers and colleagues who are physicians and avert the demise of compassion in our health care system.

I would love to hear your examples of situations when one of your peers met and actually exceeded your expectations of compassionate health care. Please send your responses to this editorial to [email protected].

The other day, I saw my health care practitioner for a routine visit and noticed that the office had started using an electronic medical record (EMR). He came into the exam room with a small laptop computer, sat facing the computer, and entered information while asking me questions. At the conclusion of the visit, he handed me a computerized form that had both my prescriptions and laboratory orders.

As I came up the ranks in health care, the medical record (we always called it the “chart”) had been stored in a paper file in the physician’s office and contained various levels of information. The chart was a retrospective record of the encounter between clinician and patient. Over the years, government and regulatory agencies started dictating what the chart should contain. Attorneys now rely on the medical record as the legal documentation of what actually happened between clinician and patient.

Currently, there are snippets of medical information in records kept in various places where the patient has received treatment. A consistent effort to unify that information is lacking. The keeper of the record was always, of course, the physician. In recent years, we found that the physician and the patient actually “owned” the information and that both were entitled to control the access. Some say that the only way to create consistency of medical information is to move from the paper record to electronic storage and linkage: the EMR. 

The strongest rationale for adopting the EMR is that it will allow all significant information to be accessible in one place. It can be organized, efficient, and searchable. Patient safety is another major justification. An EMR could inform the clinician about a patient’s allergy to a medication or an unfavorable interaction with another medication the patient is taking. Access to the complete medical record, whether in the clinic, the hospital, or any other health care setting, would save time, money—and certainly, lives. The biggest system using EMRs, the Department of Veterans Affairs (VA), has managed to improve every benchmark of quality in health care in the past decade. According to the VA, costs per patient were reduced 32% in the past decade, while the medical consumer price index has increased by 50%. 

There must be some downside to this concept: Would the increasing longitudinal infor-mation—encompassing personal and family history, clinical encounters, laboratory and radiographic data, and referral material—result in data overload? The EMR should be capable of revealing complex trends and patterns. Who has the ability to create and/or alter an entry? Who will be keeping the record, and who owns it? What about retention? Whose responsibility is it to keep the records for the legally required amount of time? Aside from the obvious cost of EMRs, what about privacy and access? There must be both ethical and legal barriers. Recent well-publicized episodes of lost electronic health care data by the VA and the military illustrate that scrupulous ownership is imperative.

According to a report in the LA Times, about 150 people (from clinicians to technicians to billers) currently have access to at least part of a patient’s medical record during hospitalization, with more than 600,000 payers, providers, and others also having some access. If EMRs were instituted universally, would these numbers increase? Multiple access points may be a problem for protected health information and may cause HIPAA violations.

Do the benefits of EMRs outweigh the risks? If so, it may be clinically wrong to delay the development and implementation of EMRs in this country. Medical records are legal documents that must be kept unaltered and authenticated by the clinician or creator of the document. If we all agree that the patient owns the EMR and has the authority to grant privileges and access to the record, then the issues of privacy fall by the wayside.

During the presidential election campaign this past year, Barack Obama discussed extensive plans for investment in EMRs. In a postelection radio address he stated, “In addition to connecting our libraries and schools to the Internet, we must also ensure that our hospitals are connected to each other through the Internet. That is why the economic recovery plan I’m proposing will help modernize our health care system—and that won’t just save jobs, it will save lives. We will make sure that every doctor’s office and hospital in this country is using cutting edge technology and electronic medical records so that we can cut red tape, prevent medical mistakes, and help save billions of dollars each year” (see http://change.gov/newsroom/entry/the_key_parts_of_the_jobs_plan).

According to a 2008 survey conducted by the CDC, only 38.4% of physicians reported they were using full or partial EMR systems, and 20.4% said they were using minimally functioning EMRs for e-prescribing, ordering, and viewing results of lab tests. Only 17% of physicians reported using basic EMR systems. Clinicians are reluctant to use a system that does not mirror their practice style. Since programmers, who are not clinicians, develop most EMRs, the applications are not widely accepted.

What about hospital-based EMRs? A survey recently reported in the New England Journal of Medicine (2009;360[16]:1628-1638) showed that only 1.5% of hospitals in the United States have a comprehensive electronic-records system. An additional 7.6% have a basic system. According to the study, larger hospitals and teaching hospitals were more likely to have electronic-records systems. Hospitals responding to this survey cited “capital requirements and high maintenance costs as the primary barriers to implementation.”

Based on what I hear from clinicians, the main reasons they are not readily adopting the EMR include: (1) it is too cumbersome and fosters depersonalization, (2) too much typing is required, (3) too many clicks are required for even minor tasks, (4) it is user-unfriendly, (5) it is too rigid—all notes look the same, (6) it is too time-consuming, and (7) it is too costly. One would think that EMRs should be built to conform to the individual practice style.

Although dictation remains one of the most efficient uses of a clinician’s time, a clinician may be drawn to utilize an EMR if there are offset benefits such as automated scheduling, ordering, billing, and prescription writing and integrated information systems. It appears that initial costs of an EMR system start around $71,000, with an annual cost of around $2,000. Unfortunately, we cannot simply go into an office supply mart and compare the features of various EMR products and choose the one that meets our need and is within our price range. There doesn’t seem to be uniform price structure to allow that kind of shopping.

Should we demand progress on implementation of user-friendly, cost-effective EMRs so that we can have access to a safer, more effective health care system, or is it all just “smoke and mirrors” and too much trouble? I welcome your comments about EMRs. Please send your responses to [email protected].

The other day, I saw my health care practitioner for a routine visit and noticed that the office had started using an electronic medical record (EMR). He came into the exam room with a small laptop computer, sat facing the computer, and entered information while asking me questions. At the conclusion of the visit, he handed me a computerized form that had both my prescriptions and laboratory orders.

As I came up the ranks in health care, the medical record (we always called it the “chart”) had been stored in a paper file in the physician’s office and contained various levels of information. The chart was a retrospective record of the encounter between clinician and patient. Over the years, government and regulatory agencies started dictating what the chart should contain. Attorneys now rely on the medical record as the legal documentation of what actually happened between clinician and patient.

Currently, there are snippets of medical information in records kept in various places where the patient has received treatment. A consistent effort to unify that information is lacking. The keeper of the record was always, of course, the physician. In recent years, we found that the physician and the patient actually “owned” the information and that both were entitled to control the access. Some say that the only way to create consistency of medical information is to move from the paper record to electronic storage and linkage: the EMR. 

The strongest rationale for adopting the EMR is that it will allow all significant information to be accessible in one place. It can be organized, efficient, and searchable. Patient safety is another major justification. An EMR could inform the clinician about a patient’s allergy to a medication or an unfavorable interaction with another medication the patient is taking. Access to the complete medical record, whether in the clinic, the hospital, or any other health care setting, would save time, money—and certainly, lives. The biggest system using EMRs, the Department of Veterans Affairs (VA), has managed to improve every benchmark of quality in health care in the past decade. According to the VA, costs per patient were reduced 32% in the past decade, while the medical consumer price index has increased by 50%. 

There must be some downside to this concept: Would the increasing longitudinal infor-mation—encompassing personal and family history, clinical encounters, laboratory and radiographic data, and referral material—result in data overload? The EMR should be capable of revealing complex trends and patterns. Who has the ability to create and/or alter an entry? Who will be keeping the record, and who owns it? What about retention? Whose responsibility is it to keep the records for the legally required amount of time? Aside from the obvious cost of EMRs, what about privacy and access? There must be both ethical and legal barriers. Recent well-publicized episodes of lost electronic health care data by the VA and the military illustrate that scrupulous ownership is imperative.

According to a report in the LA Times, about 150 people (from clinicians to technicians to billers) currently have access to at least part of a patient’s medical record during hospitalization, with more than 600,000 payers, providers, and others also having some access. If EMRs were instituted universally, would these numbers increase? Multiple access points may be a problem for protected health information and may cause HIPAA violations.

Do the benefits of EMRs outweigh the risks? If so, it may be clinically wrong to delay the development and implementation of EMRs in this country. Medical records are legal documents that must be kept unaltered and authenticated by the clinician or creator of the document. If we all agree that the patient owns the EMR and has the authority to grant privileges and access to the record, then the issues of privacy fall by the wayside.

During the presidential election campaign this past year, Barack Obama discussed extensive plans for investment in EMRs. In a postelection radio address he stated, “In addition to connecting our libraries and schools to the Internet, we must also ensure that our hospitals are connected to each other through the Internet. That is why the economic recovery plan I’m proposing will help modernize our health care system—and that won’t just save jobs, it will save lives. We will make sure that every doctor’s office and hospital in this country is using cutting edge technology and electronic medical records so that we can cut red tape, prevent medical mistakes, and help save billions of dollars each year” (see http://change.gov/newsroom/entry/the_key_parts_of_the_jobs_plan).

According to a 2008 survey conducted by the CDC, only 38.4% of physicians reported they were using full or partial EMR systems, and 20.4% said they were using minimally functioning EMRs for e-prescribing, ordering, and viewing results of lab tests. Only 17% of physicians reported using basic EMR systems. Clinicians are reluctant to use a system that does not mirror their practice style. Since programmers, who are not clinicians, develop most EMRs, the applications are not widely accepted.

What about hospital-based EMRs? A survey recently reported in the New England Journal of Medicine (2009;360[16]:1628-1638) showed that only 1.5% of hospitals in the United States have a comprehensive electronic-records system. An additional 7.6% have a basic system. According to the study, larger hospitals and teaching hospitals were more likely to have electronic-records systems. Hospitals responding to this survey cited “capital requirements and high maintenance costs as the primary barriers to implementation.”

Based on what I hear from clinicians, the main reasons they are not readily adopting the EMR include: (1) it is too cumbersome and fosters depersonalization, (2) too much typing is required, (3) too many clicks are required for even minor tasks, (4) it is user-unfriendly, (5) it is too rigid—all notes look the same, (6) it is too time-consuming, and (7) it is too costly. One would think that EMRs should be built to conform to the individual practice style.

Although dictation remains one of the most efficient uses of a clinician’s time, a clinician may be drawn to utilize an EMR if there are offset benefits such as automated scheduling, ordering, billing, and prescription writing and integrated information systems. It appears that initial costs of an EMR system start around $71,000, with an annual cost of around $2,000. Unfortunately, we cannot simply go into an office supply mart and compare the features of various EMR products and choose the one that meets our need and is within our price range. There doesn’t seem to be uniform price structure to allow that kind of shopping.

Should we demand progress on implementation of user-friendly, cost-effective EMRs so that we can have access to a safer, more effective health care system, or is it all just “smoke and mirrors” and too much trouble? I welcome your comments about EMRs. Please send your responses to [email protected].

The other day, I saw my health care practitioner for a routine visit and noticed that the office had started using an electronic medical record (EMR). He came into the exam room with a small laptop computer, sat facing the computer, and entered information while asking me questions. At the conclusion of the visit, he handed me a computerized form that had both my prescriptions and laboratory orders.

As I came up the ranks in health care, the medical record (we always called it the “chart”) had been stored in a paper file in the physician’s office and contained various levels of information. The chart was a retrospective record of the encounter between clinician and patient. Over the years, government and regulatory agencies started dictating what the chart should contain. Attorneys now rely on the medical record as the legal documentation of what actually happened between clinician and patient.

Currently, there are snippets of medical information in records kept in various places where the patient has received treatment. A consistent effort to unify that information is lacking. The keeper of the record was always, of course, the physician. In recent years, we found that the physician and the patient actually “owned” the information and that both were entitled to control the access. Some say that the only way to create consistency of medical information is to move from the paper record to electronic storage and linkage: the EMR. 

The strongest rationale for adopting the EMR is that it will allow all significant information to be accessible in one place. It can be organized, efficient, and searchable. Patient safety is another major justification. An EMR could inform the clinician about a patient’s allergy to a medication or an unfavorable interaction with another medication the patient is taking. Access to the complete medical record, whether in the clinic, the hospital, or any other health care setting, would save time, money—and certainly, lives. The biggest system using EMRs, the Department of Veterans Affairs (VA), has managed to improve every benchmark of quality in health care in the past decade. According to the VA, costs per patient were reduced 32% in the past decade, while the medical consumer price index has increased by 50%. 

There must be some downside to this concept: Would the increasing longitudinal infor-mation—encompassing personal and family history, clinical encounters, laboratory and radiographic data, and referral material—result in data overload? The EMR should be capable of revealing complex trends and patterns. Who has the ability to create and/or alter an entry? Who will be keeping the record, and who owns it? What about retention? Whose responsibility is it to keep the records for the legally required amount of time? Aside from the obvious cost of EMRs, what about privacy and access? There must be both ethical and legal barriers. Recent well-publicized episodes of lost electronic health care data by the VA and the military illustrate that scrupulous ownership is imperative.

According to a report in the LA Times, about 150 people (from clinicians to technicians to billers) currently have access to at least part of a patient’s medical record during hospitalization, with more than 600,000 payers, providers, and others also having some access. If EMRs were instituted universally, would these numbers increase? Multiple access points may be a problem for protected health information and may cause HIPAA violations.

Do the benefits of EMRs outweigh the risks? If so, it may be clinically wrong to delay the development and implementation of EMRs in this country. Medical records are legal documents that must be kept unaltered and authenticated by the clinician or creator of the document. If we all agree that the patient owns the EMR and has the authority to grant privileges and access to the record, then the issues of privacy fall by the wayside.

During the presidential election campaign this past year, Barack Obama discussed extensive plans for investment in EMRs. In a postelection radio address he stated, “In addition to connecting our libraries and schools to the Internet, we must also ensure that our hospitals are connected to each other through the Internet. That is why the economic recovery plan I’m proposing will help modernize our health care system—and that won’t just save jobs, it will save lives. We will make sure that every doctor’s office and hospital in this country is using cutting edge technology and electronic medical records so that we can cut red tape, prevent medical mistakes, and help save billions of dollars each year” (see http://change.gov/newsroom/entry/the_key_parts_of_the_jobs_plan).

According to a 2008 survey conducted by the CDC, only 38.4% of physicians reported they were using full or partial EMR systems, and 20.4% said they were using minimally functioning EMRs for e-prescribing, ordering, and viewing results of lab tests. Only 17% of physicians reported using basic EMR systems. Clinicians are reluctant to use a system that does not mirror their practice style. Since programmers, who are not clinicians, develop most EMRs, the applications are not widely accepted.

What about hospital-based EMRs? A survey recently reported in the New England Journal of Medicine (2009;360[16]:1628-1638) showed that only 1.5% of hospitals in the United States have a comprehensive electronic-records system. An additional 7.6% have a basic system. According to the study, larger hospitals and teaching hospitals were more likely to have electronic-records systems. Hospitals responding to this survey cited “capital requirements and high maintenance costs as the primary barriers to implementation.”

Based on what I hear from clinicians, the main reasons they are not readily adopting the EMR include: (1) it is too cumbersome and fosters depersonalization, (2) too much typing is required, (3) too many clicks are required for even minor tasks, (4) it is user-unfriendly, (5) it is too rigid—all notes look the same, (6) it is too time-consuming, and (7) it is too costly. One would think that EMRs should be built to conform to the individual practice style.

Although dictation remains one of the most efficient uses of a clinician’s time, a clinician may be drawn to utilize an EMR if there are offset benefits such as automated scheduling, ordering, billing, and prescription writing and integrated information systems. It appears that initial costs of an EMR system start around $71,000, with an annual cost of around $2,000. Unfortunately, we cannot simply go into an office supply mart and compare the features of various EMR products and choose the one that meets our need and is within our price range. There doesn’t seem to be uniform price structure to allow that kind of shopping.

Should we demand progress on implementation of user-friendly, cost-effective EMRs so that we can have access to a safer, more effective health care system, or is it all just “smoke and mirrors” and too much trouble? I welcome your comments about EMRs. Please send your responses to [email protected].

As a young PA, I was hesitant about introducing myself to new patients. Should I call myself Mr. Danielsen or just use my first name? Should I address patients as Mr. or Mrs.? Should I call all women Ms.? Should I use patients’ full names or just their first names?

I started by introducing myself as Randy and confirming my patient’s full name by reading it off the medical record. This worked well, and I believed that not using formal titles suggested we were equal partners in their health care. Plus, it gave patients some choices about what to call me.

Those choices were revealing. Some would choose—against my wishes—Dr. Randy, which suggested a preference for a “traditional” doctor-patient relationship. Others would call me Randy, suggesting a desire for a relationship on a more equal footing. The most telling were those who not only called me by my first name but also never missed an opportunity to fit it into our conversation. I soon recognized this practice as a sign that they hoped to use our “friendship” to ask for special treatment (or to sell me an insurance policy) in the future.

Most problematic were the patients who looked at me blankly. The telling look said, “I am pleased to meet you, but I am waiting for the doctor.” Even if they knew I was a PA, my reluctance to call myself “Doctor” apparently suggested that I wasn’t ready for the job of providing their care. These patients see “the doctor” as “the healer,” and since I didn’t use that title, these patients inferred that I wasn’t ready to fill those shoes. 

As a seasoned PA with a few gray hairs to prove it, I usually begin an appointment by introducing myself as Randy Danielsen, a physician assistant, and then using the patient’s full name if he or she is younger than I am, and Mr. or Ms. if older. My patients deserve my respect, and they expect me to act the role of “doctor” whether I feel ready or not.

Now let me throw a wrench into the conversation. Enter a new kind of hybrid: either the doctor nurse wearing a name tag with the letters “DNP” or—dare I say it?—the doctor PA sporting a name tag with “DHSc” or “DSc.” Seen as one answer to the looming shortage of physicians, doctor nurses or doctor PAs take the NP or PA concept to yet another level. How, now, do our patients—and even our colleagues—understand what we offer?

Interestingly, many state statutes prohibit the use of the title Doctor by nonphysicians in clinical settings because it misleads the public that the person seeing them is a physician. Using Doctor or the abbreviation “Dr.” on a name tag or in a way that leads the public to believe the PA is licensed to practice as an allopathic or an osteopathic physician is considered unprofessional conduct in my state and will get you invited to come before the board.

Use of Doctor is also troubling because it could lead physicians to believe that PAs are seeking independent status. The issue for NPs is a bit tricky, as their desire to get the DNP is to have parallel status with physicians and to make an impact in primary care.

Where to go from here? How those new doctor NPs and doctor PAs will introduce themselves is just the tip of a controversial iceberg. Will these newly minted providers seek professional silos that separate them from “lesser” NPs and PAs? Could this be a stepping stone for PAs to seek independent practice? What about reimbursement schedules? And supervision? Will some of these new “doctors” be hiring or supervising other NPs or PAs? What about cross-profession interactions, such as a doctor NP employing PAs or doctor PAs supervising doctor NPs? The possibilities are endless—and confusing.

On top of this, there is some debate as to the role of academic institutions in the credential creep of NPs and PAs. I think our academic institutions are trying to build a better world, but sometimes—and this may be one such time—they are only doing the bidding of the tuition-paying client. When we consider the additional time needed to provide higher degrees to NPs and PAs, does that translate into less availability for patient services? Absolutely! We are taking a practicing provider away from patient care for additional training, when he or she could be seeing patients. 

Doctoral degrees will not improve the quantity of health care provided; providers with these degrees will still see and take care of the same number of patients they cared for prior to their career expansion. However, advanced training will translate into additional costs for the health care component of the gross domestic product, which is already higher in the United States than in most other countries. And it will create a whole new cadre of doctoral educators who used to practice and see patients.

While that might enhance the quality of education and training, do we really need that when numerous studies have shown PAs and NPs provide care equivalent to physicians’? It really gets down to the everlasting question PAs and NPs face from patients: “When will you be a doctor?”

My answer is: When they go to medical school, complete residency training, and are licensed by their state. The only alternative I see is to semantically spin the term doctor with practitioner and to do so in the public’s mind. Then if you are a doctor NP, doctor PA, or doctor MD/DO, it won’t matter—they’ll all just be providers.

There are now many people on the medical team who have doctoral degrees (physical therapists, audiologists, pharmacists) with more to come. The lesson learned is that it’s critically important for us to appropriately identify ourselves as clinicians without causing confusion and conflict for our patients. This latter point, as we already know, has legal implications.

Whether PAs and NPs should have doctoral degrees is a question that has been and will continue to be vetted in forums industry-wide. This discussion, albeit a bit tongue-in-cheek, is really about patients and their perceptions of what their health care professionals are or should be.

I would love to hear your thoughts. Please e-mail me at [email protected].

As a young PA, I was hesitant about introducing myself to new patients. Should I call myself Mr. Danielsen or just use my first name? Should I address patients as Mr. or Mrs.? Should I call all women Ms.? Should I use patients’ full names or just their first names?

I started by introducing myself as Randy and confirming my patient’s full name by reading it off the medical record. This worked well, and I believed that not using formal titles suggested we were equal partners in their health care. Plus, it gave patients some choices about what to call me.

Those choices were revealing. Some would choose—against my wishes—Dr. Randy, which suggested a preference for a “traditional” doctor-patient relationship. Others would call me Randy, suggesting a desire for a relationship on a more equal footing. The most telling were those who not only called me by my first name but also never missed an opportunity to fit it into our conversation. I soon recognized this practice as a sign that they hoped to use our “friendship” to ask for special treatment (or to sell me an insurance policy) in the future.

Most problematic were the patients who looked at me blankly. The telling look said, “I am pleased to meet you, but I am waiting for the doctor.” Even if they knew I was a PA, my reluctance to call myself “Doctor” apparently suggested that I wasn’t ready for the job of providing their care. These patients see “the doctor” as “the healer,” and since I didn’t use that title, these patients inferred that I wasn’t ready to fill those shoes. 

As a seasoned PA with a few gray hairs to prove it, I usually begin an appointment by introducing myself as Randy Danielsen, a physician assistant, and then using the patient’s full name if he or she is younger than I am, and Mr. or Ms. if older. My patients deserve my respect, and they expect me to act the role of “doctor” whether I feel ready or not.

Now let me throw a wrench into the conversation. Enter a new kind of hybrid: either the doctor nurse wearing a name tag with the letters “DNP” or—dare I say it?—the doctor PA sporting a name tag with “DHSc” or “DSc.” Seen as one answer to the looming shortage of physicians, doctor nurses or doctor PAs take the NP or PA concept to yet another level. How, now, do our patients—and even our colleagues—understand what we offer?

Interestingly, many state statutes prohibit the use of the title Doctor by nonphysicians in clinical settings because it misleads the public that the person seeing them is a physician. Using Doctor or the abbreviation “Dr.” on a name tag or in a way that leads the public to believe the PA is licensed to practice as an allopathic or an osteopathic physician is considered unprofessional conduct in my state and will get you invited to come before the board.

Use of Doctor is also troubling because it could lead physicians to believe that PAs are seeking independent status. The issue for NPs is a bit tricky, as their desire to get the DNP is to have parallel status with physicians and to make an impact in primary care.

Where to go from here? How those new doctor NPs and doctor PAs will introduce themselves is just the tip of a controversial iceberg. Will these newly minted providers seek professional silos that separate them from “lesser” NPs and PAs? Could this be a stepping stone for PAs to seek independent practice? What about reimbursement schedules? And supervision? Will some of these new “doctors” be hiring or supervising other NPs or PAs? What about cross-profession interactions, such as a doctor NP employing PAs or doctor PAs supervising doctor NPs? The possibilities are endless—and confusing.

On top of this, there is some debate as to the role of academic institutions in the credential creep of NPs and PAs. I think our academic institutions are trying to build a better world, but sometimes—and this may be one such time—they are only doing the bidding of the tuition-paying client. When we consider the additional time needed to provide higher degrees to NPs and PAs, does that translate into less availability for patient services? Absolutely! We are taking a practicing provider away from patient care for additional training, when he or she could be seeing patients. 

Doctoral degrees will not improve the quantity of health care provided; providers with these degrees will still see and take care of the same number of patients they cared for prior to their career expansion. However, advanced training will translate into additional costs for the health care component of the gross domestic product, which is already higher in the United States than in most other countries. And it will create a whole new cadre of doctoral educators who used to practice and see patients.

While that might enhance the quality of education and training, do we really need that when numerous studies have shown PAs and NPs provide care equivalent to physicians’? It really gets down to the everlasting question PAs and NPs face from patients: “When will you be a doctor?”

My answer is: When they go to medical school, complete residency training, and are licensed by their state. The only alternative I see is to semantically spin the term doctor with practitioner and to do so in the public’s mind. Then if you are a doctor NP, doctor PA, or doctor MD/DO, it won’t matter—they’ll all just be providers.

There are now many people on the medical team who have doctoral degrees (physical therapists, audiologists, pharmacists) with more to come. The lesson learned is that it’s critically important for us to appropriately identify ourselves as clinicians without causing confusion and conflict for our patients. This latter point, as we already know, has legal implications.

Whether PAs and NPs should have doctoral degrees is a question that has been and will continue to be vetted in forums industry-wide. This discussion, albeit a bit tongue-in-cheek, is really about patients and their perceptions of what their health care professionals are or should be.

I would love to hear your thoughts. Please e-mail me at [email protected].

As a young PA, I was hesitant about introducing myself to new patients. Should I call myself Mr. Danielsen or just use my first name? Should I address patients as Mr. or Mrs.? Should I call all women Ms.? Should I use patients’ full names or just their first names?

I started by introducing myself as Randy and confirming my patient’s full name by reading it off the medical record. This worked well, and I believed that not using formal titles suggested we were equal partners in their health care. Plus, it gave patients some choices about what to call me.

Those choices were revealing. Some would choose—against my wishes—Dr. Randy, which suggested a preference for a “traditional” doctor-patient relationship. Others would call me Randy, suggesting a desire for a relationship on a more equal footing. The most telling were those who not only called me by my first name but also never missed an opportunity to fit it into our conversation. I soon recognized this practice as a sign that they hoped to use our “friendship” to ask for special treatment (or to sell me an insurance policy) in the future.

Most problematic were the patients who looked at me blankly. The telling look said, “I am pleased to meet you, but I am waiting for the doctor.” Even if they knew I was a PA, my reluctance to call myself “Doctor” apparently suggested that I wasn’t ready for the job of providing their care. These patients see “the doctor” as “the healer,” and since I didn’t use that title, these patients inferred that I wasn’t ready to fill those shoes. 

As a seasoned PA with a few gray hairs to prove it, I usually begin an appointment by introducing myself as Randy Danielsen, a physician assistant, and then using the patient’s full name if he or she is younger than I am, and Mr. or Ms. if older. My patients deserve my respect, and they expect me to act the role of “doctor” whether I feel ready or not.

Now let me throw a wrench into the conversation. Enter a new kind of hybrid: either the doctor nurse wearing a name tag with the letters “DNP” or—dare I say it?—the doctor PA sporting a name tag with “DHSc” or “DSc.” Seen as one answer to the looming shortage of physicians, doctor nurses or doctor PAs take the NP or PA concept to yet another level. How, now, do our patients—and even our colleagues—understand what we offer?

Interestingly, many state statutes prohibit the use of the title Doctor by nonphysicians in clinical settings because it misleads the public that the person seeing them is a physician. Using Doctor or the abbreviation “Dr.” on a name tag or in a way that leads the public to believe the PA is licensed to practice as an allopathic or an osteopathic physician is considered unprofessional conduct in my state and will get you invited to come before the board.

Use of Doctor is also troubling because it could lead physicians to believe that PAs are seeking independent status. The issue for NPs is a bit tricky, as their desire to get the DNP is to have parallel status with physicians and to make an impact in primary care.

Where to go from here? How those new doctor NPs and doctor PAs will introduce themselves is just the tip of a controversial iceberg. Will these newly minted providers seek professional silos that separate them from “lesser” NPs and PAs? Could this be a stepping stone for PAs to seek independent practice? What about reimbursement schedules? And supervision? Will some of these new “doctors” be hiring or supervising other NPs or PAs? What about cross-profession interactions, such as a doctor NP employing PAs or doctor PAs supervising doctor NPs? The possibilities are endless—and confusing.

On top of this, there is some debate as to the role of academic institutions in the credential creep of NPs and PAs. I think our academic institutions are trying to build a better world, but sometimes—and this may be one such time—they are only doing the bidding of the tuition-paying client. When we consider the additional time needed to provide higher degrees to NPs and PAs, does that translate into less availability for patient services? Absolutely! We are taking a practicing provider away from patient care for additional training, when he or she could be seeing patients. 

Doctoral degrees will not improve the quantity of health care provided; providers with these degrees will still see and take care of the same number of patients they cared for prior to their career expansion. However, advanced training will translate into additional costs for the health care component of the gross domestic product, which is already higher in the United States than in most other countries. And it will create a whole new cadre of doctoral educators who used to practice and see patients.

While that might enhance the quality of education and training, do we really need that when numerous studies have shown PAs and NPs provide care equivalent to physicians’? It really gets down to the everlasting question PAs and NPs face from patients: “When will you be a doctor?”

My answer is: When they go to medical school, complete residency training, and are licensed by their state. The only alternative I see is to semantically spin the term doctor with practitioner and to do so in the public’s mind. Then if you are a doctor NP, doctor PA, or doctor MD/DO, it won’t matter—they’ll all just be providers.

There are now many people on the medical team who have doctoral degrees (physical therapists, audiologists, pharmacists) with more to come. The lesson learned is that it’s critically important for us to appropriately identify ourselves as clinicians without causing confusion and conflict for our patients. This latter point, as we already know, has legal implications.

Whether PAs and NPs should have doctoral degrees is a question that has been and will continue to be vetted in forums industry-wide. This discussion, albeit a bit tongue-in-cheek, is really about patients and their perceptions of what their health care professionals are or should be.

I would love to hear your thoughts. Please e-mail me at [email protected].