Why Should Physician Assistants Have to Retest at All?

By Dawn Morton-Rias, Ed.D, PA-C, NCCPA President/CEO

The following was adapted from an article published on January 30, 2016 in NCCPA’s leader-to-leader newsletter, Insights & Inquiries.

As NCCPA has invited dialogue and feedback on a proposed model for the PA recertification exam, some have started raising a different question: Why should PAs have to retest at all?

I would make the following points in answer to that question.

1.  The challenge of periodically retesting has a positive impact on our patients.

    • Recertifying by exam supports knowledge retention. There is a significant body of evidence that suggests the more you test—and the more frequently you test—the more knowledge you retain. Clearly, that’s good for patients.

    • And yes, there is evidence that recertifying by exam is linked to improved patient outcomes. There are well-designed, fundamentally sound studies that demonstrate a link between certification andrecertification test scores and positive patient outcomes. That’s good for patients.

    • In contrast, there is evidence that conventional, didactic CME that is not interactive has little to no impact on patient outcomes or improvements in practice behaviors. There is a wealth of research in cognitive psychology that explains why preparing for, taking, and receiving results from an exam has a positive impact on behavior while typical self-directed CME lectures do not. Admittedly, few if any of us like to take exams, but exams work to help push us further, and that is better for patients.

    • We often don’t know what we don’t know. A number of studies show that physicians have a limited ability to accurately self-assess. The physicians with the worst accuracy in self-assessment were the most confident in their knowledge and were also the least skilled. Similar results have been seen with other professions. Clearly, practitioners who are in the greatest need of remediation are likely the least able to self-identify their learning needs. Standardized exams provide feedback that can illuminate areas of knowledge deficiency and inability to demonstrate minimum proficiency standards as established by a group of their peers. Yes, that is hard to take in, but again, shouldn't we know what we don't know? Isn't that good for patients?

Based on an initial review of the literature, there is a preponderance of evidence to support the points made above, and we will share some of the varied sources on this over the next few weeks for those who would like to review the literature for themselves. What we know and what the evidence bears out is that testing AND specific types of CME do have a positive impact on knowledge and skills. Further, this positive impact can and will translate into improved outcomes for patients of PAs who take it to heart.

In advance of the publication of that more extensive list of articles, later in this message, I have provided links to a short list for those who want to start examining the evidence base.

2.  The public expects it.

Do your patients ask if you’re certified? Probably not (or not often). Mine didn’t either. However, survey after survey demonstrates that patients prefer certified health care providers over non-certified providers, that they believe regular retesting is important, and – often – that they believe certification programs are or should be more rigorous than they actually are. Why? Because people know – based on their own experience as students and sometimes as professionals – that testing supports learning, and they want health care providers who are maintaining current knowledge. Don't you want to know that your health care provider has demonstrated their abilities in a standardized way?

3.  The PA certification maintenance process supports the profession.

The PA profession has a 40-plus year history of holding itself to high standards, which is a critical part of the story of our collective success. Licensure, prescribing privileges, expansion of scope of practice, reimbursement, demand in every setting and specialty, and patient acceptance are just some examples of successes supported by our career long certification process. That process has been cited as evidence of PA qualifications and commitment to excellence by those who have lobbied and worked to create the incredible opportunities the profession enjoys today. To suggest that we should just undo that – with no way to know what the real consequences of that might be for our profession – is a dereliction of duty. To those who would argue that we don’t need the exam, that CME only is enough, that there would be no negative consequences to tossing aside recertification by exam, I would ask this: What if you’re wrong?

Short List of Supporting Articles

  • Swankin, D., LeBuhn, R. A., & Morrison, R. (2006). Implementing continuing competency requirements for health care practitioners. AARP, Public Policy Institute. http://www.nbcrna.com/about-us/Documents/ImplementingCC%20Requirements%20for%20HCP%202006.pdf

  • Larsen, D. P. (2013). When I say … test-enhanced learning. Medical Education, 47(10), 961–961. http://doi.org/10.1111/medu.12238 

  • Larsen, D. P., Butler, A. C., & Roediger III, H. L. (2008). Test-enhanced learning in medical education. Medical Education, 42(10), 959–966. http://doi.org/10.1111/j.1365-2923.2008.03124.x

  • Larsen, D. P., Butler, A. C., Lawson, A. L., & Roediger, H. L. (2013). The importance of seeing the patient: test-enhanced learning with standardized patients and written tests improves clinical application of knowledge. Advances in Health Sciences Education, 18(3), 409–425. http://doi.org/10.1007/s10459-012-9379-7

  • Larsen, D. P., Butler, A. C., & Roediger III, H. L. (2013). Comparative effects of test-enhanced learning and self-explanation on long-term retention. Medical Education, 47(7), 674–682. http://doi.org/10.1111/medu.12141

  • Kromann, C. B., Jensen, M. L., & Ringsted, C. (2009). The effect of testing on skills learning. Medical Education, 43(1), 21–27. http://doi.org/10.1111/j.1365-2923.2008.03245.x

  • Holmboe, E. S., Wang, Y., Meehan, T. P., Tate, J. P., Ho, S. Y., Starkey, K. S., & Lipner, R. S. (2008). Association between maintenance of certification examination scores and quality of care for Medicare beneficiaries. Archives of Internal Medicine, 168(13), 1396-1403. http://archinte.jamanetwork.com/article.aspx?articleid=414352

  • Davis, D. A., Thomson, M. A., Oxman, A. D., & Haynes, R. B. (1995). Changing physician performance: a systematic review of the effect of continuing medical education strategies. Jama, 274(9), 700-705. http://www.ncbi.nlm.nih.gov/pubmed/7650822

  • Davis, D., O'Brien, M. A. T., Freemantle, N., Wolf, F. M., Mazmanian, P., & Taylor-Vaisey, A. (1999). Impact of formal continuing medical education: do conferences, workshops, rounds, and other traditional continuing education activities change physician behavior or health care outcomes?. Jama, 282(9), 867-874. http://www.ncbi.nlm.nih.gov/pubmed/10478694

  • Bloom, B. S. (2005). Effects of continuing medical education on improving physician clinical care and patient health: a review of systematic reviews. International journal of technology assessment in health care, 21(03), 380-385. http://www.ncbi.nlm.nih.gov/pubmed/16110718

  • Institute of Medicine (US). Committee on Planning a Continuing Health Care Professional Education Institute. (2010). Redesigning continuing education in the health professions. National Academies Press. http://www.ncbi.nlm.nih.gov/books/NBK219811/