a closer look at physician assistants' performance on the nccpa recertification examinations

PurposeThe National Commission on

Certification of Physician Assistants(NCCPA) is the public agency that existsto credential physician assistants (PAs) inthe United States. Although this institu-tion provides a public service toAmericans, its origin and role have notbeen well documented and reported inliterature. We offer this brief summaryof the NCCPA and its history of certify-

ing PAs to stimulate further interest inand study of this unique professionalcertifying agency.

OverviewConceived in 1972 and developed in

1973, the NCCPA was formally organizedin 1974 and opened offices in Atlanta,Georgia, in early 1975. As of 2004, theNCCPA has certified over 50,000 PAs.The mission of the NCCPA is to assurethe public and professional medical orga-nizations that NCCPA-credentialed PAsmeet established standards of knowledgeand clinical skills upon entry into practiceand throughout their careers.

Three examinations are adminis-tered by the NCCPA: the PhysicianAssistant National Certifying Examination(PANCE); the Physician AssistantNational Recertifying Examination(PANRE); and the Pathway IIExamination. The National Board ofMedical Examiners (NBME) developsthese examinations under contract to

the NCCPA. Most state medical licens-ing boards use the PANCE to credentialPAs applying for licensure.1

Other NCCPA functions include:

• Establishing eligibility require-ments for the examinations.

• Establishing passing standards forthe examinations.

• Issuing and verifying certificates.• Establishing and maintaining crite-

ria and standards governing main-tenance of certification, includingcontinuing medical educationrequirements and reporting proce-dures.

HistoryThe NCCPA grew out of the need for

an independent agency to certify entry-level preparedness of PA graduates forclinical practice. Since program accredita-tion only assures minimum standards ofeducation, an additional mechanism wasconsidered necessary to assure a minimal

After formal education and training in an accredited program, the final stage in the professional preparation ofthe physician assistant (PA) is national certification. The process used to certify PAs is distinct, differing fromthat used by most other health professions, which oversee the process themselves. As a certifying agency, theNational Commission on Certification of Physician Assistants (NCCPA) is responsible to the general publicand represents no single professionally vested interest. Since its inception, it has remained a freestandingcertifying body. Formed by 14 health professional organizations in 1973 and formally organized as a not-for-profit organization in 1974, the NCCPA is dedicated to assuring the public that certified PAs meet establishedstandards of clinical knowledge and skills upon entry into practice and throughout their careers. Thedevelopment of an independent system of national certification and recertification for PAs is considered ahallmark and an asset of the profession. Almost all U.S. jurisdictions rely on NCCPA certification criteria forlicensure or registration of PAs. As of 2004, over 50,000 PAs have been certified by the NCCPA. This papertraces the evolution of the NCCPA, trends in the different examinations, and the national certification processthat is unique to the PA profession.

8 2004 ¶ Perspective on Physician Assistant Education ¶ Volume 15, Number 1

NCCPA Spec ial I s sue

Roderick S. Hooker, PhD, PA; Reginald Carter, PhD, PA; James F. Cawley, MPH, PA

The National Commission on Certification ofPhysician Assistants: History and Role

(Perspective on Physician Assistant Education 2004;15(1):8-15)

Roderick Hooker is a researcher and rheumatology PAwith the Department of Veterans Affairs Medical Center,Dallas, Texas. Reginald Carter is the director of the PAHistory Project at Duke University Medical CenterArchives Center, Durham, North Carolina. James F.Cawley is a professor in the Department of PhysicianAssistant Studies and in the School of Public Health atThe George Washington University, Washington, D.C.

Correspondence should be addressed to:

Roderick S. Hooker, PhD, PADepartment of Veterans Affairs Dallas, TX 75216-7191Voice: 214-857-1544Fax: 214-857-1457E-Mail: [email protected]

level of clinical knowledge and skills forPAs entering the health care workforce. In1971, leaders of the PA professionapproached the Division of AssociatedHealth Professions of the U.S.Department of Health, Education andWelfare (DAHP/DHEW) and the KelloggFoundation for funding support todevelop a certifying examination. In April1972, the National Board of MedicalExaminers (NBME) accepted the recom-mendation of its Committee on Goalsand Priorities, that the NBME shouldassume responsibility for developing anational certifying examination for assis-tants to the primary care physician. Anadvisory committee was appointed toadvise the NBME on policy mattersrelated to the development of the certify-ing examination.2

Parallel with developing a nationalcertifying examination for PAs, keyphysicians in the American MedicalAssociation’s (AMA) Council on HealthManpower led the effort in 1972 tocreate an independent certifying agencyconsisting of various health professionalorganizations. The American Academyof Physician Assistants (AAPA) and theAssociation of Physician AssistantPrograms (APAP) were invited to meetwith other participants in late 1973 toorganize and seek funding for an inde-pendent national commission.3 In July1974, the DAHP/DHEW and theRobert Wood Johnson (RWJ) Foundationawarded contracts to the AMA’s Educationand Research Foundation to “establish asystem to evaluate the competency of assis-tants to primary care physicians.” In devel-oping the system, the contractor agreed tocreate an independent national commis-sion, later designated the NationalCommission on Certification of PhysicianAssistants.

Believing that PA certification shouldnot be the domain of any one organiza-tion, the AMA and the NBME worked tobring together representatives of anumber of medical organizations to forma freestanding, independent commission.According to early minutes of APAPmeetings, educators were somewhatapprehensive about the direction that the

commission might take and “opposed theinterposition of any group between theNBME and State licensure bodies.”4

Leaders of the AAPA were concernedabout how many representatives theywould have on the commission. At ageneral planning meeting held onNovember 28, 1973, in Chicago, Illinois,Thomas Piemme, MD, representingAPAP, and Paul Moson, PA, representingthe AAPA, pressed their conviction that afinancially independent, freestandingcommission would best serve the interestsof the profession and public. APAP wouldhave one representative, like the otherparticipating organizations, while theAAPA would have five representatives.The intent of this configuration was toensure that the bylaws could not be easilychanged without adequate PA input. Finaldetails and agreements were reached at ameeting in Chicago on August 9, 1974,and the commission was organized.

The objective was to assure employers,state boards, and patients that a standardrelated to the competency of PAs was inplace and a certifying examination wasavailable for state medical licensing boards.In February 1975, the NCCPA openednational headquarters in Atlanta, Georgia,with a staff of six (Figure 1). TheCertifying Examination for Assistants tothe Primary Care Physician was first

administered in December 1973 (Figure2). A number of new health practitionerprograms, such as nurse practitioner (NP),PRIMEX, nurse clinician, MEDEX,surgeon’s assistant, and child health associ-ate, were gaining momentum, as were PAprograms. Eligibility criteria for the initial1973 certifying examination were devel-oped by the NBME and limited to gradu-ates of “physician’s assistant” and MEDEXtraining programs approved by the AMACouncil on Medical Education, andfunded by the Bureau of Health ResourcesDevelopment. In the case of family andpediatric nurse practitioners, they wereeligible if they were graduates of programsof at least 4 months’ duration and locatedwithin nursing or medical schools.5

In addition to developing criteria forformally educated PAs, federal and privatefoundation contracts required the NBMEto develop eligibility criteria for those PAswho met a definition of having priorgeneric experience working in a “physi-cian assistant”-like role but who had notgraduated from a formal program. In1974, the NCCPA reviewed and approvedthe NBME’s eligibility criteria for infor-mally trained PAs and accepted this defin-ition as a continuation of the federalcontract, extending it through 1978 as agrandfather clause.6 In 1987, the NCCPAclosed the entry-level certifying examina-

2004 ¶ Perspective on Physician Assistant Education ¶ Volume 15, Number 1 9

The National Commission on Certification of Physician Assistants: History and Role

Figure 1

NCCPA Staff, 1974

Left to right: Ginger Thompson, Connie Gibson, John Winburn, Hank Datelle, David Glazer, Jan Mathias.Photo from NCCPA Newsletter, Vol. 1, No. 1, November 1974. Courtesy of DUMC Archives, PA History Collection.

tion to informally trained PAs becauseonly a few hundred had taken the examand the failure rate was high. Between1974 and 1979, 83% of formally trainedcandidates (ie, PA, Medex, NP) passed theexaminations, while only 32% of infor-mally trained candidates passed.7

To create the initial examinationadministered in 1973, the NBMEsurveyed a large number of PAs and theirsupervising physicians to determine thescope of tasks performed by PAs in clin-ical practice. This information was givento various test committees to write ques-tions. Over the first 5 years, the entry-level examination evolved into threecomponents, analyzed and scored sepa-rately, then combined and weighted togive an overall composite score. Thethree components were:

• Multiple Choice Questions(MCQ)

• Patient Management Problems(PMP), separated into “data gath-ering” and “management andtherapy” sections

• Performance Assessment Skills(PAS)

The PAS component representedNBME’s first attempt to measure clinicalcompetency.8 It evaluated the candidates’abilities to perform routine physical exam-inations of the heart, lungs, and abdomenand to do fundoscopic and neurologicalexaminations. In 1978, the PAS evolvedinto the Clinical Skills Portion (CSP),which presented historical and pathologi-cal data to candidates and required themto complete an appropriate physical exam-ination based on the clinical case scenar-ios. The CSP portion proved to bedifficult to administer since it was impos-sible to achieve standardized testingconditions given the variability of theenvironments in which it was conducted.In 1997, as NCCPA began converting thePANCE to a computer-based examina-tion, the organization eliminated the CSPportion of the exam.

Three people played pivotal roles inestablishing the legitimacy of theNCCPA: the first executive director of theNCCPA, David Glazer (1973 to 1996);Thomas Piemme, MD, the first presidentof the NCCPA (1974); and DonaldFisher, PhD, the first executive director ofthe APAP and AAPA joint national office(1973–1980). The 14 charter organiza-tions constituting the NCCPA Board ofDirectors are listed in Table 1.

The board had three at-largemembers representing the public andemploying physicians. With the excep-tion of the nurses’ association, all thecharter organizations continue to partic-ipate by sending representatives to thecommission. In addition, the NCCPABoard of Directors includes four PAdirectors at large and appointees fromthe following organizations:

• The American College of EmergencyMedicine

• The American Osteopathic Association • The U.S. Department of Veterans

Affairs

The NCCPA Board of Directorsdetermines the goals and responsibilitiesof the NCCPA and provides direction forits work. A president who reports to theboard directs the staff of the NCCPA. As

of 2004 there are 30 full-time employeesspread over eight departments.

The main NCCPA responsibilitiesinclude creating a content blueprint ofthe examinations, undertaking practiceanalysis studies, and overseeing thequality of the examinations for certifica-tion and recertification purposes.

NCCPA Content BlueprintThe NCCPA Content Blueprint is a

primary reference for identifying theclinical problems the PA should beprepared to encounter in a typicalprimary care practice and is the basisfor the construction of the PANCE,PANRE, and Pathway II examinations.This outline of the organ systems andmedical specialties was compiled usinga variety of sources, including datafrom the National Ambulatory MedicalCare Survey and the National HospitalDischarge Survey (Table 2). It isupdated periodically based on practiceanalysis studies.

Practice AnalysisContent specifications for NCCPA

exams are developed and validated, in



Figure 2

National Board of Medical ExaminersAnnouncement of First Certifying

Examination, 1973

Courtesy of DUMC Archives, PA History Collection.

Table 1

NCCPA Board of Directors

• The American Academy of FamilyPhysicians

• The American Academy of Pediatrics

• The American Academy of PhysicianAssistants

• The American College of Physicians

• The American College of Surgeons

• The American Hospital Association

• The American Medical Association

• The American Nurses Association

• The American Society of InternalMedicine

• The Association of American MedicalColleges

• The Association of Physician AssistantPrograms

• The Federation of State Medical Boardsof the U.S.

• The National Board of Medical Examiners

• The U.S. Department of Defense

part, through the use of role delineationstudies. The first study was conductedby the NBME in the early 1970s andadditional studies were done by theAAPA in 1979 and 1985.

The 1998 NCCPA PA PracticeAnalysis Project provided the funda-mental basis of the content blueprintused in NCCPA certifying and recertify-ing examinations beginning in 2001.9Investigators identified the tasks andessential knowledge and skills that arerepresentative of the actual clinical prac-tice roles, specific tasks and knowledge,and skills and abilities required of PAs.The results of this analysis identified theknowledge and skills rated most highlyby practicing PAs as:

• Skills in identifying pertinentphysical findings

• Knowledge of signs and symptomsof medical conditions

• Skill in recognizing conditions thatconstitute medical emergencies

• Skill in performing physical exam-inations

• Skill in conducting a patient inter-view

• Knowledge of conditions thatconstitute medical emergencies

• Skill in associating currentcomplaints with presenting historyand identifying pertinent factor(s)

• Knowledge of physical examina-tion directed to a specific conditionand knowledge of physical exami-nation techniques

• Skill in effective communication

The NCCPA study found few differ-ences in the tasks performed by PAs

based on the length of time they hadworked in the profession, althoughgenerally, the longer individuals hadbeen employed as PAs, the more tasksthey performed. Response patternsdiffered across specialties, with a higherrate particularly among PAs in cardiovas-cular/thoracic surgery, general surgery,and orthopedic surgery. However, andperhaps more importantly, PAs engagein a wide range of tasks essential for clin-ical practice. Consistently high ratingswere observed in the domains consid-ered to be the core functions of PA clin-icians—history taking and physicaldiagnosis—which suggests that there arecentral cores of medical knowledge,tasks, and skills that are used orperformed often and regularly by prac-ticing PAs. This core of knowledge andskills appears to apply to virtually allspecialties and settings (Table 3).

PAs appear to place great value onthe additional skills required in the prac-tice of clinical medicine—diagnosticacumen coupled with judgment andknowledge in the development of aneffective management plan. They engagein a wide variety of specialized practiceactivities, identified by differences in thespecific clinical interventions and proce-dures performed in various practicesettings. While PAs across the countryperform procedures in widely diversepractice domains, not all PAs consis-tently perform the same procedures inall areas of medicine. The authorsconcluded that PAs rated the knowledgeand skills required for clinical procedures



Table 2

Examination Blueprint: PANCE and PANRE Content by Organ System Disorders and Assessed by Knowledge and Skills

Percentage of Diseases, Disorders, and Medical Assessment Exam Content

16 Cardiovascular system12 Pulmonary system10 Gastrointestinal/nutritional system10 Musculoskeletal system

9 Eye, ear, nose, and throat8 Reproductive system6 Endocrine system6 Neurologic system6 Psychiatric/behavioral system6 Renal/urinary system5 Dermatological3 Hematologic system3 Infectious disease

100%

Percentage of Knowledge and Skill Areas Exam Content

18 Clinical therapeutics18 Formulating most likely diagnosis16 History taking and performing physical exams14 Clinical intervention14 Using laboratory and diagnostic studies10 Applying scientific concepts10 Health maintenance

100%

Source: NCCPA Examination Content Blueprint 2001. Atlanta, Ga:2001.

Table 3

Role Delineation: Domains of KnowledgeDeemed Most Important by Physician

Assistants (rank ordered)

1. Subjective data gathering2. Assessment3. Objective data gathering4. Formulating and implementing a plan5. Clinical intervention procedures6. Health promotion and disease prevention7. Ancillary professional responsibilitiesSource: Cawley, Andrews, Barnhill, et al. JAAPA 2001.

and interventions as very important tobeing able to practice medicine.9

ExaminationsThe NCCPA administers four exam-

inations: PANCE, PANRE, Pathway II,and the Surgery Examination. Theseexaminations assess essential knowledgeand skills of PAs in performing a varietyof health care functions normallyencountered in practice. Initial certifica-tion through the PANCE is required forPA licensure in almost all states as wellas the District of Columbia, Guam, andU.S. jurisdictions such as the military,Department of Veterans Affairs, Bureauof Prisons, and other agencies. ThePANCE consists of 300 standardizedquestions (and 360 questions for thePANRE) developed by the NBME andtaken by nearly all PA educationalprogram graduates. In 1999, PANCEexaminations were administered in theU.S. via computer at more than 300contracted testing centers. The comput-erization of the PANRE followed in2000.

Several committees generate testquestions for the PANCE, PANRE, andPathway II examinations. Test-writingcommittee members are appointed bythe NCCPA and staffed by the NBME.Committees are composed of physiciansand PAs employed in both academic andclinical settings, including the primarycare and clinical specialties. Test commit-tees meet regularly to develop thecontent for each examination, review theprevious year’s examination perfor-mance, finalize the current examination“content blueprint,” and make assign-ments for and prepare new test items.

CertificationFor the PA, the PANCE is the quali-

fying entrée into U.S. medical practice.A candidate for PANCE must be a grad-uate of an accredited PA program.

The examination has been in exis-tence since 1973, and as of 2003, over50,000 people have taken the examina-tion. In most years the number of thosetaking the PANCE has risen. In 2003there were 5,480 test takers (first time

and repeat) with an overall pass rate of80% (see Figure 3). This cadre of testtakers represented 130 PA programs. Inthe same year, there were 1,140 repeatersof the PANCE; 44% of them passed.Historically, since the PANCE was initi-ated, the pass rate has fluctuated between69.0 and 94.6 percent.

Since the PANCE was introduced in1973, there has been a shift in thenumber of test takers and the pass rate.In 1973 there were 880 PANCE testtakers (770 passed, 110 failed; 87.5%pass rate), and in 1983 the number was1238 (1,605 passed, 367 failed; 79%pass rate). In 2003, the number of certi-fying examinations administered totaled5,480, with 4,340 candidates attainingcertification. The failure rate was 20.1%;1104 candidates were unsuccessful.

RecertificationIn an effort to assure the public of

career-long clinical knowledge andskills, NCCPA established a certificatemaintenance system requiring re-regis-tration every 2 years. This is a processbased on the acquisition of a requirednumber of continuing medical educa-tion (CME) credits every 2 years, andrecertification through the PANRE orPathway II every 6 years. To maintain

NCCPA certification PAs must completea process involving documentation ofCME, submission of registration mate-rials, and successful completion of therecertification exam.

In 1981, NCCPA began to adminis-ter the entry-level PANCE for thepurpose of recertification. This was thefirst recertification examination for PAsand marked a milestone as possibly thefirst recertification for any healthprofessional. In 1984, the PANRE wasdeveloped as a separate recertificationexamination and has been administeredever since. For many years, the pass ratewas relatively high on the PANRE andPAs were recertified on the basis of theexamination alone. Those who failedwere issued updated certificates andwere eligible to retake the exam every 2years for an indefinite period. Based onan NCCPA policy adopted in 1998, PAsare now required to pass the recertify-ing examination to maintain certifica-tion. Failure to pass the recertifyingexamination by the end of year 6 nowresults in loss of certification. To regaincertification, PAs must pass PANCEagain, or, if CME requirements are met,PANRE or Pathway II.

The PANRE consists of 360 multiple-choice questions arranged into six 60-



Figure 3

Annual Number of Physician Assistant National Certifying Examinations, 1973–2003

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question blocks. In 2003, the PANREwas taken by 3,862 examinees; 96%passed (see Figure 4).

Pathway IIAn alternative mechanism for meeting

NCCPA certificate maintenance require-ments grew out of an AAPA-NCCPApartnership begun in 1992. The result isPathway II, a recertifying process admin-istered by NCCPA since it was initiated in1997. Pathway II consists of a take-home examination plus an electivecomponent. This test-taking option wasdeveloped in response to the needs ofPAs who specialize in a particularmedical field outside of primary care.The elective component is divided intonine categories of education and experi-ential activities, and PAs are required toearn a certain number of points throughthose activities to gain eligibility for thetake-at-home examination

In 2003, 1,034 PAs took thePathway II examination and 915 (88%)passed. Approximately half of thePathway II test-takers were repeatingthe test, having failed it the first time(see Figure 5).

Optional Specialty ExaminationsTo address problems of specialization,

at one time the multiple-choice section of

the PANCE was divided into a requiredcore component and two optionalextended core components; one ingeneral medicine and the other in surgery.Candidates had the option of taking oneor both of the extended core compo-nents. To be certified, candidates had topass the core and at least one of theoptional extended core components. Thegeneral medicine component was discon-tinued in 1997, along with the CSP.

The optional surgical examinationwas introduced in 1980 for both PANCEand PANRE test takers. This was inrecognition of two surgical PA programsand a growing number of PAs selectingsurgery as a specialty. It is administeredas a stand-alone examination open toboth certified and certifying PAs whowant to earn “special recognition” insurgery to enhance and broaden their jobopportunities. In 2003, 329 PAs electedto take this examination and 77%passed; this represents a declining trendfrom a peak of 2,378 surgery componenttest takers in 1996 (Figure 6). Thisexamination was phased out in 2004.

Continuing Medical EducationNCCPA established a policy in 1980

that every 2 years all certified PAs mustearn and submit documentation of atleast 100 hours of CME. The concept of

certificate maintenance is based on theongoing acquisition of new medicalknowledge obtained through attendanceat formal CME sessions and periodicrecertification examinations. A notedfeature of the PA profession is the recer-tification process. It was determined in1975 that every 6 years was an appro-priate duration of time to retest individ-uals on their basic medical knowledge.This unprecedented medical educationpolicy was intended to assure the publicthat PAs are staying abreast of ever-changing core knowledge needed topractice contemporary medicine.

DiscussionThe NCCPA and, in particular, its

method of recertification through exam-ination have been the subject of discus-sion and debate within the PA professiongoing back to the late 1980s. Thesediscussions are expressed in statementsand resolutions of the AAPA House ofDelegates (HOD) and in editorials andletters to the editor of different journalsand newsletters. Some PAs, particularlythose who worked in specialty practice,question the content relevance of thePANRE, an examination that testsgeneral medical knowledge rather thanthe knowledge they are maintaining toperform their specialized medical roles.Some consider the NCCPA require-



Figure 4

Annual Number of Physician Assistant National Recertifying Examinations, 1987–2003

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Figure 5

Annual Number of Pathway II PhysicianAssistant Recertifying Examinations,

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ments regarding certificate maintenanceand periodic recertification frustratingand time-consuming. Defenders of theNCCPA process argue that PAs need tobe mindful of the legitimacy derivedfrom the profession’s traditional willing-ness to submit to recertification byexamination system—a trend increas-ingly adopted by medical specialties andother health professions. The NCCPA’sindependence, inclusiveness, and recerti-fication requirements provided theassurance most state legislators neededto enact enabling legislation during the1970s and 1980s.

EndpointingThe NCCPA policy that requires PAs

to not only take but also pass the recerti-fication examination to maintain certifica-tion has been a topic of debate as well. Itwas always the clear intent of thecommission to require PAs to pass therecertification exam after the exam’s valid-ity had been confirmed. However, pres-sure from the profession kept thatrequirement from being implemented foralmost two decades. The implications ofthe certification maintenance policy forPAs practicing in the states that requirevalid certification as a condition of licen-sure are significant. The policy of main-taining NCCPA certification is known as“endpointing,” and it defines the final

consequences for those who fail to passPANRE or Pathway II before the end oftheir six-year recertification cycle. Underendpointing, PAs who are unable to meetthe recertification requirement lose theircertification. In order to regain certifica-tion status they must take and pass one ofthe three NCCPA examinations.

Since the endpointing policy wasimplemented in 2002, approximately300 PAs have lost certification afterattempting but failing to pass the recer-tification exam.

Predictability of the PANCEThere have also been questions raised

about the utility and predictability of thePANCE. Researchers have sought corre-lations between NCCPA examinationresults and academic achievement as ameans of validating the examination. Astudy by Cawley10 suggested that theNCCPA examination may need reevalua-tion since students without academicdegrees and those with associate degreeswho pass the NCCPA examination do soat a higher rate than those with baccalau-reate and graduate degrees. While thestudy sample was non-representative, itdid suggest that the discrepancyobserved could indicate a cultural bias inthe NCCPA examination.9

Other scholars have examinedwhether the PANCE is a predictor of

PA student characteristics and behavior.For example, there appears to be littleassociation between the academicdegree received in PA education and thelikelihood of passing the PANCE.Furthermore, there is almost no correla-tion between PANCE pass rates andcharacteristics of PA programs such aspublic versus private funding, type ofuniversity, size of class, and region of thecountry; or characteristics of studentssuch as age and gender.11 When 5 yearsof PANCE scores (n=14,850) wereexamined by type of degree (undergrad-uate versus graduate) and type of insti-tution (publicly funded versus privatelyfunded) there was little correlationbetween these variables and the averagepass rate (see Figure 7).11 Applicantsconsidering PA programs based on thePANCE score record of the program’sgraduates may be heartened that thequality of the individual probably makesmore difference in passing the PANCEthan any program attribute. Becauseprogram and student characteristics arenot reliable predictors of PANCE perfor-mance, PA educators are also questioningwhether the recertification processrequires similar scrutiny.10

Specialty TestingSpecialty testing is a broad issue

facing the profession, its representativeorganizations, specialty societies, andthe NCCPA. Since specialization appearsto be a natural evolution in most healthprofessions, it is no surprise that greaternumbers of PAs are working in non-primary care practices. PAs representingspecialty and subspecialty groups have

Figure 6

Annual Number of Surgical Specialty Examinations: 1988–2003



Figure 7

PANCE Scores by Degree and Type of Institution

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spoken openly of a desire to have someform of recognition in the recertificationprocess. This poses a challenge to theNCCPA at a time when the internalmedicine examination was discontinuedfor lack of interest and the annualnumber of surgery examination takers isdeclining. Pathway II offers a possiblemechanism for specialist examinationsbut to adopt this for specialty PAs willrequire additional staff and a larger,more refined, test bank.

ConclusionThe architects of the NCCPA envi-

sioned a national independent certify-ing agency that would be an example ofhow to introduce a new health profes-sional into the health care environmentof the United States and would allevi-ate the concerns of the public, membersof the newly emerging profession, andthe medical establishment. The resulthas been a process that assures thepublic and others that NCCPA-creden-tialed PAs meet established standards ofclinical knowledge and skills uponentry into practice and throughouttheir careers. As an independent agency

devoted to protection of the public, theNCCPA has been a leader in the devel-opment of innovative approaches indeveloping the process of credentialinghealth care professionals. It exists as amodel of public watchfulness for othercountries as the PA concept spreadsbeyond U.S. borders.

AcknowledgementsWe are grateful to Janet Lathrop and

Ragan Morrow at the NCCPA for theirvaluable assistance in making data avail-able and verifying the accuracy of ourfindings.

References1. Davis A. Putting state legislative issues in

context. JAAPA. 2002;15:27-32.2. Pellegrino E. Statements Concerning the

Development of the National CertifyingExamination for Assistants to the Primary CarePhysician. Advisory Committee Report,National Board of Medical Examiners:Philadelphia, Pa; August, 1973.

3. Todd M. National certification of physicians’assistants by uniform examinations. JAMA.1972;222:563-566.

4. Association of Physician Assistant Programs.Draft Minutes of APAP Meeting. November 7,1973, in Washington, DC.

5. Andrews B. National examination for assistantsto the primary care physician. In: Bliss AA,Cohen E, eds. The New Health Professionals:Nurse Practitioners and Physician’s Assistants. 1 ed.Aspen Systems Corporation: Germantown,Md; 1977.

6. Glazer D, Fasser CE. Clara Vanderbilt Papers.Duke University Medical Center Archives,Durham, NC. September 27, 1979.

7. Glazer D, Datelle H. Continued Establishment ofa System to Evaluate the Competency of Assistants toPrimary Care Physicians. Report to theDepartment of Health, Education and Welfare,Bureau of Health Manpower, NationalCommission on Certification of PhysicianAssistants: Atlanta, Ga; September 1980.

8. Glazier DL. National Commission onCertification of Physician’s Assistants: aprecedent in collaboration. In: Bliss AA, CohenED, eds. The New Health Professionals: NursePractitioners and Physician’s Assistants. AspenSystems Corp.: Germantown, Md; 1977.

9. Cawley JF, Andrews MD, Barnhill GC, Webb L,Hill K. What makes the day: an analysis of thecontent of physician assistant’s practice. JAAPA2001;14:41-42,44,47-50,55-56 (passim).

10. Cawley JF. Physician assistant education andPANCE performance: a passing controversy?Perspective on Physician Assistant Education.2002;13:79-80.

11. Hooker RS, Hess B, Cipher D. A comparisonof physician assistant programs by nationalcertification examination scores. Perspective onPhysician Assistant Education. 2002;13:81-86.

a closer look at physician assistants' performance on the nccpa recertification examinations

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