Identification of Alternative Physician Assistant Recertification Models: An Analysis of the Landscape and Evidence Surrounding Approaches to Recertification in the Health Professions

Periodic health professional recertification aims to ensure that professionals stay up-to-date with advances in clinical knowledge and practice; to identify professionals who might benefit from additional training; and to designate a professional who has met a certifying organization's standard to patients, peers, heath systems, insurers, and other stakeholders. Concerns have been raised regarding the burden and relevance of recertification requirements by every type of health profession subject to recertification, particularly when recertification is tied to licensure or ability to practice or when it involves high-stakes closed-book exams. Physician assistants (PAs) in the United States are subject to recertification as a requirement for licensure and the ability to practice and high-stakes closed-book exams as a required component of recertification. There have been recent proposed changes to closed-book high-stakes recertification exam requirements for PAs in the United States, and changes are in progress for many U.S. allopathic physician specialty boards. To inform considerations for recertification requirements for PAs in the United States as well as other health professionals, this report provides an assessment of the landscape of recertification requirements in the United States and other countries; the evidence regarding the implications of closed-book exams and other recertification requirements for health professionals and patients; and the experience of certifying bodies implementing recertification requirements that may not include a closed-book exam.

Assessment of the Landscape of Recertification Requirements

We reviewed published information from certifying bodies regarding the recertification, maintenance of certification (MOC), or revalidation requirements for PAs, physicians, and advanced practice nurses (APNs) in the United States and in other countries with a context and activities of practice comparable to PAs in the United States.

Requirements for maintaining, renewing, continuing, or updating certification over the course of a health professionals' practice career vary by profession and country. Recertification requirements may involve exams or assessments, continuing education (CE) or continuing professional development (CPD), and other requirements (e.g., practice improvement activities, self-assessment activities, practice hours or case logs, and/or peer or patient reviews).

For PAs in the United States, recertification is required for continued PA licensure or prescribing privileges in 19 states. Current PA recertification requirements include a high-stakes closed-book exam called the Physician Assistant National Recertifying Exam (PANRE). A pilot of a lower-stakes longitudinal assessment as an alternative to the PANRE is planned for 2019. Longitudinal assessments require smaller batches of multiple-choice questions at regular intervals over time, as alternatives to high-stakes, once-per-cycle, closed-book exams, and are considered lower-stakes because professionals do not lose certification status if a single assessment is not passed, as is the case with a once-per-cycle exam.

Among U.S. APNs, only certified registered nurse anesthetists (CRNAs) have a closed-book exam requirement for recertification, which is required for either licensure or practice under the title of nurse anesthetist in all states. Although certification is required for nurse practitioners (NPs) in 47 states and in most states for certified nurse midwives (CNMs), they may be recertified by completing CE and satisfying a clinical practice component in lieu of an exam and are not required to take high-stakes closed-book exams for recertification

For physicians in the United States, neither initial nor ongoing board specialty certification is required for licensure. Closed-book recertification exams have been required for allopathic physician specialty board certification in the United States, but many specialty boards are implementing or piloting lower-stakes longitudinal assessments. Closed-book exams are a more recent mandated recertification requirement for osteopathic physician specialty boards in the United States.

Internationally, recertification exams are not required for health professionals, except in the United Kingdom, where voluntary registration for physician associates requires passing an exam. An exam is also a rarely used option for physicians lacking other means to complete revalidation requirements.

CE or CPD is also required for PAs in the United States and is required by most certifying bodies in the United States and internationally, with some exceptions (e.g., some U.S. APN organizations with flexible requirements and some physician certifying organizations outside the United States). Other recertification requirements vary substantially by profession, setting, and certifying body and may include reporting practice hours or cases, self-assessment activities, practice improvement activities, and multisource feedback (MSF) activities with peer or patient reviews.

Review of the Literature Surrounding Recertification Requirements

We conducted a structured search of the literature regarding recertification requirements, including closed-book exam-based approaches versus alternative or complementary requirements and their effect on patients and health professionals.

The peer-reviewed literature surrounding recertification requirements for health professionals is dominated by MOC requirements for allopathic physicians in the United States. Evidence regarding the impact of recertification requirements of U.S. PAs and APNs is limited; our review did not identify any studies that directly addressed the impact of these requirements on health-care quality or outcomes.

The literature revealed that U.S. physicians report burden and barriers to MOC participation including time, expense, and inconvenience and also professional benefits such as demonstration of competence and engagement in lifelong learning. Some studies found associations between MOC program participation overall and improvements in patient care quality and outcomes. For the exam component of MOC requirements, in particular, physicians in group practice tended to perform better on the exam; greater use of educational activities and resources was associated with better exam performance; and among internal medicine physicians, higher scores were associated with better performance on some clinical quality process or intermediate outcome measures. Evidence regarding longitudinal assessment alternatives to closed-book exams was not found in the literature reviewed. A sizeable literature addressed self-assessment or practice improvement activities undertaken for MOC credit. Views regarding these self-assessment and practice improvement activities varied by specialty and situation, reflecting a tension between the positive aspects of these requirements (i.e., relevance to practice, ability to improve practice) and the negative aspects (i.e., participant cost and time burden or confusion regarding requirements). Multiple studies of self-assessment and practice improvement activities found improvements in care process or quality relative to voluntary participants' own baselines in self-selected activities; however, studies that employed a control group had mixed findings, with modest improvements in some measures, but not others.

Internationally, implementation of MSF from peers and patients for physicians in Canada resulted in mixed ratings of relevance and impact on practice, with some physicians finding activities relevant and likely to change practice and others not. Studies reflecting the recent implementation of a comprehensive “revalidation” program to recertify physicians in the United Kingdom indicated that the requirements may be increasing engagement with quality and safety data, but the burden and quality of peer appraisals is greater for physicians in some practice types and settings (e.g., more transient or nontraditional employment). Moreover, identification of physicians not fit to practice has not been impacted, and inpatient quality indicators have not improved. The literature about a parallel revalidation program for nurses, including APNs and midwives, was more limited in size and scope given the regency of implementation of the nursing revalidation program, but revalidation activities appeared to enhance one's reflection on one's clinical practice and resulted in inconsistent burden experienced by nurses with different employers.

The literature reviewed regarding CME activities revealed that interactive, multimodal, longitudinal, and sequenced activities that allowed for reflection and practice improved knowledge and clinical practice more effectively than passive, single-session techniques. The literature also noted that health professionals' ability to accurately assess their own knowledge gaps is limited, which could affect the ability of CME activities to improve practice.

Interviews with Health Professional Certifying Organizations

We conducted interviews with leaders or other representatives of ten health professional certifying organizations, preferentially including organizations whose scope of practice had substantial overlap with PAs in the United States and/or who had or were planning alternative requirements to closed-book exams for recertification. Several themes emerged from our interviews. First, interviewees reported that organizations carefully considered the balance between summative (i.e., evaluative) and formative (i.e., instructive) goals of their recertification requirements, particularly regarding assessment or exam requirements. Interviewees said they carefully weighed the types and degrees of burden from recertification requirements, including exams or longitudinal assessments, and sought to ensure relevance of requirements to practice. Interviewees also discussed the balance between the organizations' duty to the public to ensure health professional knowledge and competence and a desire to address health professional needs, preferences, and concerns. Interviewees from organizations transitioning from an exam to a longitudinal assessment perceived this transition as serving both the public and health professionals by providing effective formative education, informed by learning theory, to better ensure professionals' competence through a more collaborative and supportive approach and a more continuous assessment of knowledge. Finally, organizations who made recent transitions in their requirements shared the following recommendations: ensure adequate time and budget to address inevitable technology or platform challenges; conduct robust multimodal communication with health professionals to address outliers, slower adoption, and interaction with new technology platforms; and seek feedback and input from health professionals.