ABSTRACT

Physician assistants (PAs) must pass the National Commission on Certification of Physician Assistants (NCCPA) certification exam to become licensed; and to remain certified, they must earn continuing medical education credits as well as pass an assessment every 10 years. However, there is a dearth of research on public knowledge of and beliefs regarding licensure, certification and medical education of PAs. Thus, we examined public knowledge and beliefs by conducting an online survey in late 2018. When asked if the statement “PAs must pass a national certifying exam as one requirement for obtaining an initial license to practice medicine” was true or false, the majority (75.9%) correctly indicated that the statement is true. Regarding beliefs, most respondents strongly agreed or agreed that PAs should be licensed by state medical boards (87.6%), should continually learn about new medical information (91.7%), should be assessed regularly on their medical knowledge (82.0%), should be held to the same standards of care as physicians (78.6%) and should be well-educated in medicine (77.7%). Evaluation of public knowledge and beliefs about licensure, certification and medical education of PAs is important, as members of the public are vital stakeholders for certification organizations and medical regulatory bodies. Certification organizations and medical regulatory bodies are accountable to the public, and periodic assessment of public perspectives can provide insight and help inform decision-making regarding regulatory and certification changes to meet patient expectations regarding safe, high-quality medical care.

Introduction

The physician assistant (PA) profession is a capable and robust health care workforce that significantly contributes to the provision of health care services in the United States. It was initially developed in the 1960s to help relieve primary care physician shortages and increase access to health care for patients living in medically underserved inner-cities and rural areas.1  Early PA programs were derived from medical schools, and thus PA education is based on the medical model, with intense basic, behavioral, and clinical science education and clinical training, leading to a master’s degree. PAs conduct physical exams, diagnose medical conditions, develop and manage treatment plans, order and interpret diagnostic studies and prescribe medications. PAs provide patient care in all U.S. states and every practice setting and specialty.2  As of 2019, there were more than 139,000 certified PAs, with projections indicating a further 31% growth between 2018 and 2028.3 

The National Commission on Certification of Physician Assistants (NCCPA) was created as an independent certifying organization to serve the public by providing a mechanism to demonstrate that certified PAs meet standards of medical knowledge, reasoning and other essential competencies and skills.4,5  All U.S. states and territories rely on initial certification from NCCPA as one criterion for licensure or regulation of PAs.

As part of the requirements to become licensed, PAs must graduate from an accredited PA program and become certified by achieving a passing score on the physician assistant national certifying exam (PANCE). Rapidly advancing change in medicine challenges PAs to continually learn and update their knowledge to remain current. To maintain NCCPA certification throughout their careers, PAs must earn continuing medical education credits and pass the Physician Assistant National Recertifying Exam (PANRE) assessment every 10 years. At the beginning of 2019, NCCPA initiated a pilot alternative to the PANRE to foster continuous learning, in which PAs participated in a two-year online longitudinal assessment consisting of 25 questions per quarter, with immediate feedback after each question.6 

Certifying organizations are tasked with assuring the public that practitioners have the competencies necessary to provide safe and high-quality medical care. Since the primary constituency for certification is the public, it is important to evaluate public perspectives of medical provider certification. Prior research shows that certification status is consistently among the most important criteria for patients when choosing physicians.710  However, only a few studies have directly investigated public knowledge and attitudes toward certification. A survey conducted by the Gallup organization showed that the majority of the public was aware that prior to being allowed to practice medicine in the United States, physicians have to pass a written exam of their medical knowledge and be licensed by the state in which they work.11  Moreover, most (84%) believed that physicians must be evaluated by an independent board of physicians as to their ability to practice medicine; and 68% indicated that it was very important that physicians periodically pass a written assessment of medical knowledge. However, 18% of adults either did not know if their physician was state-licensed or did not know what state licensing entailed; 11% did not know what “board-certified” meant and 15% did not know if their physician was board-certified. Similarly, Mainous et al. found that despite 79% of patients reporting that it was very important that the physician providing their treatment passed a board-certification assessment, a large proportion (40%) did not know whether their physician was certified.12  Freed et al. found that 88% believe it is very important or important for physicians who care for children to pass a written assessment at regular intervals.10  More than three-quarters of parents indicated they would be likely to change their child’s physician if the provider did not maintain their board certification.10 

Physicians also believe that patients prefer certified physicians.1315  In a survey study of family physicians, Peabody et al. found that 37% report that patients prefer being treated by a board-certified provider.13  Similarly, Freed et al. found that the vast majority of general (82%) and subspecialist (79%) pediatricians agreed that parents prefer board-certified pediatricians.14  Culley et al. found that 86% of anesthesiologists agreed that patients perceive board-certified physicians as more competent, and 45% reported that their practice publicizes board certification.15 

Evidence exists that patients prefer board-certified physicians, and physicians acknowledge this preference among their patients. However, we found no previous research that directly explored public knowledge of and beliefs regarding PA licensure, certification and medical education. Moreover, there is a dearth of research investigating if public knowledge and beliefs about PA licensure, certification and medical education vary across patient and consumer characteristics such as age, gender and education as well as health status and insurance status. To start to address these gaps, we surveyed the public to answer the following research questions:

  1. Does the public know that PAs must pass a national certifying exam as one requirement for obtaining an initial license to practice medicine?

  2. What does the public believe about PAs’ licensure, certification and medical education?

  3. How do knowledge and beliefs vary according to public demographic characteristics and number of provider visits in the past year, self-reported health, and health insurance?

We anticipated that older participants, those with more visits to providers in the past year and those with worse self-reported health status (given the higher likelihood of using more health services) would have more knowledge and more favorable beliefs about licensure, certification and medical education of PAs.

Methods

Study Design

This study was reviewed by an independent Institutional Review Board (IRB) (Sterling IRB) and deemed not-human-subjects research. A cross-sectional online panel survey was conducted from November–December 2018 using quota sampling to approximate the proportions in demographics of the U.S. population. The sample was obtained from Qualtrics, which maintains a panel with more than 90 million respondents. At the start of the survey, we supplied a brief description of the study, noting that responses would be anonymous and reported in aggregate. Respondents read a description and affirmed their consent to participate. We used a combination of demographic screening questions and recruitment quotas to reflect the U.S. population’s demographic profile in terms of gender, race/ethnicity, education and geographic setting. When limits were met for each demographic group, no additional participants were asked to complete the survey. This study was part of a more extensive multi-part survey exploring public perceptions, knowledge of, and attitudes about PAs; prior experiences with physicians, PAs and nurse practitioners (NPs); and factors important in choosing providers. Of the 19 survey items, one question focused explicitly on knowledge of certification/licensure of PAs and five centered on beliefs. After being presented with the true/false/not sure knowledge-items about PAs and prior to being asked about beliefs, participants were provided the explanations for correct responses.

Data Source

Participants were recruited from a Qualtrics (Provo, Utah) panel, which consists of a nationally representative sample of U.S. adults. To be included in the study, participants had to be 18 years or older, reside in the United States and have been treated by a medical provider in the past two years or decided on a provider for a dependent. Participants who reported to be a health care provider or who had one in the family were excluded.

Measures

We focused survey development efforts on understanding public views of PAs. An extensive literature search did not reveal an existing survey instrument that specifically addressed our questions regarding public knowledge of, and beliefs regarding, licensure, certification and PAs’ medical education, so we created a new questionnaire. We used prior studies to generate a list of relevant topics of interest. Using these topics, we subsequently drafted survey items exploring public perceptions, knowledge of and attitudes about PAs; prior experiences with physicians, PAs and NPs and factors important in choosing providers. The authors have training and experience in survey item development. We evaluated the wording of each survey item and iteratively revised and modified items, as needed. We also incorporated findings from our previously conducted survey that explored similar content areas.16 

Respondents were asked to indicate true/false/not sure to the following statement: “PAs must pass a national certifying exam as one requirement for obtaining an initial license to practice medicine.” Response options of “false” and “not sure” were collapsed. Participants were also assessed regarding various beliefs related to PAs and certification/licensure with the following survey items: “For each of the statements below, please indicate your level of agreement: (1) I believe PAs should be licensed by state medical boards; (2) I believe PAs should continually learn about new medical information; (3) I believe PAs should be assessed regularly on their medical knowledge; (4) I believe PAs should be held to the same standards of care as physicians; and (5) I believe PAs are well educated in medicine.” Response options included “strongly agree,” “agree,” “neither agree or disagree,” “disagree,” “strongly disagree” and “not sure.” In inferential analyses, responses of “strongly agree” and “agree” were combined, as well as “disagree” and “strongly disagree.” Responses of “not sure” were excluded. Several demographic and background variables were collected, including age, gender, race, ethnicity, education, urban-suburban-rural home setting, number of visits to a provider in the last year, health status and health insurance type. To ensure quality responses, we embedded an attention check item whereby participants were asked, “From the options below, please select neither agree nor disagree.” All participants who failed the attention check (did not select neither agree nor disagree) were excluded from the survey’s final sample.

Statistical Analysis

Each survey item had less than 1% missing responses. Chi-square tests for independence were used to detect significant associations between knowledge/beliefs and participant demographic characteristics, number of provider visits, self-reported health and health insurance status.

Results

There was a total of 1,388 respondents in the study. Table 1 summarizes demographic characteristics, number of provider visits in the past year, self-reported health and health insurance status. A slight majority were female (51.2%) and between the ages of 35 and 64 (51.1%). The highest proportion of participants were white (72.4%), non-Hispanic/Latino (84.1%), had some college up to an associate degree (27.2%) and lived in a suburban setting (47.0%). Most reported having between one and five visits to a provider in the last 12 months (68.4%) and being in good health (56.4%). The most common health insurance type was private insurance only (38.9%), followed by Medicare only (20.7%).

Table 1

Demographic Characteristics, Number of Provider Visits, Self-Reported Health and Health Insurance for All Respondents (N = 1388)

Demographic Characteristics, Number of Provider Visits, Self-Reported Health and Health Insurance for All Respondents (N = 1388)
Demographic Characteristics, Number of Provider Visits, Self-Reported Health and Health Insurance for All Respondents (N = 1388)

Most (75.9%) respondents correctly indicated “true” to the statement that “PAs must pass a national certifying exam as one requirement for obtaining an initial license to practice medicine” (Table 2). Only 4% believed this statement was false; however, a sizeable proportion was not sure (20.1%). The highest proportion strongly agreed/agreed that PAs should continually learn about new medical information (90.4%), followed by the belief that PAs should be licensed by state medical boards (86.0%) and that PAs should be assessed regularly on their medical knowledge (80.2%). A large majority also believed that PAs should be held to the same standard of care as physicians (77.0%) and that PAs are well educated in medicine (75.5%).

Table 2

Knowledge and Beliefs Regarding PA Certification, Licensure and Medical Education

Knowledge and Beliefs Regarding PA Certification, Licensure and Medical Education
Knowledge and Beliefs Regarding PA Certification, Licensure and Medical Education

Table 3 presents differences in public knowledge and beliefs regarding PA certification and licensure by demographic characteristics. Despite the high overall proportion of respondents knowing that PAs must pass a certifying exam and having favorable beliefs regarding PA licensure and certification, we found a consistent pattern whereby the youngest participant age group (18–34) and those with less education were more likely not to know/be unsure about PAs and certification and hold more neutral beliefs. Respondents in the 18–34 age group compared to those 65 and over (29.2% vs. 19.8%; p=0.010) and those who had less than a bachelor’s degree compared to more education (27.0% vs. 18.5%; p<0.001) were more likely to incorrectly indicate “false” or be unsure that PAs must pass a national certifying exam as one requirement for obtaining an initial license to practice medicine.

Table 3

Knowledge and Beliefs Regarding PA Certification, Licensure and Medical Education by Demographic Characteristics

Knowledge and Beliefs Regarding PA Certification, Licensure and Medical Education by Demographic Characteristics
Knowledge and Beliefs Regarding PA Certification, Licensure and Medical Education by Demographic Characteristics

Regarding beliefs, a significantly higher proportion of respondents aged 18–34 compared to 35–64 and 65-and-over were neutral to believing that PAs should be licensed by state medical boards (17.6% vs. 9.5% and 6.2%; p<0.001), that PAs should continually learn new medical information (10.7% vs. 6.9% and 3.1%; p<0.001) and that PAs should be held to the same standards of care as physicians (22.0% vs. 14.9% and 10.9%; p<0.001). Participants with less than a bachelor’s degree were more likely compared to those with a bachelor’s degree or higher to indicate “neither agree nor disagree” to believing that PAs should be licensed by state medical boards (13.0% vs. 7.9%; p=0.011), should continually learn about new medical information (8.9% vs. 4.2%; p=0.004), should be assessed regularly on their medical knowledge (18.4% vs. 10.7%; p<0.001) and that PAs are well educated in medicine (21.1% vs. 13.9%; p=0.005). We did not detect differences in knowledge and beliefs by gender and home setting (urban-suburban-rural).

Table 4 provides a detailed characterization of knowledge and beliefs by number of provider visits in the past year, self-reported health and health insurance status. The only statistically significant association we found was that participants with private health insurance compared to none and Medicaid only (82.2% vs. 69.3% vs. 65.9%; p<0.001) were more likely to know that PAs must pass a national certifying exam to obtain a license to practice medicine.

Table 4

Knowledge and Beliefs Regarding PA Certification, Licensure and Medical Education by Provider Visits, Self-Reported Health and Health Insurance

Knowledge and Beliefs Regarding PA Certification, Licensure and Medical Education by Provider Visits, Self-Reported Health and Health Insurance
Knowledge and Beliefs Regarding PA Certification, Licensure and Medical Education by Provider Visits, Self-Reported Health and Health Insurance

Discussion

This research aimed to explore public knowledge and beliefs regarding certification, medical education and licensure of PAs. Three main findings emerged from our analysis. First, the majority of the public knew that PAs are required to pass a national certifying exam as one requirement for obtaining an initial license to practice medicine. However, opportunities still exist to educate the public on PA licensure and certification, as about a quarter of those surveyed either incorrectly responded or did not know. The second major finding is that beliefs about PA licensure, certification and medical education are very favorable. A large majority agree that PAs are well educated in medicine and should be licensed by state medical boards, continually learn new medical information, be assessed regularly on their medical knowledge and be held to the same standards of care as physicians. Third, we found consistent differences between younger and older participants and between those with less than a bachelor’s degree and those with more education regarding beliefs and knowledge of PA licensure and certification. Members of the public who were younger and those who had completed less education were less knowledgeable and had more neutral beliefs.

Although no earlier research has investigated public perspectives regarding licensure, certification and medical education of PAs, there are few available studies of public views of physician certification. Confidence in our findings is bolstered by the fact that our results are comparable with previous research. In our study, most respondents (76%) knew that PAs must pass a national certifying exam as one requirement for obtaining an initial license to practice medicine. In a Gallup study of awareness of and attitudes toward board-certification of physicians, 98% of respondents indicated that physicians need to pass a written exam of their medical knowledge and be licensed in the state where they work.11  The Gallup study also found that 68% rated as “very important” that physicians pass a written test of medical knowledge at regular intervals. Similarly, in the Freed et al. study, 88% of members of the public believed that pediatricians should pass a written test at regular intervals.10  These findings are consistent with our results, in which 80% agreed that PAs should be assessed regularly on their medical knowledge.

Although we anticipated that older participants and those with more visits to providers in the past year, as well as worse self-reported health status, would be more knowledgeable and have more favorable beliefs about licensure, certification and medical education of PAs, we found a consistent pattern of statistical differences only by age and educational level. We found that older adults and those with more education were more likely to correctly know that PAs must pass a national certifying exam as one requirement for obtaining an initial license to practice medicine. This finding is comparable with that of the Gallup study, which also found that older, compared to younger, adults were more likely to report being aware of whether their physician was board-certified. However, in the Gallup study, the researchers did not detect any significant differences by education. More research is needed to better illuminate the relationship between health care utilization, health status and knowledge and beliefs about licensure, certification and medical education of PAs.

Limitations

The current research is not without limitations. First, as with all surveys, responses may reflect social desirability or recall bias. Second, we used a Qualtrics panel using quota-sampling rather than random-probability sampling. This sampling strategy may have introduced selection bias, thus limiting the generalizability of our findings. The demographic distribution among respondents in our study mirrored the U.S. Census. Demographic comparisons with U.S. Census data showed that respondents in our study matched those of the U.S. population in terms of gender, age, race, ethnicity, education and insurance status.17  Previous research has found that participants from Qualtrics panels are similar to benchmarks in terms of demographics, cooperation and experimental replication.18  A variety of previously conducted studies have recruited participants using quota sampling from Qualtrics panels.1921  Despite the similarity in demographics of our sample compared to the U.S. census, respondents in the present study may have differed in other unmeasured characteristics. Additionally, we could not calculate the response rate because the Qualtrics platform uses its panel to recruit respondents, and the research team is only provided with information on participants who completed the questionnaire.

To our best knowledge, the present study is the first to analyze public knowledge and beliefs of licensure, certification and medical education of PAs. Most of the public knew that PAs must pass a national certifying exam and had favorable beliefs about PA education, licensure, continual learning and assessment of medical knowledge. Given that the public is a key stakeholder for certification and medical regulation, it is important to evaluate their perspectives. The role of the public is of growing importance in medical regulation.22,23  Certification organizations and medical regulatory bodies are accountable to the public, and periodic assessment of public perspectives can provide insight and help inform decision-making regarding regulatory and certification changes to meet patient expectations regarding safe, high-quality medical care.

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About the Authors

Andrzej Kozikowski, PhD, is Director of Research at the National Commission on Certification of Physician Assistants.

Sheila Mauldin, MNM, is Vice President of Research and Exam Programs at the National Commission on Certification of Physician Assistants.

Colette Jeffery, MA, is Senior Research Analyst at the National Commission on Certification of Physician Assistants.

Kasey Kavanaugh, MPH, is Research Analyst at the National Commission on Certification of Physician Assistants.

Grady Barnhill, MEd, is Senior Assessment Advisor at the National Commission on Certification of Physician Assistants.

Dawn Morton-Rias, EdD, PA-C, is President and CEO of the National Commission on Certification of Physician Assistants.