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Friday, December 12, 2014

Certificates of Added Qualification (CAQ) Exams for Physician Assistants

Specialty Certificates of Added Qualifications (CAQ) Exams

CAQ exams for physician assistants are utilized for one purpose: to receive recognition for having obtained advanced clinical training and skills in your specialty. Since September of 2011, these exams have been given by the NCCPA just like the PANCE, and awarded to those who perform exceptionally. The CAQ emphasizes that PAs are grounded first in generalist medicine and then pursue additional qualifications in specialites. It serves as excellent documentation of knowledge, training, and experience in specialty practice. It also helps to avoid the confusion of any new PA “certification” program or any new specialty certification designation, as this credential is achieved in addition to the PA-C. According to Janet Lanthrop, old CEO of NCCPA, there were two desires in producing this exam: to have documentation to show hiring physicians that PAs were knowledgeable in specialty areas and to give hiring physicians assurance that the PA had experience in the specialty to come in at a certain level of acuity than your typical newly hired PA.




However, we must remember that these exams also pose a threat to our profession. Karen CalcaƱo, a cardiothoracic surgery PA from South Florida, writes an amazing blog post about this, which we also discussed in our Professional Practice Issues course last semester.
A few points to be addressed about CAQ:
  • PA mobility may be compromised. If we look at NPs who once welcomed specialty certification we will quickly realize that they are now required to specialize in an area of medicine and experience difficulty transitioning between fields. Additionally, we don’t want specialties that are more economically desirable to be brought to the forefront, leaving less economically desirable specialties behind. This could change the landscape of healthcare as it stands today.
  • Change in education of PA students. The current focus of PA student education is primary care. Thus, institutions may feel more pressure to train their students in specialty areas if students were required to have specialty training. Adding more training to programs could extend the length of the program and tuition costs.
  • Change in coverage by third party payers. Private and government insurers could someday require PAs to be “specialized” in order to receive reimbursement. The Physician Assistants in Orthopaedic Surgery (PAOS) board also brought up that hospitals and insurance carriers could make certification mandatory for anyone submitting claims or working in their facilities.
  • Loss of employment opportunities. As it stands, employers are already asking new grads for experience right out of school. If the CAQ exam requires PAs to have at least 2 years of full-time experience, new grads may be unable to find jobs or be discouraged from entering certain specialty fields. Take an example from Adirondack Health, which already stated in October of 2013 that “Adirondack Medical Center has now set the CAQ ‘as a standard for PAs in emergency medicine as a measure to prove their high-level of competence.’”
  • Decreased salaries. If some PAs are obtaining CAQ recognition and others are not, employers may soon ask to see certification in order to start at higher salaries or for bonuses and raises.
  • Increased professional liability.
  • Change in licensure of PAs.
  • Fellowships and residencies not mentioned as equivalent requirements. Some PAs who have undergone a fellowship or residency in their area are frustrated because they feel that they have adequate experience and knowledge, yet NCCPA is not allowing them to be recognized for it.
  • “AAPA is opposed to specialty certification, the use of specialty examinations and certificates of added qualification that could reduce the profession’s versatility and flexibility, drastically altering its value to society. (AAPA, 2012).
  • “We, as a Board, feel that this program is not in the best interest for the growth of our profession and ask that you think long and hard before you decide to jump into the unknown.” (PAOS Board, 2011).

However, there are numerous benefits to having a specialty CAQ, and there are organizations like APACVS that do endorse the specialty CAQ program. APACVS is one organization working to create a review handbook to prepare PAs for this exam. Roger Best, PA-C, wrote an article about his endorsement for CAQ, but he also mentions how the added qualification could be changed into an “extended core” examination given in addition to PANCE or PANRE. This is similar to how PANCE exams were given until 1997, with extended core exams given in surgery or primary care. CAQ exams are also endorsed by Emergency Medicine PAs of California, which asks EMPAs to “show some EMPA pride and take the test.”

Notably, of the 533 CAQ recipients so far since 2011:
  1. 75% found or anticipate finding a new job
  2. 40% successfully sought a promotion.
  3. 60% achieved or expected an increase in job responsibilities.
  4. 50% received or anticipate a pay increase, while 33% received a cash bonus.
  5. 33% achieved or anticipate broadening of eligibility for reimbursement.
  6. 75% have received greater recognition from physicians or other health providers
  7. 66% reported greater respect or acceptance from patients

Of the 533 CAQ recipients:
  • 27 have obtained CAQ in CVTS
  • 334 have obtained CAQ in emergency medicine
  • 12 have obtained CAQ in nephrology
  • 63 have obtained CAQ in orthopaedic surgery
  • 97 have obtained CAQ in psychiatry
  • 3 PAs have obtained CAQ in two specialties

There are currently 7 CAQ specialties you may apply to obtain: cardiovascular and thoracic surgery, emergency medicine, hospital medicine, nephrology, orthopaedic surgery, pediatrics, and psychiatry. These specialties were decided by factors that included: population size, assessment of need, focus on procedures, criticality of patients, PA mobility trends, support of PA specialty organizations, and the degree of specialty being hospital-based.

Each two-hour exam includes 120 multiple choice questions administered in two blocks of 60 questions each, with 60 minutes allotted for each. There is no break time between. You have 15 minutes to complete a CAQ tutorial beforehand. After you exit a block of test questions or time runs out for that block, you may not go back to review the its questions or change your answers.

To qualify to take the exam, you must:
  • Currently be licensed as a physician assistant, PA-C
  • Possess a valid, unrestricted license to practice as a PA in at least one jurisdiction (state) in the United States or its territories, or have unrestricted privileges to practice as a PA for a government agency

Additionally, four core requirements must be met:
  1. You must obtain 150 credits of Category 1 Specialty CME focused on the specialty within the 6 year period, ending on the date which you plan to apply for the CAQ exam. At least 50 of those CME credits must be earned two years prior to the date of application for the CAQ exam. Specific requirements can be found in the Appendix (page 5) for CAQ.
  2. Must have 1-2 years of specialty experience in your field
    1. Note: the hours of experience vary from 2,000-4,000 hours depending on the specialty. Check it here. The hours must be obtained within 6 years prior to the date you attest to NCCPA that the experience requirement has been satisfied.
  3. Must have performed specialty procedures and have patient case experience appropriate for the specialty
  4. Must complete the specialty CAQ exam. Sample exam questions for specialty CAQ exams are available online. If you are unsuccessful, you may apply for a subsequent exam, but will have to meet the CAQ eligibility requirements at the time of your next application.

Additional, additional, requirements not readily exposed on the website:
  1. Your supervising physician must attest that you have (1) performed the procedures and patient management relevant to the practice setting and (2) that you understand how and when the procedures should be performed by filling out the required physician attestation form.

Of the 2011 CAQ exam registrants (n = 250), the average age was 45 and the number of years certified prior to taking the exam was 11-15 years, followed by 6-10 years. Hopefully that puts things into perspective on how many years of experience people had before taking this exam.

Cost: Just $350 for the exam, says NCCPA, as if that is not a lot of money. Oh, but wait, there is also a $100 administrative fee and you have to pay $250 to even register for the exam! Exam re-takers only have to pay the registration fee once.

Registration is always open and is valid for 6 years from the date you initiate the process to the date you complete all requirements. You may initiate the process by paying your $100 administration fee and satisfying any one of the first 3 core requirements. PAs may not register to repeat an exam if they have scores pending from a previous administration of the same exam. PAs may be registered for more than one CAQ program at a time.

The application registration for all CAQ exams opens in January with the last day to register for an exam around August 19. There is ONE exam date for ALL CAQ exams now, usually around August 24. They are administered at Pearson VUE testing centers nationwide.

How long is the CAQ valid for? 10 years, provided you remain licensed at the state and national level. You must pass the specialty CAQ exam again before expiration of your current CAQ to maintain it. You have 3 attempts to pass the exam. Between CAQ exams, you must obtain 125 credits of Category I CME focused in the area of your CAQ specialty.

The CAQ exam score will not be released and the individual will not receive the CAQ until a final decision has been reached by NCCPA. Scores are typically released in mid December. If your CAQ is under review by the NCCPA, but your PA-C certification is still valid, you may apply for and participate in CAQ maintenance activities, but you will not receive credit for them until a final decision has been made. In 2013, the pass rate among the first 5 specialties ranged (not including pediatrics and hospital medicine) between 80-97%.

Detailed information for each specialty CAQ exam can be found below.

  • Applicants are required to complete an Advanced Cardiac Life Support course in addition to their 150 credits of specialty-focused Category 1 CME.
  • CME Recommendations: activities should encompass knowledge of post-op critical care management and knowledge of of surgical management of CAD, congenital heart disease, thoracic disease, and central and peripheral vascular disease.
  • Experience requirement: 4,000 hours (2 years full-time practice) in cardiovascular and/or cardiothoracic surgery
  • Specialty procedures and patient cases: see pages 5 and 6 of Appendix

  • Applicants are required to complete an Advanced Cardiac Life Support course in addition to their 150 credits of specialty-focused Category 1 CME. Must also complete the following: Pediatric Advanced Life Support (Advanced Pediatric Life Support), Advanced Trauma Life Support, Airway Course
  • CME Recommendations: complete a comprehensive EM course reflecting the guidelines in the most current version of the Model of the Clinical Practice of Emergency Medicine.
  • Experience requirement: 3,000 hours (18 months full-time practice) in emergency medicine
  • Specialty procedures and patient cases: see pages 6 and 7 of Appendix

Tintinalli’s Emergency Medicine Manual - study guide for emergency medicine CAQ

New in 2014: Hospital Medicine
  • Applicants are required to complete an Advanced Cardiac Life Support course in addition to their 150 credits of specialty-focused Category 1 CME. Must also complete the a CME activity related to risk management.
  • CME Recommendations: None
  • Experience requirement: 3,000 hours (18 months full-time practice) in a practice that involves the management of hospitalized adult patients
  • Specialty procedures and patient cases: see page 7 of Appendix

  • Applicants are required to complete an Advanced Cardiac Life Support course in addition to their 150 credits of specialty-focused Category 1 CME.
  • CME Recommendations: Complete CME activities that encompass knowledge of the evaluation of kidney function, urinalysis, radiological assessment of renal disease, the kidney in systemic disease, chronic kidney disease, peritoneal dialysis, hemodialysis, medications and the kidney, the kidney in special circumstances (pediatric, pregnant, aging), hypertension, billing and coding, and kidney transplantation.
  • Experience requirement: 4,000 hours (24 months full-time practice) in practice as a PA, including at least 2,000 hours (12 months full-time) in nephrology
  • Specialty procedures and patient cases: see page 8 of Appendix

  • Applicants are required to complete an Advanced Cardiac Life Support course in addition to their 150 credits of specialty-focused Category 1 CME.
  • CME Recommendations: Complete CME activities focused in orthopaedic surgery
  • Experience requirement: 4,000 hours (24 months full-time practice) in orthopaedic surgery
  • Specialty procedures and patient cases: see page 9 of Appendix

New in 2014: Pediatrics
  • Applicants are required to complete a Pediatric Cardiac Life Support (or Neonatal Resuscitation Program) course in addition to their 150 credits of specialty-focused Category 1 CME.
  • CME Recommendations: Complete CME activities focused in pediatrics.
  • Experience requirement: 4,000 hours (24 months full-time practice) in orthopaedic surgery
  • Specialty procedures and patient cases: see page 10 of Appendix

  • No additional CME requirements specified.
  • CME Recommendations: Complete CME activities focused in psychiatry.
  • Experience requirement: 2,000 hours (12 months full-time practice) in psychiatry.
  • Specialty procedures and patient cases: see page 11 of Appendix

General CAQ Exam Reviews
Physician Assistant: A Guide to Clinical Practice by Ballweg, Sullivan, Brown, and Vetrosky


Sources:
CAQ Governing Policies - Includes Appendix (pg. 5-11)






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