how to become a physician

How to Become a Physician Assistant (PA-C)

Choosing one's path to become a physician assistant (PA-C) is no simple undertaking, mainly because there are several valid routes, all of which converge and culminate with passing the Physician Assistant National Certifying Exam (PANCE). While one candidate might enter a baccalaureate PA program right out of high school, another might pursue a 4-year undergraduate degree in, say, molecular biology, and then complete a PA master's program. Others might spend time in the medical workforce as EMTs, paramedics, or nurses before stepping onto their physician assistant career pathway.

Those choosing this career have plenty of research to do and more than a few critical decisions to make — and as they weigh each decision, they must consider its outcome. Despite all the differences in potential paths to becoming a PA-C, all the paths should merge to meet the following goals:

Being accepted into and graduating from an accredited PA program
Gaining access to high-quality clinical training opportunities
Passing the PANCE
Becoming licensed to practice in one's state(s) of choice
Getting hired as a PA
Maintaining PA certification and licensing over the course of one's career

For example, while virtually every U.S.-state licensing board for PAs requires graduation from an accredited PA program and a passing score on the PANCE, several states also specify baccalaureate or master's degrees. And, while one does not need a master's degree to sit for the PANCE, an MA may be needed to obtain the best jobs or salaries and will most definitely influence career progression in this field.

While it is outside the scope of this post to discuss every important decision in detail, we will address some of the bigger forks in the road where poor choices can end up limiting one's chances of ever becoming a certified physician assistant (PA-C).

Choosing a PA Program

Physician assistant program admissions are highly competitive, and prerequisites vary widely. Prospective students should begin their preparation and application processes with a clear idea of the programs they would ultimately like to attend. Among the many factors one must carefully consider are the two most important: program accreditation and PANCE pass rates.

One thing is certain: you can sit for the PANCE only after graduating from a PA program that has been accredited by the Accreditation Review Commission on Education for the Physician Assistant (ARC-PA). There are several possible accreditation statuses that a program might have:

Accredited (Accredited-Continuing)
Accredited-Provisional
Accredited-Probationary
Developing-Not Accredited

Any of the first three statuses signifies that a program is permitted to accept students and considered valid in terms of their graduates' eligibility to sit for the PANCE. Provisional accreditation typically means a program is new — although it has met accreditation standards on paper, it has not completed a full cycle, demonstrating compliance with the accreditation standards. There is a risk, therefore, that a provisionally accredited program will not end up achieving Accredited-Continuing status.

Accredited-Probationary programs, meanwhile, have fallen out of compliance with accreditation standards. This might be because of a simple administrative infraction — such as a failure to file a certain data report on time, for example — but it could also signify problems with administrative or faculty turnover or consistently poor student performance on the PANCE. If you are considering a program that is designated as Accredited-Probationary, be sure to find out specifically why the program is on probation.

When selecting an accredited PA program, pay attention to the program's schedule for future accreditation reviews, because the program's status could change during one's tenure as a student.

The National Commission on Certification of Physician Assistants (NCCPA) allows PA program graduates to sit for the PANCE as long as their program was accredited — including provisional or probationary status — at their time of matriculation (enrollment) — not their graduation.

Less clear, however, is how various state licensing boards for PAs might interpret the stated requirement of "graduation from an accredited program." If you are considering a program whose accreditation status may be at risk, be sure to check with state licensing boards for clarification before enrolling.

While there is always a chance that at-risk programs might lose their accreditation, the risk is also relatively low; programs have made substantial investments in achieving accreditation and will, in all likelihood, do what is needed to attain or return to Accredited-Continuing status. Loss or withdrawal from accreditation is relatively rare: over the past five decades, some 41 PA schools, an average of less than one per year, have either closed or withdrawn from accreditation, and several of those programs, along with their students, were transferred to other schools.

One might assume that a more mature program that has long been accredited is the only safe bet. This is not a given, however, as administrative and faculty turnover can bring dramatic changes and turmoil even in well-established programs.

As the number of accredited PA programs is projected to increase from 187 in 2013 to 262 in 2019, there will clearly be many students matriculating into Accredited-Provisional programs over the coming 5 years. New programs can only achieve Accredited-Continuing status if they have students with which to demonstrate their compliance to accreditation standards; growth in the overall number of PA programs must be seen as a positive in a field where the number of highly qualified candidates dramatically outweighs the number of program spots and demand for PAs is growing rapidly. The bottom line is that, regardless of changes in accreditation status, students who enroll in accredited programs will be eligible to sit for the PANCE upon graduation.

PANCE Pass Rates

Another key criterion for choosing a program should be its PANCE pass rates — both its percentages relative to the national average and its pass-rate trend. Each program will typically supply its past 5 years' worth of NCCPA-reported data for first-time test takers alongside the national average pass rates. While newer PA programs will have less data to show, they will likely be well prepared to discuss their strategies for

Ensuring high student performance — not just on the PANCE, but across many other PA success metrics
Identifying students at greatest risk of failing the PANCE
Providing academic support to those who might need it

Graduating from an accredited PA program is a strong indicator that one will pass the PANCE. The national first-time test taker pass rate for the class of 2014 was 95%, according to the NCCPA; the lowest the first-time pass rate has gone in the past 6 years is 91%, in 2011. High average pass rates for first-time test takers are likely a function of the fact that the supply of PA program seats is limited relative to demand. Even highly qualified students don't always get into a program, and students failing to meet rigorous program performance benchmarks do not usually make it to graduation. The upshot: If one is enrolled in a PA program and meeting the academic performance benchmarks to stay in, there is a very good chance one is also on track to pass the PANCE.

Passing rates for PANCE and PANRE are available through the NCCPA's website:

Passing rate for PANCE
Passing rate for PANRE

At-Risk PA Students

That said, a small number of PANCE candidates don't pass on their first try. There is a substantial body of research attempting to establish reliable models for predicting, as early as possible, which students those might be. The research is typically motivated by PA schools looking to refine their admissions criteria and to identify and better support at-risk students, but it can also be instructive for PA students hoping to focus their own PANCE preparation.

For example, a 2011 study out of Chatham University attempted to create a predictive model for early identification of students at risk of failing the PANCE. Ultimately, the Chatham researchers found that:

…at-risk students could be most effectively identified three months before graduation from the program. Although this is not as desirable [as earlier], if used effectively, 3 months can be sufficient to intervene and increase the likelihood of PANCE passage.

Among interventions, the researchers noted: individualized tutoring, providing at-risk students with opportunities to be evaluated for learning and test-taking disabilities, and requiring regular use by at-risk students of a PANCE-type question database for self-assessment, which, according to the researchers, "can be a very effective tool for not only medical knowledge reinforcement and learning, but also for familiarizing students with computer-based timed examinations."

Take PACKRAT Seriously

Created by the Physician Assistant Education Association (PAEA), the Physician Assistant Clinical Knowledge Rating Assessment Tool (PACKRAT) is a 225-question, multiple-choice examination that allows for student self-assessment and program evaluation and is similar in style and architecture to the PANCE. Created by PA educators and exam experts specifically for PA programs, the PAEA claims that some 90% of PA programs nationwide use the PACKRAT. Schools typically administer the test twice — once before and once after clinical rotations.

While student performance on the PACKRAT has been strongly correlated with PANCE pass/fail performance across numerous studies, those studies are typically aimed at educators and administrators rather than PA students. Different programs use the PACKRAT in different ways and for different purposes — for example, to assess the effectiveness of a program's didactic and clinical portions. As a consequence, PA students may not consider their performance on the PACKRAT as an indicator of whether or not they are prepared for the PANCE.

A safety net of sorts for PA students is that the accrediting body (ARC-PA) keeps a close eye on the PANCE pass rates of accredited programs. Beginning with the class of 2013, programs with PANCE pass rates at 82% or lower for their most recent cohort are required to submit detailed analyses of their PANCE performance trends along with comprehensive action plans for improving performance to the ARC-PA or they risk losing accreditation.

Timing and Studying for the PANCE

Accredited PA programs are clearly motivated to ensure their that students are well prepared to pass the PANCE on the first try. Indeed, most PA students take the PANCE within just a few study-intensive weeks of graduating. While students with lower GPAs or other poor performance markers may hesitate to take the PANCE right after graduating, waiting may not be in their favor. A Drexel University study found that: "…students with lower GPAs delayed longer before taking PANCE with poorer results…" If you are a PA student and feel that you may be at risk of not passing the PANCE on the first try, you should consider intensifying preparation for test taking in general and the PANCE in particular rather than delaying PANCE and risking post-graduation memory decay.

PA-program graduates are usually prepared to pass the PANCE and become a certified physician assistant (PA-C) on their first try, and specific preparation for the board exam is typically confined to just a few weeks of intensive study. There are plenty of options and tools for review, including review courses (both in-person and online), CD and DVD courses, question banks, and so forth. Specific study tips can be found here, and we will continue our exploration of the various study methods in future posts on this blog.

Developed with busy clinicians in mind, NEJM Knowledge+ Family Medicine Board Review's adaptive learning program helps PAs meet certification maintenance requirements by providing the ability to earn up to 20 self-assessment CME credits, up to 296 AMA PRA Category 1 Credits™, prepare for board exams with Physician Assistant Exam Review, and refresh and retain the broad body of general medical knowledge you learned in your training.

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