Rapid Growth in Dermatology PAs: New Certification Exam Shows Reasonable Alignment with US Skin Disease Burden, Potential for Refinement

Dermatology physician assistants (PAs) enter the field after completing a master's degree and passing the PA National Certification Examination, which consists of 300 questions and is administered by the National Commission on Certification for PAs (NCCPA). In 2023, the NCCPA introduced a Certificate of Added Qualifications (CAQ) in dermatology, marking the first accredited recognition of PA competence in this specialty. This CAQ requires a combination of clinical experience, continuing education, and passing a written exam.¹

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In 2017, the American Academy of Dermatology published the "Burden of Skin Disease Report" (BSDR), a comprehensive analysis of skin disease prevalence, costs, and mortality in the United States, using data from 2013 insurance claims across 24 skin disease categories.²

A recent study published in the Journal of Dermatology for Physician Assistants aimed to evaluate how well the CAQ blueprint for dermatology PAs aligns with the dermatologic needs of the US population by comparing it with the BSDR.³

Background and Methods

To assess the alignment between the CAQ blueprint and the actual burden of skin disease, diagnoses listed on the CAQ blueprint were quantified based on their representation in an idealized CAQ test. For instance, dyshidrotic eczema is one of 18 conditions classified under "inflammatory" diseases, which make up 11% of the exam. Thus, dyshidrotic eczema represents 0.61% of the CAQ exam. These diagnoses were then categorized according to the BSDR schema, and their prevalence and blueprint representation were compared.

The study included 133 diagnoses from the CAQ blueprint, with 2 conditions (hyperhidrosis and livedo reticularis) not fitting into the BSDR schema. The results were summarized, focusing on the discrepancies between prevalence and exam representation.

Findings

The findings indicated a general alignment between high-ranking CAQ categories and their prevalence in the BSDR, with some exceptions. For example, conditions such as connective tissue diseases, drug eruptions, and bullous diseases are less common but can be fatal and costly, thus receiving significant attention in the CAQ.

Conversely, highly prevalent categories such as HPV/molluscum, wounds/burns, cutaneous infections, and viral/fungal diseases had lower representation in the CAQ. This might be because conditions like molluscum and HPV are straightforward, and wound/burn patients often seek care in emergency departments rather than dermatology clinics, according to authors of the study.

Specifically, nonmelanoma skin cancer is considerably more prevalent and deadly than connective tissue diseases, yet it has a slightly smaller representation in the CAQ blueprint. Similarly, melanoma, despite having a high mortality rate, is less emphasized in the CAQ compared to connective tissue diseases. A revised CAQ blueprint might better balance content based on mortality and cost-prevalence ratios, giving more weight to skin cancers, which are responsible for a significant proportion of skin disease-related deaths.

Conclusions

The comparison of the CAQ blueprint to the BSDR revealed a reasonable alignment between exam content and the burden of skin disease, with some areas for improvement. For instance, given the high prevalence and mortality of skin cancers, increasing their representation in the CAQ could be beneficial.

The study's limitations include the granularity of the BSDR, which encompasses a wide range of clinicians' diagnoses, and the fact that the BSDR data is from 2013, with the report updated in 2017. Future research should consider comparing the CAQ to more recent data to ensure continued relevance and accuracy, according to authors.

"When comparing the CAQ to the BSDR, we found reasonable concordance between written examination content and the actual burden of skin disease, with some potential areas for refinement," wrote study authors Young et al. "For example, based on the high prevalence and mortality of skin cancers and their relatively small representation in the CAQ blueprint, increasing emphasis of this topic area could be considered for future iterations of the test."

References

1. National Commission on Certification of Physician Assistants. Specialty certificates. Accessed June 13, 2024. https://www.nccpa.net/specialty-certificates/
2. American Academy of Dermatology. Burden of skin disease. Accessed June 13, 2024. https://www.aad.org/member/clinical-quality/clinical-care/bsd
3. Young PA, Prajapati S, Bae GH, Feldman SR. A comparison of national skin disease burden with standardized examination content for dermatology physician assistants. J Dermatol Physician Assist. 18(2):p 12-14, Spring 2024. DOI: 10.1097/jdpa.0000000000000018