Integrating Physician Assistants in Canada
After several decades working in the Canadian military, Physician Assistants (PAs) are being introduced into provincial health care systems.
In Ontario, PAs were part of Ontario’s broader health human resources strategy to give Ontarians “access to the right number and mix of qualified health care providers”.
The work of a PA is clear from their name – they support physicians in a wide range of health care settings. The decision about the extent of clinical work PAs can do is determined by the supervising physicians’ assessment of their clinical competencies, skills and experiences in a particular setting.
PAs are trained to take detailed medical histories, conduct physical exams, diagnose and treat some illnesses, order and interpret diagnostic tests, and counsel patients on preventative health. However, what PAs do in practice varies depending on the setting they work in, their experience and physician supervisor.
PAs work in many different settings – from hospital emergency departments and operating rooms to community family medicine practices.
The introduction of PAs has been hailed as important in ensuring better access to health care services through their role as a “physician-extender“. However, there are some outstanding questions about how PAs interact with other health care providers, and are integrated into the health care system.
Physician Assistants in practice
Unlike many other clinicians who practice independently, PAs work under the supervision of physicians. While PAs are a regulated health profession in Manitoba, they are not in Ontario and Alberta. Being an unregulated, non-autonomous health care provider means that a PA’s scope of practice is not defined in regulation.
Consequently, the work that PAs do is established through individual negotiations with a supervising physician or through framework agreements. Paramedics are another unregulated provider group in Ontario.
Research suggests that PAs in emergency departments can improve patient flow and decrease wait times. When surveyed about working with PAs, physicians are generally supportive of their role in improving access to care. Similarly, a study surveying parents at a pediatric emergency department found that most were willing to have their child be seen by a PA.
Robin Griller, executive director of the Inner City Family Health Team in Toronto says that a PA has been integrated into their practice to help reduce demands on physicians. Griller says this clears up time for the physicians to focus on caring for more complex patients. With a PA’s starting salary at $75,000, Griller says “it’s a cost effective way to manage physicians’ workload and time.”
The question of whether PAs are cost effective in Canada has not been studied. A 2011 economic analysis led by researchers at McMaster University described evidence around the cost effectiveness of PAs as anecdotal, and difficult to translate to the Ontario context.
Griller notes some of the challenges of integrating PAs into an interprofessional care team. He says that prior to introducing the PA into the Family Health Team, outreach and education around this role was done for other providers. “Everyone knows what a Nurse Practitioner or Social Worker does, but people are unclear about PAs and what they can and cannot do” he says.
Mary-Anne Robinson, CEO of the College & Association of Registered Nurses of Alberta outlines concerns with the regulation, scope and supervision of PAs.
“We are concerned about the impact on patient care and safety by virtue of creating a chaotic environment when you are introducing a new health care provider where no other professions understand what they do.” Robinson suggests that in the absence of clear guidelines of a PA’s scope of practice, patients’ safety is at stake. “There is a higher risk of error and adverse events in an environment where there isn’t good collaboration and it is unclear who is doing what” she says.
Maureen Taylor, a PA who has worked in Toronto’s Sunnybrook Health Sciences emergency department says that in spite of “press releases that unions and associations put out, we all care about patients.” Taylor says that this shared focus on providing patient care means “on the ground we [PAs] have good working relationships with nurses and NPs.”
History of Physician Assistants
PAs are a new, relatively small group of health care providers in Canada with about 300 currently in practice, mainly in Ontario and Manitoba. However, they are well established in the United States and the Canadian Forces.
In the United States there are more than 70,000 PAs working in both primary care and subspecialty practices alongside physicians. PAs were introduced in the years following the Vietnam War to address physician shortages and the need to increase access to health care in underserviced areas. Work as a PA also helped to employ soldiers returning from overseas who had been trained as medics.
In Canada, PAs were first introduced in the Canadian Forces to deal with the shortage of military physicians and have been working in that capacity since the 1970s.
However, it has only been in the past decade that PAs have been part of government strategies to mitigate a shortage of physicians and improve access to health care. PAs were first introduced into civilian practice in Manitoba in 1999 , Ontario in 2007 and just this year in Alberta.
When they were first introduced, the majority of PAs were trained in the Canadian Forces, the United States or were foreign-trained physicians. However, along with these demonstration projects have come PA training programs.
Training Physician Assistants
PAs in the Canadian Forces are trained alongside medics and other military health care providers. In the past decade, three civilian PA training programs have been introduced.
In Ontario, the University of Toronto, Northern Ontario School of Medicine and the Michener Institute for Applied Health Sciences have partnered in the Consortium of PA Education. This program offers a BScPA degree through the University of Toronto Faculty of Medicine, Department of Family and Community Medicine.
This program is a distance-education model and accepts 30 students per year. Maureen Gottesman, medical director of the program suggests distance learning is “an innovative, creative and cost effective” approach to training their student body, which are drawn from across the province. This is particularly important for remote and rural communities in Ontario, which face chronic physician shortages. Local community members trained as PAs have been seen as a possible sustainable approach to dealing with physician staffing challenges.
McMaster University also runs a Bachelor of Health Science (Physician Assistant) program and graduated 21 students in 2010.
The University of Manitoba Faculty of Medicine has a Master of Physician Assistant Studies which is a 25 month program. It was recently announced that all 12 graduates of this program accepted positions as PAs within the province.
Gottesman suggests that training programs “have a responsibility and social accountability to ensure that grads have suitable jobs.” She says “we haven’t done the research – we all say that we’re responding to a health human resources planning need, but no one can tell me specifically where PAs are needed.”
The Ontario Ministry of Health and Long-Term Care tracks the number of PAs who work in jobs that are government-funded. However, Gottesman points out that these are only a portion of PAs working in Ontario.
Keeping track of PAs, their training and current employment is argued as being an important step in further integrating this provider into the health care system. Gottesman says a publicly accessible registry “would make people more comfortable and allay some fears and criticisms of PAs and what they do.”
The question of self-regulation
In Ontario and Alberta, PAs are non-regulated health care providers.
In 2012 the Ontario Ministry of Health and Long-Term Care asked the Ontario Health Professions Regulatory Advisory Council (HPRAC) for advice about whether PAs should be brought under legislation for self-regulation.
The HPRAC recommendations, released in January 2013, stated that there is not enough evidence that the lack of self-regulation is causing patients harm. The recommendations supported this assertion by noting the relatively recent introduction of PAs, their small numbers and close physician supervision.
However, HPRAC did recommend that a compulsory registry for PAs be implemented under the oversight of the College of Physicians & Surgeons of Ontario.
Jill Hefley, Associate Director of Communications for the College of Physicians & Surgeons of Ontario says that while “the College has been supportive of the development of a registry for PAs “it is currently at the “discussion stage.” Because of this, Hefley was unable to provide an estimation of when such a registry would go live.
However, for critics like Mary-Anne Robinson, registries, like the one currently in place through the College of Physicians & Surgeons of Alberta, are not enough.
“Its just a list of names, which are not overseen or vetted in any way” she says, noting “this doesn’t meet the minimum requirements of regulation.” However such registries have been used for other unregulated health care provider groups, like personal support workers.
Chris Rhule, a Physician Assistant in Winnipeg and President of the Canadian Association of Physician Assistants also highlights regulation as a major barrier. He says that “integration [of PAs] is slowed down by regulation issues”.
In Manitoba, where Rhule practices, PAs are regulated through the College of Physicians & Surgeons. He says “regulation is key because then you don’t have to rely on medical directives for all of the delegation of duties … making it a lot less cumbersome in practice.”
“Regulation gives the public and other professionals comfort, security and safety to know that the profession has a body to report to” he says.
Rhule says that the major physician shortages at the time PAs were introduced helped galvanize support from the College and medical community. He says “having them on board helped influence government on legislative change.”
Plans for Alberta
The Alberta Health Services PA Demonstration Project was recently introduced as a “sustainable workforce strategy.”
There is currently no Alberta-based training program for PAs, and the majority of PAs in the province have been trained through the Canadian Forces.
Ten PA positions were introduced into locations deemed to have high needs across the province, including Milk River, Red Deer and Beaverlodge.
Mary-Anne Robinson questions the logic of introducing PAs in these communities. She says “registered nurses or nurse practitioners are underemployed professionals who are already regulated and autonomous” noting “it would make sense to have an autonomous provider rather than one who requires direct supervision from a physician, especially in communities where physicians are in short supply.”
Rollie Nichol, Associate Chief Medical Officer with Alberta Health Services has led the PA Demonstration Project. Nichol suggests that “we don’t see PAs competing with NPs – they have a different field of knowledge and different working relationships since NPs are designed for independent practice, but PAs are accountable to physicians.”
He points to the United States where NPs and PAs are both well established health care providers and “have found a way to have their own territory, and to collaborate.”
Nichol highlights that the PA Demonstration Project will undergo rigorous evaluation, and that the findings of this evaluation will inform future plans for PAs in Alberta. However, he frames the PA Demonstration Project within broader health system trends. “Finding alternative professionals or health care workers is happening everywhere in the system – it’s about finding the right provider at the lowest cost.”