Physician Assistant regulation: can nurses’ unions have it both ways?

Physician Assistants are “handmaids” to doctors. PAs were “created by physicians” who were frustrated that nurses no longer tolerate being ordered around by MDs. And that’s just a taste of the negative reaction from some nurses to a recent Healthy Debate article on integration of physician assistants in Canada. I found it disheartening, but not entirely surprising that nurses left these comments. Doris Grinspun, the executive director of the Registered Nurses Association of Ontario, once told CBC News, “I would say to my family, friends, colleagues, to the public: don’t let (PAs) touch you. Make sure to ask who is taking care of you.”

Since their introduction in Ontario in 2006, nursing and midwife unions have argued that PAs are unsafe because they are an unregulated profession, that their training is too short and that the healthcare system doesn’t need them because unlike nurse practitioners and midwives, they can’t practice independently of physicians.

I won’t tackle the issue of PA training programs, which are based on programs in the US that go back 50 years. But let’s just deconstruct the regulation thing here:

It was Ontario PAs, led by the Canadian Association of Physician Assistants, who applied to the Ontario Health Professions Regulatory Advisory Council (HPRAC) for self-regulation, and in 2012, the Minister of Health asked HPRAC to give the matter priority. HPRAC ‘s primary criterion for determining whether a health profession should be regulated states: “the applicant must present a solid, evidence-based argument, based on a preponderance of evidence, that there is a risk of harm to the public.” If this criterion is not met, the application is rejected.

This put nursing groups in an awkward position. After saying publicly for years that PAs are a danger to patients because they are unregulated, now they would have to make the opposite case: that regulating PAs is unnecessary because there is no evidence they have harmed the public. If you read through the hundreds of pages of submissions to HPRAC on the question of PA regulation, you may admire, as I did, the verbal gymnastics exhibited by the RNAO, which criticized everything from the renumeration physicians are paid to supervise PAs and the “generous funding models of the Ministry”, to the underemployment of NPs. But HPRAC is not interested in the question of whether a health profession is as good or better than another health profession. Its primary concern is patient safety. And here, the RNAO wrote that “existing mechanisms (i.e. physician supervision, delegation procedures, medical directive procedures, communication requirements, assessment of competency, etc.) are sufficient to address the risk of harm arising from the physician-delegated practice of physician assistants.”

HPRAC, and the Minister of Health agreed with the RNAO. PAs, said HPRAC’s report, do not pose sufficient harm to patients to require regulation, although as their numbers grow, that may change. Of course, now that nursing groups got the decision they were hoping for, which was to keep PAs unregulated and marginalized, they are back to slamming PAs, equating “unregulated” with “unsafe.” That’s pretty rich.

The other interesting twist in the comments on the Healthy Debate article, is how quickly it turned into a nurse/doctor catfight once a physician stepped in to criticize nurses and NPs. And this is why, after following (and living) the bumpy introduction of PAs in Ontario for the last five years, I don’t take the nursing unions’ criticisms all that seriously. Because really, folks: it’s not about us. It’s not even all about protecting nursing turf. What’s really broken is the relationship between physicians and nurses, at least at the organizational level. PAs, whose practice of medicine depends entirely on collaborating and consulting with physicians, are just collateral damage in a century-old war.

There are signs that in the US, where PAs are one of the fastest-growing professions and in high demand, some PAs want to break out of their “assistant” shackles to practice more autonomously, which many of them already do in underserviced areas where physicians choose not to practice. In fact, in the US, I see PA and NP associations banding together to battle large medical associations such as the AAFP (American Academy of Family Practice) which insists only a physician can lead a team in the “medical home” model.

With the PA role so new to Canada, and with so many bugs still to be worked out before they are fully integrated, I think it will be decades before PAs in this country demand the kind of autonomy that seems so core to the nurse practitioner role. PAs work with and are supervised by physicians. We’re okay with that, and it appears that physicians hire them, not for the stipends the RNAO takes umbrage with, but to improve patient access to care. A qualitative study I helped to write, published last month in the Canadian Family Physician Journal, showed that although physicians are still frustrated by what they see as barriers to hiring PAs (lack of familiarity with the PA role and scope of practice, absence of a funding model, and recruiting and integrating PAs into practice), these MDS said PAs make patient care more manageable, help decrease wait times, improve continuity of care, and improve the physician’s quality of life. Most of those interviewed had not seen a financial benefit, although some felt that might be possible once their PAs had more experience.