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.

The comments section is closed.

  • Shawn Whatley says:

    Thanks for your well written article.

    Providers seek autonomy but not responsibility. Someone in the system needs to shoulder the final responsibility for a patient’s care. We need to identify the “Most Responsible Provider” (MRP). I don’t mind having non-physician providers present their case why they should be the MRP, but I only hear arguments about provider autonomy.

    It is specious to characterize providers standing behind the MRP as being ‘subservient’.

    Let’s put patient care first, encourage all providers to work to their full scope and ability, and give autonomy in proportion to responsibility.

    Thanks again!



  • Paul says:

    RNAO is not a union, it’s a professional association. This should be corrected.

  • Sonny says:

    I find it interesting that the arguments that are being propagated in Canada currently are the exact same arguments that were thrown around in the US when PA’s and NP’s were first introduced into our own healthcare system. Tragically, some of these falsehoods are still being tossed about here in the US (thinking about our VA healthcare system of late).

    Perhaps I am too idealistic or simple minded, but I simply wish that EVERYONE (MD, PA, or NP) would just put patient care first. Our ability to care for those that are sick or injured should be in the forefront of our minds daily. It should not be a turf war of who is better or more capable to provide medical care. In my experience, the patient sitting across from me in the exam room or laying on the ER gurney just wants someone (anyone for that matter) to help them feel better.

    We (the entire healthcare spectrum NP, PA, or MD) are all well trained and highly skilled medical providers that are more than capable to care for the massive amount of patients that need us desperately. – Sonny

  • Sue, Nurse Practitioner says:

    Many areas of Canada are a bit behind the US in implementing medical practice innovations mainly due to the government bureaucracy. I have a lot of family members still stuck in that system, although I’m an American. As I continue to say to every NP like me and all PAs, we have to stick together and stop fighting each other. I said this to a speaker in New Orleans, and I will continue to say this. Stop arguing about who is better or more educated, stop arguing about who is more independent and how we got there.

  • Dave Mittman, P.A., DFAAPA, Founder of Clinician1.com says:

    I would be cautious to ever think that PAs will be happy being subservient to physicians in any way. What happens here will happen in Canada. Professions grow. People show they are competent to do certain things. If so, they should be allowed to do it. I suppose that PAs will have an easier time in Canada as the USA will blaze a trail and hopefully you will do research and not have they same problems documenting your good work as we have.

    As far as the nurses, we had the same problems in the USA. One the RNs realized were were their advocates and respected them, it all went away. Those remarks by Ms. Grinspun are now years old-has she started a new diatribe? She seems ignorant of what PAs do and how we work. It is more than telling that she is not representing her NP members, but feels she is representing her RN members. I would wonder what she is fearful of? Maybe a few people from the Board meeting with their Board would be helpful. We had USA NPs write the RNAO and Doris never answered them! These were NP leaders who were very well known in America and very pro-PA.

    You will also have to be “regulated”. You need laws to practice and protect yourself. Why would you not want to be?


  • Ian Jones, MPAS, PA-C, CCPA says:

    Well written Ms. Taylor.

    %featured%We should not forget that outside the corporate board rooms of the medical and nursing associations health care providers such as PAs, NPs, RN, MDs etc are getting on with the job at hand of providing optimum patient care. Most “workers” tend to ignore their association until it comes down to fees and wages. They also work well with each other with rare exceptions that I believe are related more with miscommunication, fear, pride and ignorance than factual reality.%featured% We need to focus on ensuring increased access to the appropriate level and quality care within the framework of limited economic resources. Those economic resources included health workforce costs and system infrastructure.

    Concerning the PA Autonomy comment. A very very small number of American PAs have ever spoken in favor of independant practice. Team based practice with inter and intra-profession approaches is optimal for the patient. 35 years of practice has shown me no one works alone; you always have someone smarter available. The hard part is learning and knowing that.


Maureen Taylor


Maureen Taylor is a Physician Assistant who worked as a medical journalist and television reporter for the CBC for two decades.

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