Physician assistants (PAs) in Ontario
will soon see their role expanded into diabetes and
longterm care settings. But the move has MDs in the
province wondering where these as-yet unregulated professionals
fit in the chain of command.
Last year, Ontario became only
the second province after Manitoba to embrace PAs, a
profession that got its start in the military. Ontario's
PAs were originally limited to working in emergency
departments, in the hopes of reducing notoriously long
wait times and reducing doctors' workloads. The project
has been deemed a success, prompting the Ontario Medical
Association (OMA) to recommend the government expand
PAs' roles. They should be set up in their new duties
by next April.
But as with most of these new professional
roles — which in Ontario include anesthesia assistants
and nurse practitioners — figuring out scope of
practice and responsibilities is a challenge. "Obviously,
there's going to be an initial period of more intense
work, as physicians learn about these new providers,"
admits Barb Leblanc, executive director of health policy
at the OMA. But the OMA and the Ontario government are
confident that PAs will fulfill their promise —
to assist physicians — and will prove themselves
worth the faith gamble.
THE
MANITOBA EXPERIMENT
Since Manitoba's PAs — or clinical assistants as
they are known there — came on board in 2002, OR
efficiency has nearly doubled. "They're working in the
OR mainly, in plastic surgery and orthopedic surgery,
and they have decreased wait times significantly," explains
Cpt Hans Jung, Deputy Surgeon General of the Canadian
Armed Forces, who has campaigned extensively to bring
PAs to civilian settings.
PAs have also been a tremendous
help in areas like neonatology and orthopedics, adds
Dr Bill Pope, Registrar of the Manitoba College of Physicians
and Surgeons. "They have also allowed us to continue
to do certain operations, like bone marrow transplants,
which we might have had to stop or seriously curtail
otherwise."
REGULATION
DEBATE
One of Ontario doctors' biggest gripes about PAs is
that they have no college to regulate them, meaning
their bosses (physicians) could be responsible if they
screw up.
Manitoba has dealt with this by
bringing PAs into the physician College, but Ontario's
College of Physicians and Surgeons isn't ready to follow
suit.. "The view is that until there's a clearly established
role for PAs, we would not regulate them," says Registrar
Dr Rocco Gerace.
And that may leave some physicians
uneasy dealing with PAs. "You can count on regulated
health professionals to be held to standards of practice
and competence in a way that you cannot with unregulated
personnel," explains Paula May Ponesse, a registered
nurse who consults for the Ontario government on interdisciplinary
health teams. Some hospitals, for instance have new
staff sign patient confidentiality agreements. That's
not necessary for regulated providers, who are bound
to maintain patient confidentiality as part of their
registration with their College, according to Ms Ponesse.
But being unregulated doesn't mean
they won't have the same standards as other healthcare
providers, insists the OMA's Ms Leblanc. "PAs will be
tested against a set of core competencies. There's a
benchmark that's been set for them," she says.
HOW
WILL I KNOW?
So is the PA assigned to your department competent?
Well, that's up to you, as the supervising doc, to figure
out. That will mean extra work for physicians at least
in the beginning, says Ms Ponesse. But you're not completely
on your own. The Canadian Forces currently runs the
only training program for PAs; their PA accreditation
has been recognized by the Canadian Medical Association
since 2003. The training includes 2,000 hours of clinical
experience ranging from emergency medicine to general
surgery, and by the end of it, PAs are equipped to take
patient histories, do physicals, diagnose and even treat
— under the supervision of a doctor.
"The physician will outline the
parameters of their work and it has to be within the
physician's scope of practice," says Cpt Jung. So if
the supervising doctor is an orthopedic surgeon, their
PA can't dabble in obstetrics. Plus, the PA is only
allowed to perform particular tasks the MD delegates
to them.
As to whether or not they are capable
of carrying out the delegated task — the doc is
not only responsible to assess that, they are also accountable
for it. Ontario has been working on streamlining their
processes for establishing directives — written
orders — and that includes ensuring competency,
says the OMA. The provider carrying out the delegated
act, ie the PA, is then accountable to do as directed.
If they go beyond that, they are then themselves liable.
The Canadian Medical Protective
Association (CMPA) offers some reassurance for docs
on that score. It provides professional liability protection
for physicians who supervise and work with PAs. "In
some circumstances, the CMPA will even cover PAs," says
Dr Pope. But in most cases, they will fall under the
general liability insurance of their employer, be it
a hospital or a clinic.
PART
OF THE TEAM
Another question people involved in PA implementation
are hearing a lot is "How do PAs differ from nurse practitioners?"
Both can do sutures, for example or dress wounds, but
a PA would require a delegation to do that, and a nurse
would not, explains Ms Ponesse. So you need to make
sure you know who's allowed to do what, she adds.
"Conflict may also arise between
a PA and a nurse practitioner working side by side,
because of the overlap in their scope of practice,"
notes Cpt Jung. Manitoba has solved that problem by
placing PAs in the hospital environment and nurse practitioners
in primary care settings, adds Dr Pope.
Ontario, however, is looking to
bring PAs into broad use, across the medical spectrum.
So to deal with potential conflicts and confusion, the
government hired medical staffing company Med-Emerg
Inc to create job descriptions for each of the team
members, in places where PAs are currently working,
outlining their roles. "We also do team building sessions
in each of the hospitals and surveys to assess effectiveness,"
says Nicola Morris of Med-Emerg.
Med-Emerg will present its first
evaluation report on the impact of PAs' addition to
emerg department teams later this month, the Ontario
Health Ministry told NRM. "We're very optimistic
that PAs are going to be a positive contribution to
the system," says Ms Leblanc. "Especially in terms of
access to care and helping physicians."
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