Physician assistants on eve of regulation in Ont.

On any given day, Sahand Ensafi comes into work ready to take on a diverse range of clinical tasks–from examining and diagnosing patients to ordering tests and suturing post-surgery. But being neither doctor nor resident nor nurse, his role has been called into question a few times by patients and, at the start of his career, by other clinicians. “You have the occasional patient who might get confused when they find out I’m not actually a doctor,” said Ensafi, a physician assistant who’s been working for the last seven-and-a-half years in the emergency departments of the University Health Network’s Toronto Western and Toronto General hospitals. “Among people here there was a little hesitancy initially, when the department took a leap of faith and started working for the first time with a PA.” From being the first and only PA in his department, Ensafi is now among more than 25 PAs at UHN. The number of PAs has also grown on a national scale over the last four decades, from a few dozen working in Canadian army outposts to about 800 certified PAs across the country. With the impending regulation of PAs in Ontario–which has 500 practitioners, the highest total among the country’s provinces and territories–this relatively new class of healthcare professionals is taking yet another step forward in a 60-year history that began in the United States during the Vietnam War and has evolved into an integrated part of healthcare teams in various clinical settings. “I think it’s a fantastic development,” said Dr. Sam Sabbah, medical director at Toronto General and Toronto Western. “Regulation will bring benefits on a number of fronts.” For Ontario hospitals and clinics, the regulation of PAs–a process now underway at the College of Physicians and Surgeons of Ontario–will mean the elimination of medical directives that set out what PAs can and cannot do, based on each PA’s competencies and on the scope of practice of supervising physicians. This will make it easier for hospitals to add PAs to their clinical teams, said Dr. Sabbah. Over the years, he noted, a number of small and remote hospitals have asked UHN to share its PA medical directives because they lack the resources to create their own from scratch. “It takes considerable time and effort to develop and build out these medical directives,” said Dr. Sabbah. “It took us a couple of years. In the absence of a provincial standard and given the diversity of care environments within a hospital, we needed to create something that was generalized without being too high-level so that there was enough flexibility for individual departments to determine the scope of practice for their PAs.” Beyond removing the need for medical directives, regulating PAs also boosts their credibility as healthcare professionals and improves accountability in their practice. Once PAs are regulated in Ontario, patients will be able to go to the CPSO for complaints about conduct or quality of care. Perhaps most importantly, however, regulating Ontario PAs will allow them to perform to the full scope of their practice–as defined jointly by the CPSO and by the Canadian Association of Physician Assistants, the Ottawa-based national association for PAs–and do even more to support doctors and other members of the healthcare team. “I’ve had almost eight years of emergency experience so I’ve learned a lot and I’m able to do a lot but, as with all PAs in Ontario, my scope of practice is heavily tied to the physicians we work with,” said Ensafi. “So if you’re a PA who works for two different departments, like orthopedics and emergency, you may not be able to apply all of your skills in both roles if a supervising physician in one department isn’t comfortable with certain procedures that you’re already performing in the other department.” This ability to work to the full scope of his practice has made a big difference for Steve Piotrowski, a PA at a family practice in Winnipeg, Man., which in 1999 became the first province in Canada to regulate PAs. Piotrowski sees between 12 to 15 patients a day, many with complex conditions such as diabetes, congestive heart failure, substance addictions and mental illness. After graduating in 2016 from the University of Manitoba’s PA program, Piotrowski worked in family and emergency medicine in Beausejour, just north of Winnipeg, before switching just over a year ago to his current role. These transitions from school to first and second jobs, and from one city to another have been relatively easy for Piotrowski and his employers because the PA role is well defined and understood in Manitoba. “One of the biggest reasons why it’s important to be regulated is that it sets the standard of care for patients while also setting the standard for practising PAs no matter where they are in the province,” said Piotrowski. “By comparison, in areas where PAs are not regulated one PA may be able to do something that another PA in the same area can’t do.” So far, PAs are regulated in only three provinces–Alberta, Manitoba and New Brunswick–and their collective rank is minuscule compared to the total number of physicians and regulated nurses in the country. Their impact on the healthcare system in Canada is also still largely undocumented, with a handful of studies highlighting the role of PAs in reducing resident workload, improving discharge rates, decreasing length of stay and time to consultation, according to a 2016 Conference Board of Canada report. The report cites one surgical services study from 2010 that credited a PA with saving a supervising physician an average of 204 hours per year. Another study, from 2009, found PAs reduced wait times by 1.9 times and “left without being seen” rates by 50%. The profession has a long way to go before it can realize its full potential as a “physician extender” and regulation is only one of several pieces that need to come together for PAs to truly come into their own within the country’s healthcare system. One of the most critical pieces is funding, says Patrick Nelson, CAPA’s executive director. According to a Conference Board of Canada report, PA remuneration typically comes from provincial governments–some of which have funded PA pilots in recent years–block funding from academic specialty groups, and direct funding from physicians. In Ontario, the province provides funding for up to two years to employers hiring PA graduates from the University of Toronto and McMaster University. “But then it expires and it’s up to employers to work out how they’re going to continue paying their PAs,” said Nelson. “It’s even more complicated for PAs working within a fee-for-service model, where physicians need to have some level of interaction with a patient before they can bill for service.” Greater awareness of the PA profession is another important piece of the puzzle, said Nelson. Better familiarity with the role of PAs among clinicians and members of the public will lead to greater acceptance of PAs as part of the healthcare team. This will also lead to greater interest in joining the profession. PA programs of study are already seeing increasingly higher rates of applications and enrollment. At McMaster, for one, almost 1,200 applicants competed for 24 spaces available for this coming September. “The PA profession in Canada is growing, and the challenges that it’s come across are all part of the growing pains of a new health discipline that’s starting to mature,” said Dr. Neil Gibson, a clinical professor at the University of Alberta and a former Canadian Armed Forces medical officer with years of experience working alongside PAs. “Public education about PAs is critical because part of the growing pains is that most people don’t know what PAs are.” Alberta Health Services has distributed flyers and postcards at facilities that employ PAs, “but more needs to be done to raise the profile of PAs,” added Dr. Gibson, who also practices critical care at Sturgeon Community Hospital in St. Albert, just northwest of Edmonton. Ensafi says PAs are certainly ready to do more, especially when it comes to helping physicians and other members of the healthcare team look after Canadians. “With regulation coming to Ontario, it will make it easier for PAs to work with doctors, especially in remote settings where there’s poor access to care and PAs can work with indirect supervision,” he said. “We love working with physicians and we can really help them by doing a lot of the bread-and-butter stuff that they don’t have time to do or even necessarily want to do.

Physician assistants on eve of regulation in Ont.

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