CBC health reporter graduates as physician assistant

[Mamie]

That's interesting, but my experience has been the opposite here in Ontario. I truly do not trust PAs to manage anything even remotely complex. My experience is that their knowledge and skills are inferior to my junior residents. I think that the idea of PAs is a great one in theory but works out poorly in practice.

[stroom]

I have a really hard time believing PA's are such a horrible thing when they are such an integral part of the medical model in the United States. I agree that they obviously would have a much more limited scope of knowledge straight out of school but with supervision and experience it makes sense that they could be very valuable to the health care team.

[PA-guy]

Yay (???) for two years of training and no residency

While there is a place for mid-levels, I think we need to be careful about integrating people into the system who potentially have (if the article is accurate) less training than an RN or even a clincial clerk. Comments?

 

To the OP... I do not think less training is the correct term?? If that was true, wouldn't you think RN's could diagnose and prescribe?? The PA coursework is truly more rigorous and complex. This is not putting down RN's, but it is just the facts. I think you need to look to the source (ie something more credible than this article) to see why PA's are beneficial to the system. I mean clinical clerk?!?!

 

Well, I think they are given too much responsibility with very little training. At best, they should be fetching files, downloading documents, getting coffee, and maybe delivering some news and answering some questions while the doctor has his break, lol. They should also be able to take blood pressure and simple physicals.

 

I'd say these people will hurt the nursing population more than doctors due to their scope of expertise and training. They might also form a rivalries with med students and PGY1s.

 

Going back to the beginning of this thread.. just because I thought this was the most ridiculous comment. You have no idea.. although you may think you do. I am interested in what your title is, or what education you have? Obviously you have done no research in this topic but still feel the need to flail around your belligerent comment. What you don't understand is that the PA profession is widely accepted by the rest of the health system (in the US that is).. and guess what.. it works. What is the concern with hurting the nursing population, unless of course you are a nurse. Seems to me there is an ego issue here. On the other, it is not the intention of the PA profession to "hurt" nurses or even Docs for that matter. Another outrageous comment. Rivalries with med students???

 

Cmon, let's get serious

 

I think midlevels are a great addition to the health care team, but they shouldn't be replacing doctors when they have far less education and training. Canada is about 10 years behind US with these mid-level providers and if we want to prevent our country from seeing the same encroachment they have experienced, we should learn from their mistakes and nip this in the bud now.

 

I think everyone feeling the same way about this needs to realize that PA's are in no way replacing MDs. How could they even if they tried? PA's require supervision, although that may be limited, they still require it. PA's are not going behind the back of SP's and working in their own scope, its just not realistic or logical. PA's are simply an extender to the attending, and I believe they have the credentials to do so, as long as the SP oversees the work and order/Rx. I have met with several physicians in Canada that express their feelings towards PA's and how beneficial they would be for their practice because as a team they can see double the patients if not more than what the physician does on a daily basis. The physician can see the more complex cases as well as surg patients. This increases the provider:patient ratio and in the end the PA is getting paid less to see the same amount of patients. So who loses? and do not dare tell me the patient, because IMO PA's are more than prepared to practice medicine. The Canadian health care system is not perfect either, just keep that in mind.. so keep that in mind when your putting down the US system.

[A-Stark]

To the OP... I do not think less training is the correct term?? If that was true, wouldn't you think RN's could diagnose and prescribe?? The PA coursework is truly more rigorous and complex. This is not putting down RN's, but it is just the facts. I think you need to look to the source (ie something more credible than this article) to see why PA's are beneficial to the system. I mean clinical clerk?!?!

 

It seems clear enough that PAs have significantly less basic science and arguably somewhat less clinical training than any given CC4.

 

The Canadian health care system is not perfect either, just keep that in mind.. so keep that in mind when your putting down the US system.

 

I don't see that PAs are anywhere near the problematic aspects of the US system. Having said that, how will PAs help the "imperfection" of the Canadian system?

[PAstudent]

It seems clear enough that PAs have significantly less basic science and arguably somewhat less clinical training than any given CC4.

 

I disagree with the notion about basic medical science when comparing McMaster MDs and PAs. Compared with UofT MDs, for instance, where there is more didactic basic medical science than at Mac, you do have a valid point that the PAs at Mac, arguably, get less than the MDs at UofT. But that can also be said, arguably, about the MDs at Mac compared with the MDs at UofT, though I don't think that is necessarily the case. The Mac PAs only get slightly less basic medical science than the Mac MDs. Take a look at my direct comparison of the MD and PA programs at McMaster.

 

There has long been the criticism that the MD program at Mac is not as vigorous in teaching the basic medical sciences as the MD programs at other Canadian schools such as UofT where there first two years are more didactic. It seems then that this criticism could also apply to the PA program.

 

However, I am a proponent of the McMaster MD/PA PBL CANMeds based model. For me, especially because I have a good background in medical science, the PBL Tutorial style allows me a breadth and depth of learning that I don't know that I would get through a more didactic route. But that is simply my opinion. The literature looking at physician performance, though, when comparing those trained in the Mac model and those trained in a more didactic "traditional" route, shows no significant difference in the end if I recall correctly (it has been a while since I read this stuff).

[PA-guy]

I don't see that PAs are anywhere near the problematic aspects of the US system. Having said that, how will PAs help the "imperfection" of the Canadian system?

 

Low Physician (provider) : Patient ratio. That is pretty obvious. PA's will cut the ratio down immensely. Clinics will see double the patients, leaving more time for the SP to see the more difficult cases/surgeries and also cut down on the gap of downtime for electives. For ex. my brother (from Canada) had an ACL injury, was seen by a Doc and told that he would have to wait approx 3+ months.. ok, standard, no big deal. I was recently shadowing in an Orthopedic clinic is the US. Male comes in to the clinic complaining of knee pain. ACL injury... booked for surg the next day. The PA profession opens the doors to be able to do this. You can not hire more docs because the way the system is now the money is not available to support it... if it could they would be there. I think all of Canada sees the need for the mid-level providers. If we didn't PA programs wouldn't exist, bottom line.

[A-Stark]

However, I am a proponent of the McMaster MD/PA PBL CANMeds based model. For me, especially because I have a good background in medical science, the PBL Tutorial style allows me a breadth and depth of learning that I don't know that I would get through a more didactic route. But that is simply my opinion. The literature looking at physician performance, though, when comparing those trained in the Mac model and those trained in a more didactic "traditional" route, shows no significant difference in the end if I recall correctly (it has been a while since I read this stuff).

 

Mac is not especially unique in its use of PBL and hasn't been for a long time. The whole "self-directed learning" thing is somewhat misleading given how tutorials generally work and, in any case, there is a requirement to cover similar material at Mac as there is at any school.

 

Low Physician (provider) : Patient ratio. That is pretty obvious. PA's will cut the ratio down immensely. Clinics will see double the patients, leaving more time for the SP to see the more difficult cases/surgeries and also cut down on the gap of downtime for electives. For ex. my brother (from Canada) had an ACL injury, was seen by a Doc and told that he would have to wait approx 3+ months.. ok, standard, no big deal. I was recently shadowing in an Orthopedic clinic is the US. Male comes in to the clinic complaining of knee pain. ACL injury... booked for surg the next day. The PA profession opens the doors to be able to do this. You can not hire more docs because the way the system is now the money is not available to support it... if it could they would be there. I think all of Canada sees the need for the mid-level providers. If we didn't PA programs wouldn't exist, bottom line.

 

We aren't especially lacking for surgeons. OR time and sufficient numbers of beds, however, are MAJOR causes of cancellations of elective surgeries. And beds and OR time are functions of nursing staff, not medical staff. Having a PA in clinic will speed things up, I suppose, but the difference won't be dramatic, much as having a resident or clerk in clinic doesn't make a dramatic difference. Either way, the staff still has to review everything, and I'm not sure why they'd trust a PA's assessment more than a resident who is actively studying the relevant clinical background.

[PAstudent]

Hi A-Stark, the more I read your posts the more I get the impression that you are simply trying to goad me into argument. Perhaps my impression is wrong, if so, I apologize. Indeed, I hope my impression is wrong and that you will take me up on my offer to get you better acquainted with the PA-MD team model. You should know that several attending physicians, residency directors, residents, and physician assistants working at major Canadian hospitals read this thread and have read your words. We are colleagues and we should keep this conversation, shall we say, professional. Your understanding of PAs, of PA education, and of the way the Michael G. DeGroote School of Medicine functions at the undergraduate level (PA and MD) seems somewhat lacking and you don't seem interested in gaining a true understanding as demonstrated by, to my complete amazement, your attempt to point out to me, a Mac student, how tutorials and material requirements work at Mac. As for a resident "actively studying the relevant clinical background," the PA should be doing the same thing.

 

If you have a PGY1 and an experienced PA, you, as a physician, should be more inclined to trust the experienced PA over the PGY1. Just as you should also be more inclined to trust a PGY3 over an inexperienced PA. The role of a PA includes on-the-job learning, just like a resident. Many of the hospitals that make successful use of PAs do so because the PAs function like residents.

 

There is a huge difference between a new PA and a PA with 10 years of practice. As PAs we have a responsibility to always learn and improve, just as MDs have. A great deal of what a PA learns he/she learns in practice, just as a great deal of what a physician learns they learn in residency.

 

The PA role is unique as is the PA-MD relationship. You are apparently not interested in working with a PA, in teaching them, in molding them to your practice so that they are your trusted right-hand aid, so-to-speak. But that doesn't mean that the role doesn't work or that it isn't right for other future physicians.

 

If you are interested in learning more about PAs and are open to changing your mind, then let us please chat. I could even arrange for you to meet and work with a team of MDs and PAs working together. Words can explain a lot but the experience can explain a lot more.

 

 

Mac is not especially unique in its use of PBL and hasn't been for a long time. The whole "self-directed learning" thing is somewhat misleading given how tutorials generally work and, in any case, there is a requirement to cover similar material at Mac as there is at any school.

[PA-guy]

The PA role is unique as is the PA-MD relationship. You are apparently not interested in working with a PA, in teaching them, in molding them to your practice so that they are your trusted right-hand aid, so-to-speak. But that doesn't mean that the role doesn't work or that it isn't right for other future physicians.

 

Agreed. I think the problem here is the fact that the PA profession is relatively new to Canada. I think there are a lot of people in Canada, medical professionals and pateints combined that do not quite understand the role of PA's in the system and how valuable they are as a team... just as a patient in the US doesn't quite understand the role of PA's in the system.

 

Either way, the staff still has to review everything, and I'm not sure why they'd trust a PA's assessment more than a resident who is actively studying the relevant clinical background.

 

I dont understand your concept of "trusting" the said health professional. PA's are trained in the medical model just as a Med student is, mind you the amount of material is not the same once each individual finishes the program. The idea that much of the knowledge and skills to practice medicine are gained in the residency, or rotations if you will, is important in both MD and PA's ability to practice. Like I said before, PA's are not going in there thinking they are superior than the SP.. because they are not. Believe it or not there are PA's that are running their own clinics, hiring staff including MD's, and doing great. By law they have to consult with a Physician so many times a month, depending on state law, but they can be fairly independent in practice. Stark, I think you should open your mind a little bit more to the fact that PA's are very beneficial to the system, and at the end of the day are part of the team providing care to patients... isn't that what it's all about?

[Mourning Cloak]

Clinics will see double the patients

 

Physicians in Canada cannot bill for services provided by their PAs.

 

I don't get it. Why would any physician pay a salary to a PA, take on the additional cost (CMPA) and legal risk of supervising them, to have them provide a service that the MD can't bill for?

[PA-guy]

Physicians in Canada cannot bill for services provided by their PAs.

 

Somewhat true. You have to consider a few things. First, refering back to previous posts, Physicians can bill if they see the patient or "actively involved in the episode of care". From my experiences I have seen many times that a Physician will step in on a consult after the PA. Yes, that might sound redundant, but the fact is that the SP did not have to go through the whole process with the patient, and spend just a little bit of time with the patient afterwards... boom, billed. It still gives the SP time to see other patients.

Secondly, http://www.cma.ca/multimedia/CMA/Content_Images/Inside_cma/Advocacy/Physician_Assistants/PA-Toolkit_en.pdf#page=18 on page 15 states "Currently in Ontario, physicians are paid a stipend for supervising PAs within the PA–physician relationship." They do see some monetary benefits as it stands. Again, the profession is very new, and I have a hard time believing that will be set in stone. Introducing PA's to the system in Canada is a big change, which only means they can make more changes as time goes on.

[A-Stark]

Hi A-Stark, the more I read your posts the more I get the impression that you are simply trying to goad me into argument. Perhaps my impression is wrong, if so, I apologize. Indeed, I hope my impression is wrong and that you will take me up on my offer to get you better acquainted with the PA-MD team model. You should know that several attending physicians, residency directors, residents, and physician assistants working at major Canadian hospitals read this thread and have read your words. We are colleagues and we should keep this conversation, shall we say, professional. Your understanding of PAs, of PA education, and of the way the Michael G. DeGroote School of Medicine functions at the undergraduate level (PA and MD) seems somewhat lacking and you don't seem interested in gaining a true understanding as demonstrated by, to my complete amazement, your attempt to point out to me, a Mac student, how tutorials and material requirements work at Mac. As for a resident "actively studying the relevant clinical background," the PA should be doing the same thing.

 

I think it's grossly presumptuous to assume that I don't understand how PBL functions at Mac. I interviewed there and followed Dal's "case-oriented problem-stimulated" pre-clerkship PBL curriculum. These methods are all variations on a theme. I'd hope that the persons you mention aren't spending a great deal of time following anonymous online conversations regarding this issue. For that matter, it should go without saying that a certain skepticism about mid-level practitioners is hardly unique to my own views - perhaps you should look for Ian Wong's posts on the very subject! I'm not about to shrink from stating my opinion without being needlessly equivocal.

 

There is a huge difference between a new PA and a PA with 10 years of practice. As PAs we have a responsibility to always learn and improve, just as MDs have. A great deal of what a PA learns he/she learns in practice, just as a great deal of what a physician learns they learn in residency.

 

Yet there's a world of difference between learning in a structured residency program with advancing levels of responsibility and the relatively static role of a PA.

 

But that doesn't mean that the role doesn't work or that it isn't right for other future physicians.

 

Maybe. How would it work in a fee-for-service environment?

 

Believe it or not there are PA's that are running their own clinics, hiring staff including MD's, and doing great. By law they have to consult with a Physician so many times a month, depending on state law, but they can be fairly independent in practice. Stark, I think you should open your mind a little bit more to the fact that PA's are very beneficial to the system, and at the end of the day are part of the team providing care to patients... isn't that what it's all about?

 

It seems very unlikely that any PAs will be running their own clinics or hiring MDs in Canada anytime soon. As has been pointed out, they cannot bill provincial insurance plans, and it seems unclear whether physicians can bill for PA work either. I would not use the US as any kind of example - the organization and insurance/payment plans are radically different. PAs would have to review everything with staff, as all but the most senior residents should as well. A PA could not, for example, offer surgery to a patient without reviewing with the surgeon first!

[PAstudent]

A-Stark, this is why I hesitated in replying to you so many times; you are simply trying to push a fight. Several members of this board sent me PMs telling me they didn't think much of how you behave on this board and that I shouldn't bother replying to you but I gave you the benefit of the doubt as a professional courtesy. So I have answered your posts as kindly and thoughtfully as I could with an aim to being informative rather than to debate. I have no interest in fighting with you and so will no longer respond to your ignorance-fueled inflammatory posts. That said, my offer to arrange for you to work with a PA-MD team still stands. Feel free to PM me whenever you would like and I will gladly put you in touch with the appropriate people. I also encourage you to re-read my postings as you seem to think I wrote things that I never wrote as evidenced by some of your replies that seem to me to be as non-sequiturs at times. No doubt you will want to post some come-back to this post, I won't bother to respond if you do. And I advise that your time would be better spent learning about PAs rather than bashing them.

 

 

I think it's grossly presumptuous to assume that I don't understand how PBL functions at Mac. I interviewed there and followed Dal's "case-oriented problem-stimulated" pre-clerkship PBL curriculum. These methods are all variations on a theme. I'd hope that the persons you mention aren't spending a great deal of time following anonymous online conversations regarding this issue. For that matter, it should go without saying that a certain skepticism about mid-level practitioners is hardly unique to my own views - perhaps you should look for Ian Wong's posts on the very subject! I'm not about to shrink from stating my opinion without being needlessly equivocal.

 

 

 

Yet there's a world of difference between learning in a structured residency program with advancing levels of responsibility and the relatively static role of a PA.

 

 

 

Maybe. How would it work in a fee-for-service environment?

 

 

 

It seems very unlikely that any PAs will be running their own clinics or hiring MDs in Canada anytime soon. As has been pointed out, they cannot bill provincial insurance plans, and it seems unclear whether physicians can bill for PA work either. I would not use the US as any kind of example - the organization and insurance/payment plans are radically different. PAs would have to review everything with staff, as all but the most senior residents should as well. A PA could not, for example, offer surgery to a patient without reviewing with the surgeon first!

[future_doc]

Somewhat true. You have to consider a few things. First, refering back to previous posts, Physicians can bill if they see the patient or "actively involved in the episode of care". From my experiences I have seen many times that a Physician will step in on a consult after the PA. Yes, that might sound redundant, but the fact is that the SP did not have to go through the whole process with the patient, and spend just a little bit of time with the patient afterwards... boom, billed. It still gives the SP time to see other patients.

 

Secondly, http://www.cma.ca/multimedia/CMA/Content_Images/Inside_cma/Advocacy/Physician_Assistants/PA-Toolkit_en.pdf#page=18 on page 15 states "Currently in Ontario, physicians are paid a stipend for supervising PAs within the PA–physician relationship." They do see some monetary benefits as it stands. Again, the profession is very new, and I have a hard time believing that will be set in stone. Introducing PA's to the system in Canada is a big change, which only means they can make more changes as time goes on.

 

I would think that if the physician is on the premises, sees the chart snd has a discussion with the PA (for whom s(he) is responsible) concerning the patient - this would constitute being "actively involved in the episode of care". Win/win for the patient and the healthcare system!

[Mourning Cloak]

I would think that if the physician is on the premises, sees the chart snd has a discussion with the PA (for whom s(he) is responsible) concerning the patient - this would constitute being "actively involved in the episode of care". Win/win for the patient and the healthcare system!

 

Actually, in Ontario, the physician will not receive a stipend (whatever that is) for supervising the PA unless "unless physicians see the patient and are actively involved in the episode of care."

 

https://www.oma.org/Resources/Documents/2009PAOMAStatement.pdf

 

So that turn of phrase ensures some oversight. But it still seems so redundant as to be unwieldy - by the end of my husband's first year in family medicine, he was seeing patients completely autonomously (in both the clinic and ED). And his preceptor didn't want to be reviewing any of his routine patients, even at the beginning. It wasted money, and these guys hate wasting money.

[future_doc]

Interesting. The physician at present must see the patient to be able to bill for the services of the PA and this is not insurmountable pending more enlightened regulations that shall occur over time.

[PAstudent]

Interesting. The physician at present must see the patient to be able to bill for the services of the PA and this is not insurmountable pending more enlightened regulations that shall occur over time.

 

While the documents do seem to say this; I know for a fact that there are physicians billing for work done by PAs where the physician does not see the patient. When I asked about this issue (spurred by the documents in discussion here) I was told that so long as the PA reviews briefly with them such that they had some involvement in the care, they need not actually interact with the patient. But I am also confused by all this.

[future_doc]

For now, the physicians are technically in breach while working on premise of don't ask, don't tell until the regulations catch up. Not ideal. Will improve as it must.

[Mourning Cloak]

For now, the physicians are technically in breach while working on premise of don't ask, don't tell until the regulations catch up. Not ideal. Will improve as it must.

 

Especially since if anything goes wrong, the MD can have his buns sued off, and won't have a leg to stand on.

[future_doc]

Physician assumes legal responsbility whether or not OHIP pays him.

[Mourning Cloak]

Physician assumes legal responsbility whether or not OHIP pays him.

 

I was thinking more of the additional fallout of being caught in a lie: claiming to have seen a patient (to get the billings) that you never actually laid eyes on.

[future_doc]

I was thinking more of the additional fallout of being caught in a lie: claiming to have seen a patient (to get the billings) that you never actually laid eyes on.

 

You are entirely correct there!

 

Short-term gain for longterm problems. Not good judgment. I would never go there. It is not worth it. And there are no secrets.

[0593202]

Okay, so far the bottom line is:

 

Physicians can use a PA and bill for them:

- but are now liable to lose their license for saying they saw a patient they never saw

-are liable for any errors the PA makes

 

Physicians can use a PA and not bill for them:

-Physician doesn't gt anything out of it

-Physician incurs a huge liability

 

I'm just failing to see the upside to working with a PA at this point, until the regulations are cleared up?

[Mourning Cloak]

Physicians can use a PA and bill for them

 

No, they cannot.

 

In Ontario (and ONLY Ontario), they may receive a stipend (whatever that means) for supervising a PA, but to receive the stipend they must "see the patient and are actively involved in the episode of care".

[0593202]

sorry i just meant if scenario A these are the circumstances, if B.... wasn't stating whether or not they can bill for the PA services