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There are various models for what a Physician Assistant and Supervising Physician relationship may look like. The relationship can vary by practice setting (in outpatient, versus in hospital), by PA experience (new grad, versus experienced PA), and by area of medicine (family medicine vs General Surgery).

The foundation for a successful PA/MD working relationship requires mutual respect and trust, open communication, and freedom to ask questions and seek guidance for complex cases or issues related to practice.  

In this setting, PA/MD teams help to improve patient access to high quality care, saves the health care system dollars, improves practice efficiency (4), improve continuity of care (5), reduce wait times (6), increase physician time savings, reduce physician workload and burnout and expand a practice’s flexibility to provide after hour services & accommodate more same-day appointments.

Some PAs and MDs can spend their entire careers working together, and many practices are seeing the benefits of collaborative PA/MD teams:

The PA and MD work together in Collaboration

We are moving away from a single physician patient model and moving more towards team-based care in Canada. The incorporation of team based health care means other allied health professionals – social workers, dietitians, exercise physiologists, respiratory therapists, as well as providers like Physician Assistants and Nurse Practitioners are helping to extend the Physician’s hand in providing patient care.

A good PA-MD relationship requires a few things which we’ll cover here:

  • Knowledge of the PA role
  • Understanding of delegated tasks & procedures
  • Clear and appropriate level of PA supervision by the supervising physician
  • Open communication in an environment of mutual respect and understanding between the PA and MD

Knowledge of the PA Role

The Supervising physician should understand the scope of practice of Physician Assistant, and what roles and responsibilities can be assigned to the PA and the competency / level of knowledge of PA.

  • A Physician Assistant is NOT a medical secretary, medical scribe, medical assistant (which includes administrative tasks, and taking weight & vitals), and they do not performing nursing duties or duties of other members of the allied health team. Using the PA in this manner is inefficient use of the PA’s knowledge and skillset, and does not allow them to work at the top of their scope of practice. PAs can help enhance workflow, increase the physician’s capacity to take on more patients, decrease wait times while delivering quality of care.
  • Like nurse practitioners, Physician Assistants are viewed as extension of the physician, that is, they are seen as a representative of the physician. The perform delegated tasks under supervision.  They are able to:
    • Take on tasks the physician might normally perform (very similar to how a physician may delegate the task to a resident, fellow or clinical clerk)
    • Conduct histories and physical examinations
    • Order and interpret investigations (blood work, investigations)
    • use clinical reasoning to come up with a differential diagnosis
    • perform an assessment, plan and procedures.
    • They can prescribe medications under established medical directives.
    • They can first assist in surgery.
    • They can communicate with allied health to clarify questions about investigations, medications and orders. They can counsel and speak with families

Supervising physician should also be aware of what PAs cannot do, which include prescription of controlled substances. PAs cannot practice independently of a supervising physician, however supervision can be direct or indirect.

Delegated Tasks and Procedures

PAs can also perform delegated procedures, including laceration repair, suturing, wound care, casting and splinting, and more.

However PAs can only perform procedures that falls within their supervising physician’s scope of practice. For example, perhaps an experienced Emergency PA has knowledge of how to perform a thoracentesis. If that Emergency PA goes to work in Family Medicine and is no longer an Emerg PA, the PA cannot perform a thoracentesis since this does not fall under the family physician’s normal scope of practice. If the supervising physician normally does not do the procedure, then the PA should not do the procedure.

The supervising physician is also responsible for ensuring the PA is competent for the tasks that are delegated. This may be done informally, or formerly through specific documentation. Documentation may include use of an “Implementer Readiness Form”, as part of a medical directive. This is where a supervising physician or other signing authority (another PA, nurse practitioner, etc.) directly observes a procedure done competently by the PA and signs off on the Implementer Readiness Form.

Defining Supervision in PA/MD Relationship

Direct supervision involves the physician being physically present in the patient encounter.

Indirect supervision means the physician is available by phone or by electronic means (secure internet network, or EMR messaging) to review patient cases and answer PA questions.

The supervising physician is responsible for ensuring that the PA is adequately supervised, which means access to the supervising physician is reasonable should the PA wish to consult the physician. An example of inadequate indirect supervision includes when the physician is not accessible by phone, the physician is not in the country (and cannot come in to intervene, or be available to discuss the case should an issue arise). As per the CPSO, the responsibility of the delegated acts falls ultimately on the delegating physician.

SUPERVISION BY PRACTICE SETTING

In a family medicine / rostering model, it is not uncommon to have Physician Assistants seeing their own patients, without the physician physically stepping in. The PA would consult the supervising physician for difficult or unusual cases, and the physician would review the PA’s chart, and sign off on those charts and/or each case without having to be physically present in the room to interact with the patient. This supervision is considered indirect, since the physician is available in the building or via phone but not directly in the patient encounter.

In Ontario, a physician in a specialty or general setting that uses a fee for service model requires direct PA supervision if they wish to bill for the services (patient assessments, and consults) rendered by a PA. Outlined in the OHIP Schedule of Benefits, a document that outlines how physicians are paid in Ontario, it states that physicians cannot bill for delegated tasks (assessments) performed by a PA unless they actively participated in the patient encounter. This rule is not the case for PAs in the United States, or other Canadian provinces.

SUPERVISION BY PA EXPERIENCE

  • When a PA first begins working, the supervising physician may consider starting with direct supervision first.
  • This helps establish a working relationship, the physician can gauge first hand the PA’s knowledge and competency with assessment, ordering relevant investigations, assessment and plan, patient communication. It’s also a great opportunity for the physician to provide feedback and guidance on how they prefer assessments and procedures be performed as well as how they prefer their medical documentation for patient encounters. Feedback on observed PA performance can be given in the beginning, and this method is not uncommon for integration of a PA into a new practice (i.e. in the ER, family medicine, etc.).
  • With time, as the PA becomes more accustomed to the practice and patient population, a more indirect approach may be taken with supervision where physician is on site, available by phone, EMR messaging or electronically.
  • For PA/MD relationships that are more well established, or perhaps where the PA is more experienced, the PA in many practice settings performs delegated tasks autonomously in an environment of mutual trust and understanding of the strengths and skills that benefit patient outcomes and practices.

PA/MD Communication

Open communication between the PA/MD for all matters related to patient care, treatment protocols, work environment, and professional development is important. Open communication between PA and MD will lead to better patient outcomes, efficiency and benefits for the practice. Communicating expectations is important, and can be formalized through a supervisory agreement that is established at the beginning of a PA’s employment.

PA/MD SUPERVISORY AGREEMENT

A written supervisory agreement which outlines PA guidelines is a good way to formalize the PA/MD relationship. Here expectations of both the PA and MD are outlined. Note: This is different from an employment contract which includes term of contract, salary, benefits, etc. This supervisory agreement may include:

  • What physician can expect from PA (e.g. ability to handle patient problems routine to practice, willingness to seek physician input, concise case presentations, appropriate medical documentation, and performance follow-up)
  • What PA can expect from supervising physician (e.g. ready access to supervising physician, learned advice, willingness to accept care of complex or higher acuity cases, introduction of PA as a member of the team to staff and patients, professional development opportunities such as teaching and CME)
  • PA Scope of Practice (e.g. description of job and role including clinic responsibilities, common procedures, which can be expanded upon in a separate medical directive document)
  • Locations of Practice (e.g. if PA is expected to be at hospital, at the outpatient clinic, etc.)
  • Guidelines for when PA should consult with supervising physician  (e.g. irate or hostile patients, life-threatening, or unusual cases, at request of patient)

Examples include a few American supervisory agreements from California, Illinois, and North Carolina. The wording in these agreements can be adjusted to reflect rules within your jurisdiction about PA practice.

The rewards of a PA/MD relationship

PAs are trained in the medical model and learn to think and clinically reason like doctors. I completed my clinical rotations alongside fellow PA clerks, medical clinical clerks and residents. We saw the same patient case loads and often had the same responsibilities as clerks.

I graduated in 2011, and at time of writing (2017), it has been 6 years of what I would call a successful PA/MD relationship. This evolved over time, as a new grad getting to know the practice, to a respected regular member of staff who plays an important role in keeping the clinic running on time, and the practice running smoothly. With time the PAs at the practice have expanded their time to working with other physicians in the same clinic, and now the supervising physicians hesitate to run a clinic without a PA by their side.

During my early years of working, my supervising physician often compared having a PA like a “resident/fellow that would never leave his side” (residents stay on for several months at a time before moving onto another clinic for their next rotation).

During clinic hours when we are seeing patients, I arrange for all referrals and investigations, complete all dictations of patients I see, and am able to help keep the clinic running on time.  With tracking EMR data, I learned that with the introduction of PAs into clinic, we were able to more than double the number of patients seen in a clinic day, reduce the amount of time spent in clinic, and the PAs took on medical documentation and completion of forms during the clinic, freeing the physician from catching on paperwork following the clinic.

Outside of seeing patients in clinic, I am able to help my supervising physician take a large workload off their hands, which includes taking time to answer patient/allied health/provider questions, triage referrals, completion of medical legal documents, worker’s compensation forms and other letters required due to illness/injury. The staff often appreciate having easy access to someone who is a “representative of the physician” to answer their questions about patients.

The supervising physician can enjoy non-monetary benefits of a PA, such as more free time that can be used for academic or research endeavours, teaching, seeing more patients, and/or more time for leisure activities and family.  If patient volume is increased while maintaining quality patient care, the PA may also help increase the practice’s revenue to cover other overhead or operational costs of the clinic.

I always asked for feedback and consulted the physician for complex cases. With time, I became extremely comfortable with Orthopaedic assessments and treatment plans.  I knew all of the surgical procedures he performed, recovery time, and protocol for rehab following all procedures.  I learned all the protocols for routine pre-op and post-op visits,  as well as what investigations he preferred to order and when to refer. When we had medical learners on with us, I played a role in orientating the student to the clinic but also in teaching Orthopaedic Principles which supplemented what the medical learner was getting from my supervising physician.

We developed a lot of patient education materials to reduce the number of questions the administrative assistant would receive on the phone if something was not explained clearly, and I was able to spend time answering patient questions about return to work/activities after an intervention or surgical procedure.

In return, I get a long-term mentor who is very approachable and willing to answer any patient questions, or whom I can consult for complex cases. There are opportunities for continuing medical education (e.g. attending conferences, workshops), as well as direct teaching from my supervising physician and I get time to get involved with teaching and mentoring for PA students as part of my contract.

In the United States, PAs can bill for patients, even with a physician physically present. Due to limitations of billing rules in Ontario, this is not possible and physicians cannot bill for services rendered by a PA in a fee for service model without being actively involved in the patient encounter. This is why we have the physician participate in every patient interaction, however in our instance there is little duplication in work (e.g. asking the history over again, repeating the entire physical exam) as we have an established PA/MD relationship and he has trust in my ability to assess patients and present concisely pertinent details about the patient before he goes in to finish off the interaction.

If the model was similar to the United States, the PAs in fee-for-service setting could run clinics for non-complex patients, and/or routine follow-ups while, for example, the MD is in the operating room. With an established set of medical directives and supervisory agreement, there is a mutually agreed up set of guidelines and understanding of what the PA’s scope of practice and when to refer to the physician as outlined above.

There are PAs in family practice settings in a rostering model that have their own panel of patients, which has allowed easier access to a health care provider and decreased wait times.

Helpful References

  1. Ontario Schedule of Benefits under the Health Insurance Act
  2. Danielsen, R. (2003, March 11) What Factors are Necessary for a Successful PA/MD Relationship? Medscape.
  3. AAFP & AAPA Joint Policy Statement: Family Physicians and Physician Assistants: Team-Based Family Medicine
  4. Ministry of Health and Long-Term Care.(2012). Ontario Physician Assistant Implementation – Report of the Evaluation Subcommittee. p.p. 27
  5. Alberta Health Services. Demonstration Project Evaluation Report. February 2015
  6. Ducharme, Adler, Pelletier, Murray and Tepper. (2009). Impact on patient flow after the integration of nurse practitioners and physician assistants in Ontario emergency departments. The Canadian Journal of Emergency Medicine, Vol. 5, p.p. 458. Retrieved from: http://www.cjem-online.ca/v11/n5/p455
  7. Jacobson, A. 2009.  Being a good supervising physician: it’s more than just chart review. The Dermatologist  17 (6).
  8. AAPA: The Physician-PA Team.

Are there any factors that contribute to PA/MD working relationship? What other benefits do you see incorporating a PA into practice? Let me know in the comments!

Physician Assistant Blogs

As of right now, there are less than a handful of Canadian PA blogs.  I’ve listed my two favourite ones here. I’ve also linked to my reflections in my own PA practice, however I did not start blogging until I was half way through my PA clerkship in 2nd year, and did not start blogging regularly until I was well into practicing as a PA.

Also included are links to some popular American PA blogs, and other social media links you may find helpful.

Canadian PA Blogs

Canadian PA Student Association Sites

University of Manitoba and the Military Program do not have Student Association websites.

Official Canadian PA Organization Links

Pre-PA Student Forums

PA forums and communities were a valuable resource during my PA Admissions process. However, all resources available to me were American since at the time the 1st PA program in Ontario had not yet graduated the very first class. There are quite a few Pre-PA Communities available on forums, LinkedIn and Facebook. I recently started the Canadian Pre-PA Student Network which I hope you’ll join and browse through the questions that discuss everything from PA Practice in Canada, Life as a PA student and questions about admissions.

Keep in mind that the information and advice in these forums are reflections of the experiences and opinions of PA applicants, students, and alumni. The most accurate up to date information about admissions and PA information can be found on the official PA program websites, and on the Canadian Association of Physician Assistants website.

PA School after 2 years

Here I address a question which essentially asks, “When is a good time to apply to PA school?”. When you decide to apply during your career will affect what schools you apply to.

Q: I was wondering if it is too ambitious to apply in second year and if it hurts my chances for future years if I get rejected. I know many people who apply are even grad students. Or is it advantageous to apply early to have a high GPA?

If you are mid way through your 2nd year without previous health care experience, then the only program you may qualify to apply to is McMaster’s Physician Assistant Program. There are a couple of considerations for why you would want to apply in your 2nd year or why you would want to wait. First and foremost, you CAN apply as long as you meet the minimum requirements.

It is not too ambitious to apply while you are in your second year of undergraduate studies. There’s a wide demographic of students that get into the PA program each year, during my year, the average age was approximately 27, and anecdotally each year that average age gets lower and lower. Many of the classes have students have gotten into the program after completing 2 years of university and have done just as well as other students.

What if my GPA is low? As long as you make the cut off of 3.0 GPA for undergraduate studies completed so far, you can still apply. If your GPA does not meet the requirements, your application will not be considered. If your GPA is below 3.0, it may be worth waiting so that you can take courses to upgrade your GPA to meet the minimum requirements. However, waiting for your GPA to go from a 3.3 to a 3.7 GPA doesn’t make you “any less qualified” to apply, in both instances you still meet requirements and I would strongly encourage you to apply! Keep in mind there are other aspects of the admissions process – the supplementary application and Multi-Mini Interview where you can use your awesome communication skills to stand out as a PA candidate. Please check the McMaster PA Program Admission Requirements for the most up to date information.

What if I don’t get in because I wasn’t “competitive enough”? Well, sometimes it takes several rounds of interviews to get into the PA program. One advantage of going through the process is that you’ve had an opportunity this year to go through the admissions process, whether thats only as getting as far as the supplementary process, or making it all the way through to the interview round. Keep in mind that when McMaster sends out its offers, you may get waitlisted and SOME successfully PA candidates decline the offer for admission into the program. You may find out closer to the Fall start that you may have gotten in. Many PA colleagues I know did not get in the first time they applied or were wait listed after the interview, and for some reason a spot opened up. Each failure is a learning experience and opportunity to be improved upon.  You are now familiar with the supplementary application and MMI process, from which you can practice more. You now have some time to do research about the PA profession, do some shadowing, or speak with some PAs about their career.

Tip: Examine your goals

Deciding to enter any profession is no easy decision. Sometimes its based on your skillset, interest, personality, and other times a lifestyle factor. A personal decision I had on pursuing the PA program were for various reasons – it was the right amount of time in school for me (I couldn’t imagine spending another decade in school!), I enjoyed the flexibility the PA profession and liked the idea of assisting in pioneering of a new profession in Canada. Of course, at the time, I was contemplating other health care professions at the time – Medicine, Pharmacy, Optometry Physiotherapy, and Naturopathy to name a few. I attended a few career booths, and information sessions offered by my university’s Career Department, spoke with the guidance and career counselor at my university’s student centre, and quickly ruled out a few health career professions on my list.

I had to ask myself a few questions:

  • What kind of work-life balance did I want once I was out of school?
  • How much financial debt was I willing to take on?  I have had friends that have gone overseas to complete Medical School in Australia, England, The US and the Caribbean. A personal friend of mine who did not get into Optometry school in Canada relocated to Boston to attend Optometry school there. I know of some of my former undergraduate classmates who attended Dentistry in the United States as well. Some have been able to get their foreign licenses recognized in Canada, albeit it was a process, and have been able to return to Canada to practice.  I even had the option of attending PA school in the United States, which would allow me to practice in both the United States and Canada. However, to a certain extent I am risk adverse, and I also had an enormous amount of student debt to pay back to OSAP once I was done my four year undergrad living away from home prior to starting PA school. If I decided to attend a school in the United States or abroad, I would have likely required one of my parents to co-sign my a line of credit. I was also not willing to relocate overseas or across the border to attend any kind of professional school internationally or pay international fees (with no guarantee that I would get employment since I was done school at said international schools!). I knew that if I were to attend school, I’d want to stay within Canada, and if possible Ontario as it is my province of residence.
  • How many years am I willing to spend in school? Some professional schools are a 4 year program or more (e.g. Dentistry, Pharmacy, Medicine) and others are less.
  • Can I envision myself in a helping profession where I am working with others (health care staff, patients)? The fact that I enjoyed My experience with volunteering in hospitals, seniors centres, and clinical research settings, and jobs in customer service as a teenager were a great indicator that I’d enjoy be in the health care field. Reflect on what experiences you’ve had working with people, in small groups and in team settings whether in academic, paid or extra-curricular settings. 
  • Am I a self-starter and willing to learn on my own initiative? Many components of the PA programs involve Problem Based Learning. Also, medicine is an ocean. Its impossible to learn all that you need to know within 2 years of PA school, or even 4 years of medical school. As a PA, if I come across a concept I may not be familiar with,
  • Am I willing to take on an unpredictable job market?  Note: in 2009 when I applied, no civilian PAs had yet graduated and the very first iteration of the Career Start funding program was not yet announced. As of 2017, we now have a better picture of the job market since there have been many generations of PAs that have graduated from all 3 civilian programs in Canada.
  • If I don’t get into the PA program (or other health care professional schools), do I have other backups?
  • A big one for me: Am I okay not being a doctor (or insert other profession here that isn’t PA)? After careful examination, speaking to medical residents, currently practicing physicians, I realized being a physician although a possibility, was not a good fit for me at the time. The PA role better suited my long term goals. In retrospect, I feel as an individual its easier to make a bigger impact in a smaller community. 

Answers to these questions about your long term goals and career aspirations will come from self-reflection, your own research about different health care professions, speaking to campus career counselors, attending information sessions, speaking with PAs and PA students (the program info sessions are great opportunities for this!). Be well researched and always keep your options open. Take pre-requisites that you feel you can handle in your course load and that will help open up doors to application to your professional schools of interest.

Age is just a number

Just like other facets of life, age is just a number and having the characteristics that make you a good candidate for the program is not determined by age. There are some things you can’t teach, such as attitude, an eagerness to learn, passion for learning and patient care, empathy, working well with others, and willingness to take initiative. Use the time between now and when you apply to seek out enriching experiences and opportunities (whether through extracurriculars, volunteer work, mentorship, shadowing or part-time work) to develop the skills that will help you succeed in whatever you choose to do.

Q: Also, is there a way to strengthen my application aside from a high GPA and good supplementary app? The website states that an inquiry courses will benefit applicants, but I don’t think the course is open to science students. Only humanities, social science, arts and science and health science have the opportunity to take the course.

A: Do your research – Inquiry-based courses are a benefit but not a pre-requisite. Read up on the philosophy of PBL – a great guide available online is McMaster’s Guide to “Approaching PBL Practically”. It was put together by medical students and outlines how PBL is used in a medical curriculum, which is what the PA program models off of at McMaster. You may wish to reach out to your guidance counsellor or career counselor on options for courses close to the Inquiry Model or PBL as a base of courses that may be available to you. Again, this is not required to get into the program and there are PA students who got into the PA Program without taking Inquiry courses beforehand.

Try researching what characteristics you would need to succeed in a PBL-based learning environment and seek experiences that would help you achieve these.  Another good resource I recommend is the McMaster University CLL – Resources for Inquiry website, which links to resources about how to teach Inquiry.

The McMaster PA Student Resource also has an article in their Pre-PA section titled, “What is PBL?” I strongly recommend you check it out!

Speak to currently practicing PAs or PA students – and ask questions not just pertaining to “how can I strengthen my application”, but questions like:

  • How are you enjoying the program?
  • How do you like PBL?
  • What do you find challenging?
  • What was your academic background before you entered the PA program?
  • What are the students like in your PA class?

These are just a few questions; but provide you insight into the program that wouldn’t otherwise be available online.

To reach out to currently practicing PAs, I recommend you email CAPA – the national PA organization at admin@capa-acam.ca.

If you would like to reach out to a current PA student, you may try emailing the PA program, attending an upcoming information session (which occurs once a year in November on campus).

If you do not have access to either, I strongly recommend you browse through the American Physician Assistant Forum, although it is American there are similarities between the application process and some of the professional challenges we face. Many PA students, practicing PAs and pre-PAs browse the site daily and are happy to answer your questions.

IMGs becoming Physician Assistants

International Medical Graduates (IMGs) are Physicians who were trained outside of Canada. Apart from acclimating to a different country, different weather, perhaps a different language and different customs, another challenge IMGs face when arriving in Canada is often ensuring English skills (written and oral) are high enough to meet admission requirements for different health care careers, and to find a career that allows IMGs to utilize the skills they have acquired outside of Canada.

There are several options for IMGs, with one of them including becoming a Physician Assistant. I have outlined the PA pathway from an IMG perspective, and have also included other health care career options too.

IMG TO PHYSICIAN ASSISTANT

To become a Physician Assistant as an IMG, you must complete an accredited Physician Assistant Program in Canada. IMGs cannot skip or advance past any aspects of the program due to their prior medical education. To complete a PA program successfully, you must complete both the first didactic year and second clinical rotation year, finishing all courses for the program. Luckily, the PA program is approximately only 2 years (~24 months), and if you have completed your undergraduate degree, in addition to your graduate degree and with your health care experience, it is likely you qualify to apply to all 3 civilian PA programs in Canada (Manitoba, University of Toronto, and McMaster).

All PA program candidates must be Canadian citizens or permanent residents in Canada. A permanent resident is someone who is a citizen of another country, but has immigrated to Canada. Students and workers who are on temporary work visas are not considered permanent residents. You are not considered a permanent resident or citizen by marriage. Canadian citizens are those that may have been born in Canada, or have a parent born in Canada. You can also apply to be a Canadian Citizen if you have had Permanent Resident status, and have physically lived in Canada for 1460 days during the six years prior to your Canadian Citizen application with adequate knowledge of English.

The IMG applying for PA programs must meet English language requirements, and this differs for each school.

Once you have completed a Physician Assistant Program, you are to write the PA Entry Exam administered by the Physician Assistant Certification Council of Canada (PACCC).

IMG TO CLINICAL ASSISTANT

The College of Physicians and Surgeons of Manitoba have a Clinical Assistant position that is open to IMGs who qualify. Be sure to carefully check the University of Manitoba and CPSM websites carefully for the most up to date information on application criteria.

Requirements include:

  • having a medical degree from an approved faculty of medicine, OR
  • be licensed/registered to provide health care under an Act of the Manitoba Legislature, OR
  • be a graduate of an accredited Physician Assistant or Clinical Assistant training program, OR
  • be certified as an Emergency Medical Attendant – Level III

In addition the Clinical Assistant candidate must undergo a Clinical Assistant Assessment, which assesses  several medical competencies including History Taking, Physical Examination, Communication Skills, and Written as well as Oral Documentation Skills. There are several stations with a standardized patient.

If you’d like ot learn more information, visit the Physician and Clinical Assistants of Manitoba.

IMGs becoming Physicians in Canada

Becoming a Physician in Canada as an international medical graduate is difficult and competitive. There are several routes you can take:

The first being you apply to residency program in the specialty of interest through CaRMs, of which a small percentage of spots are reserved for International Medical Graduates either in a separate stream or the same stream as Canadian Medical graduates. This may take several tries to get in if the IMG candidate is successful.

IMGs may also consider starting their medical education from the very beginning, that is, applying to medical school and starting the medical training from scratch. This would involve 4 years undergraduate, with 2-6 years of residency, with 1-2 years fellowship.

Resources for IMGs to transition to Physician positions

IMGs and other Health Care Careers

Many IMGs also consider other allied health professions, such as applying to other professional schools or degree programs such as Physiotherapy, Occupational Therapy, Social Work, Respiratory Therapy, Medical Radiation Technologist, X-Ray/Ultrasound Technician, Lab Technician, Personal Support Worker (PSW), Health Care Aide, Health Policy Researcher/Analyst, Health Care Administrator, Research Assistant / Associate, Athletic therapist, Pharmacy Technician, EMG Technician, the list can go on and on.

This way, the IMG can stay within the field of healthcare and utilize some skills in order to transition to their life here in Canada.

Do you have resources for IMGs in Canada? What has your experience been like? Please let me know in the comments below!

Physician Assistant vs MD

This is a question I often get from prospective students who are looking into the PA program, except its framed, “Why did you choose to become a Physician Assistant and not an MD?”. It’s a good question, but I thought it would be more constructive to discuss the differences between the two professions as well as their similarities. Answers are based on PAs and MDs practicing in Ontario, Canada.

MD vs. PA – Education

Physicians have a much longer duration of education:

  • Medical School: 3 to 4 years. The first half usually consists of didactic learning and medical foundations (1st and 2nd year students), the second half involves “clerkship” where medical students complete clinical rotations. 
  • CaRMS: Application process to rank residencies.
  • Residency: Depending on the specialty (family 2 years, other specialties 4 to 5 years).
  • Fellowship: Extra training to sub specialize within the specialty (1 to 2 years). This is considered a “short-term” training program.
  • Apply for a Physician position: Finding work as an MD as a generalist is not difficult since there is a shortage of family physicians. To be affiliated with a teaching hospital, positions are certainly more competitive. It is easier to find work in remote settings and community hospitals. See this CBC report about the unemployment rate for recently graduated medical specialists.
  • Total duration before becoming “staff” – 6 (primary care) to 12 years (specialist) [not including undergraduate education before medical school]

Physician Assistant education is shorter in duration:

  • Physician Assistant School: 2 years. First half (year one) includes establishing medical foundations, the second half involves “clerkship” where PA students complete clinical rotations in different areas of medicine.
  • Apply for a PA position: PA’s graduate as generalists and may work immediately after graduation in any area of medicine.
  • Total duration of training before becoming “staff”: 2 years [not including undergraduate education before PA school]

PA or MD? Meet Sundance who has done both.

“Sundance describes her choice to become a physician assistant student (PA vs MD). A prior medical student, she explains her decision to become a PA.”

MD vs. PA – Teaching Philosophy & Professional Competencies

Both physicians and physician assistants use the CanMEDS Framework to determine the knowledge, skills and abilities required to treat patients. For Physician Assistants in Canada, this is outlined in the Can-MedsPA. In summary, its actually not that different.

For instance, McMaster University’s PA Education Program has a large part of their curriculum based off of the medical school curriculum. Teaching philosophy, approach and use of the medical model is almost identical to that of physicians in training. PAs learn to question, think and diagnose like doctors as Physician Assistants are educated in the medical model.

MD vs. PA – Scope of Practice

Physicians are the “most responsible provider” and have full liability over the care of their patients. They see their own list of patients, can work in an outpatient clinic, in the hospital or do a combination of both. As staff at hospital they also perform surgeries, or obtain hospital privileges to do so. The Principles and Duties of Practice are outlined on CPSO.

Physician Assistants are not independent practitioners, therefore clinical skills and procedures performed depend on several factors:

  • What the PA can perform is dependent on the skill/procedure/scope of practice of the supervising physician. If the supervising MD doesn’t perform the task to be delegated, then the PA should not perform the task either. For example, if the physician does not normally prescribe a certain medication, the PA should not prescribe that medication either without first consulting the physician.
  • What is performed by the PA must be delegated by the supervising physician. Frequently delegated tasks can be outlined in a carefully crafted medical directive.
  • PAs can perform 80-90% of what a physician may do, focusing more often on less acute, pressing problems to offload work from the supervising physician. This allows the physician to focus on more complex problems, patients that require more time, or other academic/research endeavours.

Research, Business Startups, Journalism, Advocacy, Volunteerism, and Consulting are all aspects of medicine and business that both physicians and physician assistants can partake in. 

Fore more information on Scope of Practice, see Health Force Ontario’s “Defining the Physician Assistant Role in Ontario” document.

MD vs PA – Flexibility

If a Physician were to be interested in switching specialties completely, it is much more difficult and would require additional certification or years of training. Generally if one day a Urologist wishes to become an Orthopaedic Surgeon, this would involve taking on additional years of training.

Physician Assistants may switch between specialties without requirement for additional training or certification. In fact, it is not uncommon for physician assistants to start in one area of medicine, and end up in another over the course of several years. My mentor started out in Cardiothoracic Surgery, switched to Plastic Surgery and eventually ended up in Emergency Medicine working full time as a PA. Another American PA I know of works part time in a Family Medicine practice, and other days of the week will work in a Dermatology practice. Prior to this she had been working in an Orthopaedic Surgery Practice.

Both a physician and physician assistant can cater their work schedule to best suit their lifestyle practices. For instance, if either profession wishes to only work 3 days per week for whatever reason, a physician simply sets their schedule, whereas a PA will apply for part time positions. PA contracts may or may not require shift work or call duty, however physicians who take up posts at hospitals are usually required to do call or shift work (e.g. in the ER, or in surgical/hospitalist specialties).

MD vs PA – Liability

Physicians have ultimate liability as the “most responsible physician” that come along with having more independence, autonomy and responsibility. They have their own liability insurance which they pay into annually.

Physician Assistants: Negligence on part of the PA may expose the supervising MD to liability as well (similar to the liability that occurs with supervising medical students/learners/residents). Physician Assistants who work in hospitals may be covered through HIROC, otherwise PAs may obtain their own liability insurance

For more information on Liability of Employment of PA’s, read the Ontario Hospital Association Liability of PA’s document.

MD vs PA – Compensation

Time: Physicians lead very busy lifestyles, their schedule includes performing call, surgeries, outpatient clinics, consultations to other services, and in patient wards. They manage and oversee staff and their personal clinics – which involves a lot of work similar to managing a small business. PAs are essentially “employed/supervised under physicians” and thus may, in comparison, provide more time for leisure, and having more time for family

Salary: Physicians are extremely comfortable (typical salary for family physicians in Ontario is between $200,000 to $300,000 depending on scope of practice, with specialists making more). However, as medical residents they start off making approximately ~$51,000 per year in Ontario. Keep in mind that physicians also have to pay overhead if they run their own clinics – this includes rent for their office, salaries of staff including administrative assistants / medical secretaries, PAs/NPs or RNs they may have hired, medical supplies, and EMR software, etc.

On the other hand,  Physician Assistant Salary is comfortable and enough for a good standard of living. Starting salary for physician assistants starts at $75,000-$80,000 including benefits in Ontario. Competitive salaries are higher and there are a few Physician Assistants on the Ontario Sunshine List who make $100,000+, with pay scale and benefits. PAs do not pay for overhead since they do not run their own clinics.

MD vs PA – Regulation

In Ontario – Physician Assistants are currently not a regulated profession due to not meeting the requirements for threshold of harm. At this time in Ontario, lack of regulation does not prevent PAs from practicing or affect the quality of care currently delivered; it seems to serve more as a barrier to moving the profession forward in terms of Advocacy and a larger stakeholder acceptance. Paramedics are another category of health care professional that are not regulated as well.

In Ontario, MDs are a “self-regulated” profession. The College of Physicians and Surgeons of Ontario (CPSO) is the  body that regulates the practice of medicine amongst physicians.


Hello, I'm Anne!
I'm a Canadian Physician Assistant who writes about the PA profession in Canada. Learn more »

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