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Q&A with a Canadian Emergency Medicine Physician Assistant

Q&A with a Canadian Emergency Medicine Physician Assistant

Canadian Physician Assistant in Emergency Medicine

From Anne: Sahand is a McMaster PA grad graduating from Class of 2013. He served as the McMaster PA Student Association (MPASA) President for his class, and has been an advocate for the PA Profession. He now works in Emergency Medicine at University Hospital Network (UHN)  in Toronto, Ontario.  Sahand teaches at the McMaster PA Program covering Interview Examination and Reasoning Skills (IER). He is also involved in the PA student mentorship program and preceptors for students completing clerkship rotations in Emergency Medicine at UHN.

Sahand has been a long time advocate of the PA profession, taking time to answer questions for prospective PA students, mentoring, and engaging in PA Advocacy.

Studying to be a Physician Assistant

Q. Why did you decide to become a PA? What drew you to the profession? 

A. I always knew that I wanted a career in medicine. Initially I went into undergrad thinking that I would pursue a career in Pharmacy. I felt that this wasn’t the right career for me as I was hoping for a more active role in the diagnosis and management of diseases.

At this point I started to scramble for other jobs and began searching “Careers in Healthcare”. I always knew that the MD route was not something I wanted to do. The main reason for this was the length of time it takes to do it. I always excelled in school but didn’t enjoy classes, tests, the stress etc. I wanted a clinical career – one where I would be able to practice medicine but not have to be in school for 12 years to do it.

Long story short – one day I ran across an article about PAs in the states. I immediately fell in love with the idea. The career outlooks were great, you take on a clinical role and the schooling was something that I could handle. Doing a strenuous 2-year program followed by on-the-job training was exactly what I had been looking for. Needless to say, I applied to both Pharmacy and the PA Program – was accepted to both…but decided to pursue a career as a PA.

Also, another major point of interest for me was the flexibility of the role. You are trained as a generalist and you can switch specialties as you please, you are not constrained to practice medicine in only one field. For example – as a physician, you complete Medical school followed by a Residency in a specific specialty (e.g. Orthopaedic Surgery) after you are done, you find a job in a hospital and can practice as a staff orthopedic surgeon independently. However, that surgeon can only practice orthopedic surgery. If one day they decided to switch specialties (even to go and do something like family medicine) they would need to re-apply and complete a residency for that specialty.

As a PA, you are a dependent practitioner (meaning you always work with a Physician). However, as a result, you do a lot of learning on the job (like a resident) but this also gives PAs a huge amount of flexibility and the opportunity to switch between specialties. For example, a Family Medicine PA can decide to switch to Ortho, general surgery etc as they please. Obviously – there will be a big learning curve for the first few months but they would not need to undergo formal training to do so.

Sahand was class president of MPASA Class of 2013.

Q. I noticed that you went to the PA program at McMaster. How was your experience with the program and school? 

A. I loved the McMaster PA Program. As mentioned, I am not a fan of our education system and think that it is seriously flawed. As a result, the problem based learning approach at McMaster University spoke to me. I found that the style of teaching prepares you for life long learning. This is critical in the medical field, as you will never know everything and are constantly required to keep up to date. Furthermore, it allows you to develop a good approach to patients in the clinical setting.

Sahand Ensafi with his classmates Aisha, Tracey, Deanna, Claire, and Yousra.

Sahand Ensafi with his classmates Aisha, Tracey, Deanna, Claire, and Yousra.

The program at McMaster is extremely self-directed, which allows you to understand how to learn independently, as opposed to having a ton of information spewed at you and struggling to just memorize/regurgitate it all for a test.

Q. Do you ever regret becoming a PA and not pursuing another profession (nursing, med, etc.)? Why? 

A. I never regret becoming PA and am extremely happy with the position I am in. I absolutely would not have pursued a career in nursing – ever. It does not appeal to me whatsoever.

The only frustration with the PA Profession at this time is the uncertainty around funding. At times, this makes me contemplate about what would have happened if I applied to medical school (given that I got accepted =P). But soon after I think of this, I realize that there is no way that I would be able to do another 4 years + 5 years of residency to get my MD. To deal with 3000 more tests, crippling debt and tons of stress. And even as an MD – the job prospects can be iffy depending on what program you are graduating from (e.g. orthopaedics has no jobs atm).

I am quite certain that things will fall into place with regards to funding. We just need to have patience and to continue advocating for ourselves and showing the people the tremendous value PAs can bring to our system. In a time where the government has no money, it does not make sense to pay someone 200 000 a year to deal with cough/colds that can be managed equivalently by advanced practice providers like PAs and NPs. And the government will recognize that.

Q. Any thoughts on doing PA school in Canada vs the US? 

A. Currently, we are working with the AAPA to try to allow for Canadian PAs to seek employment in the US (as this does not happen yet). So one bonus of training in the US is that you will have their huge job market available to you, and you can always come back to Canada to seek employment (although the career start program will not be available to you). The downside is that the US costs a lot more money, so you will be in much more debt when you are done!

Q. Which areas of medicine have you worked in? Which one(s) appeal to you the most and why? How easy is it to switch fields? 

A. You can take a look at my LinkedIn profile which summarizes all of the settings that I have had clinical exposure to. I have been working in the ED for the last 2 years. Theoretically – it is quite easy to switch fields – in Canada. What we are limited by is the jobs that are available given the funding model. Finding jobs in family medicine is quite easy, other specialties (depending on what you are looking for can be difficult). However, as a grad there is a career start program partially funds your employment for a set amount of time after graduation. This program is how most grads find/keep jobs and typically has a huge list of different specialties/sub specialties which you can apply to.

Q. What advice do you have for someone applying to PA school? 

A. Overall, I love being a PA and enjoying what I do on a daily basis. You need to prepare yourself to take part in an extremely rigorous process filled with a ton of stress – although luckily it is somewhat short lived. As mentioned previously, in Canada our major battle is with advocacy and recognition at the government level, so you need to be ready to help pioneer the profession. For some, that is a downside – as they want to fall right into something that has already been created. For me, it was actually a bonus – because what we do today is going to define what happens for colleagues forever. So although it is stressful, it is also an extremely unique opportunity.

Describing the PA Role

Q. How would you answer the question, “What is a PA?” What would you say are the attributes of a good physician assistant? 

A. A PA is as a physician extender. We work in a team with a physician to provide medical care to patients. PAs practice medicine. This means that our training teaches us to approach patients in the same way as physicians. We are able to take histories, perform physical exams, order and interpret diagnostic tests and come up with a treatment plan for the patients that we see. We are able to work in all areas of medicine where there is a physician working and as long as we have been adequately trained; we can do anything that is within the scope of practice of the physician we are working with.

Being a dependent practitioner is sometimes misinterpreted. Depending on the setting – PAs function differently. Ultimately, as you are an extension of the Physician with whom you work – they are responsible for the patients that you see and treat. In some settings, this means that PAs will only review cases which are complicated for which they require a second opinion (e.g. family medicine). In other, high-risk/high-stakes settings, PAs will see patients, complete their history/physical/diagnosis and treatment but discuss the case prior to patient discharge to ensure that the MD does not want anything to be done differently (e.g. in ER).

It is important for a PA to have strong interpersonal as well as communication skills. As a PA, you are constantly interacting with patients and physicians (who can both be difficult to work with at times). As a result – communication and your ability to relate to and empathize with others is a critical part of your job.

Q. Even after looking this up, I am still unclear about the difference between a NP and PA.

I realize that NPs work on more of the nursing model and PAs work off the medical model, but how does this translate to differences while working on the job? 

A. As with many health care professions there is a lot of overlap between the two. I work with two NPs at UHN and have a great relationship with both. NPs are trained in the nursing model – that is they are nurses with specialized training to diagnose and treat illnesses. They (just as of a few years ago in Canada) can also practice independently. This means for straight-forward patients, they do not need to review with a physician and can send the patients home. They are also regulated (as they have been around for the last 40 or so years).

PAs are trained in the medical model and are dependent health care providers (as discussed above). As a result, we are always in a team with a physician (although in certain places we can also function remotely – with a physician available on call). In my mind an NP as a defined scope of practice as they are independent. So when they graduate from an NP program – they can do the things that they have been trained to do independently. A PAs scope of practice is variable depending on the setting that they are working with and who they are working for and the longer that the PA has worked with a physician, the more training they will have and the more things that they will be allowed to do. For example: when I began working at UHN 2 years ago, I wasn’t doing joint aspirations, central lines, and lumbar punctures. However now that I have been trained to do these highly invasive procedures – I can do them. The NPs however do not do these procedures and need to get the physician involved should they need to have them completed. Overall the difference is very vague – and both can function in similar settings. It comes down to what the hospital/setting is looking for and what role they need filled. Ultimately – there is a role for both and I can say that we work well together.

See our post on the Differences between a Nurse Practitioner and Physician Assistant

Sahand meeting with Dr. Eric Hoskins, Ontario Minister of Health, at PA Advocacy Day.

Working as an Emergency Medicine Physician Assistant

Q. Why did you choose to work at this location? How did you go about finding a job? How hard was it to find a job? 

A. I knew that I wanted to work in the ER after my clerkship rotation. UHN was perfect as I would pioneer the role within their emergency department at Toronto Western & Toronto General hospitals. It is downtown, the commute is easy for me as I can take the subway. I found the position through the career start program.

Q. Has anything surprised you about being a PA since you started working? 

A. Nothing has really surprised me to be honest. You know what you are getting into if you have been doing some reading around the Profession (both in Canada and the US). In Canada the major issues are surrounding Ontarios extremely slow acceptance of the profession. But so long as you advocate for yourself, and look for jobs – opportunities will arise.

Sahand works as part of University Health Network (UHN) in the Emergency Department. He’s pictured here with other PAs at UHN for an article on PA Day.


Q.
How do you find working under the supervision of a physician in general? Do you feel that it limits you? How do you find the relationship with your supervising physician? 

A. I can only speak with regards to the physicians that I work with (we have 72 in our ED at UHN) and I work with all of them so I think I have big enough sample size to say overall – no.

Each person is different with what they do/don’t do. As a PA another important quality is to recognize your role within the medical team. The beauty of the PA (at least to me) is the fact that you are never completely medico-legal responsible for the patient. As a result – there will be times that your SP may want to change your management plan – and you can’t let that affect you (some people take it personally). Ultimately – the major responsibility lies with the doc – so even if I don’t agree with the plan, I will state why and if they still want to do something differently, then it’s easy…I just listen (because it is their license on the line). Now this very RARELY happens. Often you and the SP will come up with a combined management plan that takes both of your opinions into account.

My general advice is – if you are someone that needs to be the be all/end all, and you can’t take a back seat for certain things, then being a PA will be frustrating. On the other hand, you have way less stress and know that you are always covered if things take a turn for the worst. Also- it is important to remember that even physicians don’t work independently. There are numerous situations where a physician will also ask for a second opinion (whether it is from a consultant or colleague)

Q. How well have PAs been integrating into the healthcare system? The PA profession is still relatively unknown by many people in the public. How do you personally deal with this challenge? 

A. I think that I have already answered this question. In the US – it is much more well known and even in Canada word is slowly spreading. At the same time – there is always room for improvement and the more patients that we educate around our role – the better. The integration issue is more with regards to the government and funding. This is slowly being worked out as more privately funded jobs have been popping up around the province. Also – our association is working with the ministry of health regularly to help come up with a permanent funding model.

Q. Do patients respect you as a PA? Or would they rather see a physician? Do you feel that you get recognition from patients? From doctors? From other healthcare professionals? 

A. To all of these questions I have to say: Yes.

The name PA is misleading but what people need to understand is that patients don’t care about titles. A lot of the time, even though I introduce myself as a Physician Assistant/Associate – they may not process exactly what I am and still end the interaction with “Thanks doc”. What I mean by this is: If you are confident and competent people will listen to you and respect your opinion. If you are not – then the opposite will occur. Regardless of whether you are a nurse, NP, PA or MD. If a patient sees a resident who is not confident with what they do they will ask to see the staff, if they see an attending who isn’t confident they will have bad reviews to give to the doc personally, the hospital and the royal college. It is also an issue that comes up with regards to patients wanting to see specialists, “Oh well you are just a family doctor, you aren’t an ophthalmologist so how would you know”. This occurs at all levels of the health care industry.

Infographic Emergency Medicine Canada

Q. What are your work hours like? How long are your shifts? 

A. I work 16 shifts a month. This is a total of 6 – 10 hour shifts and 10 – 9 hour shifts. My shifts are all mid-day (as this works for me). So they are either between 11am – 8pm or 10am – 8pm. As I don’t have a family yet – I can sleep in, I miss traffic going downtown and I get home at a reasonable hour. I also try to work 2 weekends a month. Within the above constraints, I make my own schedule which is awesome as well, because I can just schedule around things without taking unnecessary vacation time.

Q. What procedures do you in the Emergency Department?

A. Procedures that I do in the ED include:

  • Suturing
  • casting, reducing fractures/dislocations
  • lumbar puncture
  • paracentesis
  • thoracentesis
  • Incision and Drainage
  • assisting during resuscitations
  • We are starting to explore the option of getting certified for point of care ultrasound but we are not formally trained to utilize this yet (although we still use it to guide us for certain procedures).

Q. What is the rarest medical condition you have seen in the ER?

Giant Cell Arteritis, Image from Web MD

A.  I have had one case of giant cell arteritis, the other day I had a case of a cranial nerve 3 palsy. The patient also complained of a thunderclap headache 3 weeks prior to her presenting to the ED. An MRA performed one week prior to her presentation to the ED was negative (which baffled all of us). We repeated a CTA in the ED which showed a 1cm PCOM aneurysm compressing her 3rd cranial nerve on the right. They think she probably had an intraneurysmal thrombus at the time of the MRA which is why they didn’t see it when she had the test one week prior.

Q. Do you find that you have work-life balance? 

A. I find that I have a great work life balance. Given I have 3 days off/week, I have time to catch up on other things that I do on the side while I am off. I also teach part time at McMaster which is also a great opportunity.

Q. What learning opportunities do you have as a PA? 

A. As a PA, the learning opportunities are infinite. Continuing medical education is necessary to maintain your certification with the Canadian Association of Physician Assistants, so you are constantly required to attend conferences and to take part in courses to advance your practice.

Sahand Ensafi presenting at the UHN Emergency Medicine Conference on Painless Loss of Vision.

Sahand Ensafi presenting at the UHN Emergency Medicine Conference on Painless Loss of Vision.

Q. What is most rewarding part of your job? 

A. This is a hard question and it depends on the day you ask. As a PA I have the ability to affect both the lives of the patients that I see and the Physicians with whom I work. This is a very unique aspect of my job that I enjoy. There is nothing more rewarding than treating a sick patient coming into hospital (who may have died otherwise) and seeing them make it to discharge 4 weeks later – all because of your initial diagnosis and management in the ER. The ER is an extremely high-stress area of medicine filled with chaos. We often take fore granted how much a correct (or incorrect) diagnosis can change someone’s life.

In terms of the Physicians – it is always nice coming onto a shift where the department is overwhelmed with high volumes and seeing your colleagues brighten up and say “thank god you’ve arrived!”. It makes you feel very appreciated.

Q. What are the benefits the ER has seen since implementing Physician Assistants?

A.  Having the PAs in the ED has not only helped to improve flow and patient throughput but most importantly has allowed the PA/NP team to work collaboratively with one another in order to optimize our coverage of “advanced practice providers” in the ED during the busiest times of the week.

Also, by working with one another we can also reduce stress/burnout amongst our team as prior to this it was much more difficult to arrange for time off (as specific days required coverage with a PA or NP). I think this ultimately helps to improve physician workload but also improves patient care. Both the PAs and NPs in our department have the ability to take the time necessary to complete thorough assessments in order to provide thorough and exceptional care to the patients whom we assess (e.g. ensuring subtle abnormalities in labs/imaging as well as in the patients story are not overlooked etc). I think this is the ultimate advantage of having us as a part of the team – in order to not only improve wait times but to provide both timely and exceptional care to the patients whom we are responsible for.

Q. What is the most difficult part of your job? 

A. Despite those life saving diagnoses that happen every once in a while, the ER is often a disappointing place for patients. Many come in with chronic problems that have been poorly managed for a long time – looking for answers/a quick fix. What they don’t understand is that the ER is a place for Emergencies – Heart Attacks, Strokes etc. And often, when you tell these patients that there is not much more that you can offer them – they can be quite disappointed.

MPPs had the opportunity to learn what PAs do, how they can help Canadians. Here Sahand, an ER PA, takes an MPPs blood pressure.

Sahand taking an MPP’s blood pressure at the PA Awareness Reception at Queen’s Park. This event allowed PAs to speak with their MPPs about the PA Profession, and what PAs can do for Canadian health care.

Have questions or comments for Sahand? Let us know in the comments!

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2017-08-28T09:16:36+00:00 3 Comments

About the Author:

Sahand is a Canadian trained and certified Physician Assistant working in Emergency Medicine as part of the University Health Network. He is a graduate of McMaster Physician Assistant Education Program Class of 2013 where he served as President of the McMaster PA Student Association (MPASA). He is an Assistant Professor at McMaster University teaching Interviewing, Examination and Reasoning as well as precepting the simulation program.
  • Nasir Iftikhar

    Hi thanks so much for an insightful post.
    I had some questions regarding billing. For the patients you see, if the Doctor for that shift has a meaningful interaction, are they permitted to bill? If this the case and you see more patients for them, I assume that they bill more than what they would have on there own?

    • Sahand Ensafi

      Hi Nasir,

      The short answer is that you are correct. However the long answer is a bit complicated. As long as there is a meaningful interaction with the patient (yet to be defined but classically reviewing the history/physical, being involved in the discussion of a plan etc and meeting the patient), billing can take place. The legislation is a bit vague with regards to this however (as a lot of this existed prior to the introduction of the PA Profession) and we need to continue to work towards clarifying this going forward.

    • Agree completely with Sahand! For full rules about billing in Ontario – check Ontario’s Schedule of Benefits:
      http://www.health.gov.on.ca/en/pro/programs/ohip/sob/physserv/physserv_mn.html

      which outlines the rules for billing when it comes to delegated procedures/acts and assessments.