PA PRACTICE • ONTARIO

Angela Cassell, CCPA and Deniece O’Leary, incoming CAPA Ontario Chapter President presented a great session on Medical Directives at this past Annual CAPA Conference that took place in Toronto.  I know a large challenge for PAs is that there aren’t a lot of resources available to PAs – especially around templates or best practices for implementing medical directives.

Each province’s college has different policies surrounding delegation of controlled acts. What’s presented here is based on the Ontario experience.

PAs are autonomous, but dependent practitioners. By nature Physician Assistants are not independent practitioners, we work under the supervision of physicians. As outlined by OHA, the definition of “supervision” varies – this can be direct (direct observation) or indirect (physician offsite, but accessible via phone, electronic means). At the beginning of a PA’s employment, it may be more appropriate to have “direct” supervision, however as the PA/MD relationship develops, and the PA builds knowledge, competency and skills in their area of practice, the supervision may transition to “indirect”.

In Ontario, Physician Assistants practice through the Regulated Health Professions Act (RHPA), which outlines controlled medical procedures that can be delegated to PAs by physician orders – written, verbal or medical directives. This differs from province to province, so check each province’s college website to determine how PAs can practice in your jurisdiction.

According to the College of Physician and Surgeons of Ontario (CPSO),

“Medical directives are written orders by physicians…. to other health care providers that pertain to any patient who meets the criteria set out in the medical directive. When the directive calls for acts that will require delegation. It provides authority to carry out the treatments, procedures or other interventions that are specified int he directive, provided that certain conditions and circumstances exist.”

In other words, the medical directive allows a supervising physician to delegate duties to another person without requiring the physician’s physical presence. CPSO has a list of 14 controlled acts that can be delegated. The medical directive expands on these delegated tasks to outline certain conditions under which PAs can perform those delegated asks.

Although a very simplistic example, think of medical directives like a “Protocol” with many “If, then” statements. “If patients presents with X, PA is to perform Y“.

• X being condition specific, or certain presentations, or a list of indications. It can also be related to preventative care (e.g. when patient is due for a well baby exam).
• Y being assessment (history & physical exams), ordering or performing diagnostic or therapeutic procedures and prescription of medications . Contraindications included.

Two great tidbits from Angela Cassell, CCPA during the Medical Directive Roundtable Discussion at the Toronto CAPA Annual Conference:

“Medical directives are living documents”, they should be updated frequently (at most ever 3-4 years) as guidelines change.

“Include References in Your Medical Directives”, which may include a “See Canadian Diabetes Association Clinical Practice Guidelines for Screening & Diagnosis of Diabetes” with a link to the website. You may include the actual guidelines as an Appendix at the end of the medical directive, or built right into the medical directives, however this does require a lot of upkeep when the guidelines update.

“Try to keep your directives broad instead of specific”  i.e. instead of listing individual medications list classes or medications or group together by disease processes.

• An example would be to say you can prescribe Sulfonylureas (class of medication) instead of Diamicron (speciic medicaiton) or even better, all antihypoglyemic medications (by disease process). This ensures directives don’t need to be udpated every time a new medicaiton comes on the market.”

There are three methods to take orders from physicians:

• Verbal Direct Order – in person or over the phone. Requires presence of physician.  This takes place after the PA has interacted with a patient.
• Written Direct Order – having the physician spell out/write out orders and signing off. This takes place after the PA has interacted with a patient.
• Medical Directives – PAs are able to implement an already-agreed upon  list of frequently delegated tasks under certain circumstances. This takes place in advance of the PA interacting with a patient.

In all cases, how the order was implemented (and method – verbal, written, medical directives) should be documented in the patient’s chart.

Medical directives allow PAs to perform various delegated acts under the supervision of a physician. The physician does not necessarily need to be present for the PA to perform these delegated tasks that have been outlined in the medical directive. Medical directives allows PAs to function more efficiently, especially in settings with indirect physician supervision.

It can be quite cumbersome to require your supervising physicians to give you verbal or written orders, or to chase after physicians (around a hospital, or smaller practice) for routine ordering of imaging, lab tests, and prescription of routine medications (narcotics/controlled substances fall out of this scope). Time is spent instead on patient care.

If there is a controlled act, e.g. an investigation you would like to order, medication that you would like to prescribe (such as a narcotic/controlled substance), or an intervention you would like to implement that falls outside of the medical directives, this is where you would require a direct order (e.g. written order) from the physician. 

Medical directives can be very broad or specific. They will be formatted to best suit the practice setting – Emergency Medicine Medical Directives will look very different from Medical Directives in a Family Medicine Setting, and are often institution-specific.

Some practice settings have already prepared Medical Directives, other places require the PA to develop the medical directives, which can be an enormous (but not impossible!) undertaking.

Medical Directives & Medical Documentation – Whenever you perform a delegated act outlined in the medical directive, there should be a reference to it when you are documenting your patient encounter.

• e.g. “Counseled patient  on medication use and compliance, self monitoring of blood glucose levels, smoking cessation, alcohol consumption, exercise and diet as per medical directive #12c”
• e.g. “After explaining risks and benefits, and obtaining informed consent, 80 mg of Depo-Medrol along with 4 cc of 2% Xylocaine without Epinephrine was injected into the right knee using sterile technique, no complications. Intervention performed as per medical directive #12d”

Medical Directives & Ordering Investigations – Ensure local imaging facilities have a copy of the medical directives. When signing at the bottom, sign your name, designation, medical directive reference, your supervising physician name and their CPSO number.

• e.g. John Smith, CCPA, as per medical directive #2a for Dr. Jane Appleby, CPSO # 86070. Clinic: Peach Tree CHC, 123 Long Street, Toronto, ON M3U 5Y5″

Medical Directives & Prescription Medications –  Ensure the pharmacies that your patients go to (whether hospital/inhouse pharmacy or community pharmacy) have a copy of your medical directives. Take it a step further and introduce yourself personally to the pharmacist with a copy of a photo resume, medical directives (with sections marked/highlighted as relevant to the pharmacists), a copy of the Ontario College of Pharmacists Bulletin on PAs (its page 13 and 14), clinic address, at the bottom of the prescription write e.g. John Smith, CCPA “as per medical directive #1a”, your supervising physician name and their CPSO number.

• e.g. John Smith, CCPA, as per medical directive #2a for Dr. Jane Appleby, CPSO # 86070. Clinic: Peach Tree CHC, 123 Long Street, Toronto, ON M3U 5Y5″

Being able to implement a medical directive (and also being able to delegate a controlled act) requires a few things:

• The supervising physician can only delegate an act that they themselves are competent at, and are within their scope/area of medicine that they practice in. They cannot delegate acts that fall outside of this.
• CPSO outlines that the delegate (PA) should be evaluated by supervising physician to ensure the PA has the appropriate knowledge, skill and judgement to perform the act just as well as the supervising physician. How this can be evaluated is a competency checklist. For instance, your supervising physician (or designee) can observe you do a certain delegated act (e.g. performing a lumbar puncture) 10 times, at certain time points. This can be implemented directly into the medical directives. And this can be checked annually, biannually or whatever frequency the practice deems fit.
• You can decline the delegated act for any reason, you cannot be forced by the delegating physician to perform the act.

More information can be found on CPSO’s Delegation of Controlled Acts Page.

Database of PA Medical Directives

The best place to find medical directives for PAs are on the CAPA Members Site under “Resources” > Medical Directives. This database includes several examples of Medical Directives from various areas of medicine including Family Medicine, Hospital (Internal Medicine, General Surgery, Emergency Medicine and Orthopaedic Surgery) and Specialty Medical Directives (Endocrinology, Mental Health, and Oncology).

CAPA members Natalie Dies & Ken Krosby also have put together a generic “Ideal Medical Directives Template“.

The “Ideal Medical Directive” is available to members on the CAPA website

Medical Directives Online

If you google “Physician Assistants Medical Directives” there ARE a few clinics and departments that have PDFs of their medical directives online:

• Family Medicine – Hamilton Family Health Team: List of Medical Directives [example of specific medical directives]
• Family Medicine – Thames Family Health Team: List of Medical Directives
• Family Medicine – Marathon Family Health Team Medical Directives [example or broad medical directives]
• Emergency Medicine – ED Medical Directive Templates from OHA
• Emergency Medicine – Lakeridge Health Team Medical Directives
• Emergency Medicine (Asthma) – Emergency Department Adult Asthma Medical Directive
• INR Clinic – King West: Medical Directives for INR Clinic

This answer is very institution dependent.

Many Community Health Centres (CHCs), Family Health Teams (FHTs) and hospitals have medical directives in place as part of their policy. In instances where PAs practice with a lot of indirect physician supervision medical directives can be extremely helpful.  (e.g. wards, inpatient units, hospital settings, or at a family practice setting where you have your own roster of patients),

In more direct supervision settings, medical directives may not be necessary. 

• RHPA – What are Orders? Directives? and Delegation [includes copy of medical directive template]
• CPSO – Delegation of Controlled Acts
• OHA – Roles and Responsibilities of Physicians Supervising Physician Assistants
• CMA – PA Toolkit
• HPRAC – Physician Assistants: A Jurisdictional Review
• OMA Statement on Physicians working with Physician Assistants