Physician Assistants:

• Educated in the Medical Model
• Bachelor or Master’s in PA Studies
• Regulation is dependent on jurisdiction
• Non-independent practitioner
• Practices in all areas of medicine

Nurse Practitioners:

• Educated in Nursing Model and Medical Model
• Bachelor’s in Nursing, then Master’s in NP Studies
• Regulated Health Care professional
• Independent Practitioner
• Practice in all areas of medicine

What is a Physician Assistant?

Physician Assistants (PA) are highly skilled health care professionals educated in the medical model who practice medicine.  They graduate from a Baccalaureate or Master’s Degree program that may be affiliated with a medical school. PAs practice medicine under the supervision of a licensed physician within a patient-centered health care team. PAs can work in any clinic setting to extend physician services, complement existing services and aid in improving patient access to health care.

• PAs conduct histories, physical examinations, order and interpret investigations, perform diagnostic and therapeutic interventions, diagnose and treat illnesses, and educate patients on treatment options and counsel on preventative health
• PAs assist in surgery, prescribe medications, and perform procedures that fall within their scope of training and experience, as long as it falls within the scope of their supervising physician
• A PA’s practice mirrors that of their supervising physician
• PAs work to extend physician services, but are not independent practitioners

What is a Nurse Practitioner?

A Nurse Practitioner (NP) is a registered nurse, with some working years of experience who has completed graduate level of education to provide health care to patients^[1]. The Nurse Practitioner program is a Master’s level program. NPs also write another licensing exam to practice as Nurse Practitioners.

NPs have a scope of practice that is broader than what they are able to do as Registered Nurses (RNs). NPs have additional authority including diagnosing, admitting patients, treating and discharge patients from hospital. NPs can also order diagnostic tests, and lab tests. NPs can work independently without a supervising physician. In Canada, Nurse Practitioners can also prescribe all medications including controlled substances and Narcotics.

[1] NPAO. What is a Nurse Practitioner? Accessed Feb 1, 2019 https://npao.org/about-npao/what-is-a-np/

Physician Assistants are often confused for “doctors in training”, administrative assistants/medical secretaries, or other clerk like roles because the name “assistant” is misleading. PAs are advanced practice providers who practice the same medicine physicians do, but do so in collaboration with/under the supervision of a physician.

The patient may see the PA without seeing the physician, or see the PA and MD in one visit depending on the setting, practice, and workflow.

Nurse Practitioners – Some patients think that you need to see the MD once the Nurse Practitioner has finished assessing you. As long as the condition or presentation falls within an NP’s scope of practice, knowledge and judgement, NPs can see a patient without physician involvement. If not within their scope of practice, the Nurse Practitioner will make the appropriate referral when it is outside their scope of practice just as a family physician would.

Physician Assistants have been in Ontario since 2007 at the start of the Ministry of Health and Long Term Care for Ontario (MOHLTC) as part of a PA demonstration project to evaluate impact of PA’s in Ontario recruiting Internal Medical Graduates (IMGs) and PAs trained in the US. They have been supported by the Ontario Medical Association since their introduction to Ontario.

In 2008, two PA education programs were launched by McMaster University and PA Consortium (University of Toronto Medicine, Northern Ontario School of Medicine and Michener Institute of Applied Health Sciences).

Military-trained PA’s have been working in the Canadian Forces for over 50 years graduating from the Canadian Forces Medical Services School at Borden, Ontario.

Learn more about the history of PAs in Canada at the CAPA website.

Nurse Practitioners have a 40-year-history of working in Ontario (since the 1970s). They were originally pioneered to expand the RN role in remote communities in Ontario. The Nurse Practitioner profession began in Community Health Centres (CHCs), with its origins being Registered Nurses practicing with an expanded scope to serve the needs of patients in rural communities.  Although not called NPs at the time, the work these RNs did resembles what NPs do today.

There are 3300 NPs in Ontario as of Feb 1, 2019. In Canada there are currently over 4000 NPs.

Learn more about their history at the NPAO website.

Physician Assistants: To become a PA, you are required to complete a minimum of 2-4 years of a university undergraduate degree (with some “recommended” courses), a minimum GPA, and if you are interested in PA Consortium (University of Toronto, NOSM, and Michener) then you are required to have 910 hours of health care experience (which is not a requirement of all PA schools, but there are many examples of PAs who had previous health care experience before becoming PAs). You also require a GPA of 2.7-3.0 or higher on the OMSAS scale. You do not need a science undergraduate degree to apply to the program. Nurses may also apply to become PA’s.

• In Ontario, there are two schools that offer PA programs, both are Bachelor’s degree in PA studies. Manitoba’s PA program offers a Master’s Degree.
• Education is based on the medical model
• Program length is 24 months. The first 12 months includes basic medical foundations, and the second year consists of clinical rotations through different areas of medicine. You cannot bypass any aspect of this training, and this applies irrespective of your experience or background.
• PA education is not tiered. Once a PA graduates, they are open to practice in any area of medicine (whether surgical, generalist or non-surgical specialties).

Nurse Practitioners must complete a Bachelor in Nursing first, then apply to a Master’s in Nurse Practitioner studies. The NP programs are competitive to get into and requirements differ between different programs. An example of what they may require includes: minimum 2 years of direct RN nursing experience in the last five years (3640 hours) with a GPA of B or higher in an undergraduate nursing program.

• There are three different specialty certificates (Primary Health Care, Adult and Paediatrics) with different universities offering the different programs (NP-PHC, NP-Adult, NP-Paediatrics).
• There are several schools in Ontario that offer the primary health care NP program, admission requirements differ between each school. At time of writing they include: Lakehead University, Laurentian University, McMaster University, Queen’s University (satellite site: Trent University), Ryerson University, University of Ottawa, University of Western Ontario, Windsor University and York University.
  • 9 of these schools provide NP-PHC (Nurse Practitioner – Primary Health Care) as a consortium of education, so you receive the same education if you take this track regardless of which university you attend.
  • University of Toronto is the exception as they have their own NP-PHC / primary care program which they call a global health program.
  • University of Toronto also has an NP-Adult and NP-Paediatrics certification, which leads to NP jobs primarily in hospital.
• Education is based on the nursing model AND the medical model. You can learn about course material here.
• Study is 2 years, consecutively. Education includes practicum placements, clinical placements and didactic classroom work.
  • In Ontario, the NP-PHC is a hybrid program, with some courses done online and a requirement for weekly on site sessions.
  • For the University of Toronto PA program, NP-PHC is essentially online but students are required to be on site in Toronto 1-2 weeks at a time at least twice each year for more intensive parts of the curriculum.

Physician Assistants and Physicians learn from the medical model, or what is traditionally thought of as the “disease” model of learning medicine. This includes approaching disease from the perspective of basics of anatomy & physiology, pathophysiology,  pathology, pharmacology, epidemiology, etiology, investigations, clinical presentation, and treatment.

To explain the medical model, we first have to look at a little bit of history to understand where this model comes from. The “old medical model” as described by psychiatrist Dr. George Engel in 1977, is a disease-oriented model which describes disease is a result of abnormal biological functioning (deviation from normal anatomy, physiology & molecular biology)^[2]. Restoration to normal functioning relied on the physician to correct the abnormality.

Jonathan Fuller in a 2017 paper titled “The new medical model: a renewed challenge for biomedicine”, he describes a newer medical model that incorporates prevention of chronic disease, and use of evidence-based medicine. And evidence-based medicine is in reference to clinical research, epidemiological evidence.  The goal of the new medical model is to “cure, prevent or manage the disease”.

In combination with the PA/MD’s assessment – patient history, physical examination, ancillary investigations, the physician/PA can diagnose the underlying problem and correct the dysfunction with a treatment plan (which may include different treatment modalities – patient education, counseling, therapeutic procedure, medication, encouraging lifestyle changes, topical or oral medications, injections, etc.)

Medical and PA programs today have moved towards patient centered, and interdisciplinary care, and away from physician paternalism.

[2] Engel GL. The need for a new medical model: a challenge for biomedicine. Science 1977;196:129–36

Nurse Practitioners learn in the nursing model and medical model. The nursing model is the foundation of holistic, whole person care. There is a biopsychosocial approach looking at patient needs across the whole spectrum – from cradle to grave regardless of diagnosis. And with training as nurses first, NPs focus on those patient needs, and not just the medial diagnosis.

When completing the Nurse Practitioner education program, students begin to focus on assessing, diagnosing and treatment disease, with some of the basic medical foundations but coming at it with a nursing focus.

Physician Assistants are qualified to write a licensing exam once they complete their PA certification. From there PAs have to meet annual minimum requirements of Continuing Professional Development (CPD) credits in the form of hours spent in coursework, conferences, working towards a Master’s, journal reading, and more.

Once PAs are Canadian Certified Physician Assistants (CCPAs), they do not need to write a re-certification exam.

For Nurse Practitioners once you are certified there is no re-certification exam to be completed. In the province of Ontario, NPs have mandatory Quality Assurance (QA) Programs, we do have to do annual QA as per regulatory programs.  Each province will have its own QA program. In Ontario, every regulatory health college is legally required to have a QA process. In Ontario, CNO has one that NPs are required to participate in annually, and may include an OSCE for some.

CNO is part of the QA program. NPs are expected every year to complete a learning plan, and in the process identify areas they need to expand their knowledge and skill in. And based on their r learning to participate in continuing education activities.

CNO requires nurse practitioners to maintain patient contact in a clinical setting in order to keep their license.