PA PROFILE • BY NATALIE DIES, CCPA

Natalie Dies

I am originally from British Columbia, but did my undergraduate degree in the United States through a tennis scholarship. I  found my way to Ontario. I did my Master’s in St. Catherine’s at Brock University. I learned a lot, gained a lot and I knew I wanted to leave the academic world. I haphazardly stumbled upon the PA Program and applied. That worked, it was easy enough since I was already in Ontario –  to head to Hamilton. I graduated in 2012 and it’s hard to believe I’ve been working for that long. I’ve worked in Toronto, Winnipeg and now Edmonton

On my graduation day from my Masters thesis, I bumped into my program director. A Class of 2011 graduate from McMaster had also also finished her kinesiology degree and was in the same Master’s program as I. The PA Program Director asked me what was next. I didn’t think I wanted to do my PhD at that time. I knew I was going to take a year off regardless. I need to figure out what I wanted to do. “Well Laura has applied and made it into this Physician Assistant program” I said “oh what is that!”

I had written the MCAT that year, I performed poorly – it was at the same time as my dissertation. So I didn’t get in Canada, and I got in abroad. That was a big insecure step, so I said, why not try one more time see if medicine is really what I want to do. I stumbled upon the PA program, and I know the admissions process is much more challenging these days.

Is PA for me? Absolutely. I have such an active lifestyle, I’m still able to practice in the awesome specialties that I have, I’m working with the best of the best, I am on cloud-9. Job satisfaction is a big part of my life. I don’t have any children. I have three dogs and a better half, and when my job is happy, everyone in my community is happy.

Currently I work in Otolaryngology, Head and Neck Surgery. This was formerly known as “ENT” (Ears, Neck and Throat) but surgeons are staying away from that term. The field is quite subspecialized. Previously I was in a cardiac surgery for one year, 3 months in Geriatrics which was a little stint just to get my toes wet into primary care. Prior to that, General Surgery with a focus on colorectal and surgical oncology.

I am Monday to Friday, 7:30 to 3:30 PM. I always arrive 45 minutes early, this is key as it has allowed me to work on outside projects. I will work on my podcast, read journal articles or work on research and just give myself 45 minutes to start my day. Then I have an awesome teaching for 1 hour from 7:30 to 8:30 AM. I am very fortunate to have that. The residents or staff will give lectures in Otolaryngology.

8:30 to 9:30 AM we run the list and disperse, that is when the patient care starts for myself.

9:30 to noon – We try to get the residents to the operating room and/or clinic as soon as possible. The procedural care on the ward can include tracheostomy changes, decannulations, pulling any percutaneous drains, writing orders, following labs, replacing electrolytes, etc.

We “put out fires” as they come. We have fresh tracheostomies on the ward so there are always things that can go wrong, which includes persistent desaturations that require readmission to the ICU. Dealing with acute issues as they arise. I try to get clinic myself, sometimes two times per week, otherwise the ward is quite demanding.

The resident team that I am on only has three residents on at a time, and we have two hospitals that they operate in. I often find myself alone on the ward;  it is my role to manage the 20-30 patients depending on how many we have. If there is time, I get to clinic. If there is time I will help the on-call resident as there are a lot of issues during the day that they have to deal with, including nose bleeds, tracheostomies, or acute airways.

I actually serve as the first contact point for the attending surgeon who takes all the consults from the Emergency Department and outpatient settings. Our catchment area in Edmonton is huge, so we take consults from NWT, Yukon, British Columbia. Anything west of Winnipeg comes to us, and anything East of Winnipeg comes to Toronto. From my understanding those are the two primary centres for OHNS in Canada (although I am uncertain about how Winnipeg handles OHNS).

The surgeon will contact me with any Emergency consults that come. I have to recognize how urgent it is and find the junior resident that is on-call that day, and clarify if I can get started on that consult while we’re waiting for them to come through STARS (which is similar to ORNGE helicopter transport).

At the end of the day I run through the list again. Otherwise I send a handover blurb over secure email. I am very fortunate because once my 8 hours are done I get to go home.

Similarly, if you picture a medical student model learning with the residents, I am very happy to go and start the consult, pre-admit people. I am not directly  involved in call, but because I am the continuity it is easier for the surgeon to contact me, and I disperse out the consult. This is opposed the surgeon having to be on top of the call schedule which changes all the time with the residents.

Priority for OR time does go to the residents. I want to get residents to the OR to enhance their operating ability. I did have more OR time in Toronto, however, it is more procedural on the ward. Between the Respiratory Therapists and myself, I will volunteer to do the tracheotomy changes so I can keep up with my skills.

I occasionally do get the opportunity to operate if there are multiple rooms or the residents are spread out.

In OHNS is quite a large division

• Rhinology
• Facial Plastics
• General ENT
• Head and Neck
• Paediatric OHNS

I am allotted to head and neck, so this is the Oncology side of things. The most common thing is any malignancy between nasal/oral cavities to skull base, down to the larynx and hypopharyngeal area.

For instance, laryngeal cancer, oropharyngeal cancer, and tongue cancer.  Acutely on call, we will see patients with epiglottitis and neck abscesses.

Poorly healing neck incision post-laryngectomy.

We do see unusual penetrating traumas that are rare, but when it happens it’s interesting. For example,  “I fell onto the knife and now it is in my neck”.

Neck Necrotizing Fasciitis, which involves debridements which I’ve seen several times.

Leeching an auricular hematoma

Another case was severe, profound sepsis from pharyngitis, which is scary requiring intubation and surgery just from a pharyngitis. As benign as some of the conditions our primary care colleagues see, we see the more extreme ends of the spectrum of common, benign conditions like pharyngitis in OHNS.

I don’t do Paediatrics. I got to do two weeks with each subdivision in OHNS which was a great introduction to the role. During the day they have  a Paediatric day call resident.

Our chief residents change every 3 months. In a given year I will have four different leadership opportunities where that individual is my go-to person. The intimate residency program makes it easier to accommodate to what their preferences are. Whereas if you have a larger program, I know one of my colleagues is in Urology, which is a big program. That can be challenging with a lot of resident turnover.

Most of my resident team and two attendings.

In OHNS we have a smaller service. The staff that I work are four male staff, we get along fantastically. I’m so fortunate to be in a prestigious academic centre. The criteria to work at this hospital, they have to be considerable leaders themselves. Their resumes and CVs are so impressive. So I am working with fantastic, lovely people, and I am super lucky.

It does absolutely get challenging. Some are more hands on while others are hands off. I know them well enough, for this decision I can make it on my own and review it after the fact, or do I need to talk to them first before making a decision. It’s understanding as your role as a PA. I don’t want to step on toes, you need to know how to navigate yourself through making a decision.

As early on in our career, I do not mind working in teams. I manage the ward in lower-level decision making, but for the acute things, that has to go through the the chief resident. Early on in our career, being on the academic centre on a resident team you would not find in a community position. I’m so grateful for the rounds that I get to attend. I have the privilege and opportunity for caring for a broad range of patients including palliative care and active patients.

I like being on a resident team. They are studying for their exams and it encourages me to study. If you are in a one-on-one community practice, the onus might more be on yourself to take initiative. But when I am in this environment of quizzing each other, pimping each other, PGY5 are so stressed studying for their exams in 2 weeks. I see how hard these individuals work and to better themselves in this specialty, and I get inspired by that.

The department was flexible in terms of what they could see the PA role doing. They knew they needed help with the Head and Neck subdivision of OHNS department, we knew that ultimately that was going to be my destination. As previously mentioned, I spent two weeks in each of the different subdivisions of OHNS. At each two week interval, Alberta Health Services wanted a review of my performance and evaluation.

Every two weeks for the first six weeks I had a lot of feedback. After that six week rotation, I started July 1st which was the new academic year with the new incoming residents. It was new for everyone. I think it’s interesting, we have some residents who had junior experience without me, and now they have junior experience with me. They’ve had that neat overlap, they’ve been able to comment on my role, and how the role has helped. I’ve received feedback on my role on how to improve. We have one ward that is Otolaryngology. I got very familiar very fast.

Instead of medical directives, we have a one page Statement of Supervision that Alberta Health Services had – what you can do and what you are unable to do. It’s certainly not as exhaustive as medical directives and its a vague directive. We are in the works of regulation in the province, there is not as much urgency to modify this document. We know it’s happening, the legislation is still pending. CPSA said we’d be regulated, no one is requiring more documentation. This is certainly not the process that I went through in Ontario.

When you switch specialties it is almost like starting from square one (General Surgery, Geriatrics, Cardiac Surgery, and OHNS). The most difficult transition was after doing General Surgery for 3 years into Geriatrics. I went from academic resident team to primary care. It is more broad learning. I came to learn about myself that I enjoy learning about one  thing in depth. That is why I have sought surgical subspecialties. I like acute care. I have worked in four different specialties. Each time I started in a new role, it a straight, vertical learning curve. However each time I can bring an experience with me into the new role. Although it is new, the adjustment has been less than if I had just started the role.

This role in OHNS is very similar to the PA role I had in Mount Sinai, Toronto. Once again a resident team, dealing with ward management. There is a lot of crossover. Of course, managing conditions in head and neck is different than the abdomen (General Surgery), there are brand new disease processes and learning as you go.

That’s what’s so great about being a PA – it’s that flexibility.

In Ontario we have several organizations that communicate about job opportunities including Health Force Ontario, McMaster and University of Toronto. However, Alberta does not have a PA school here, and lacking a current provincial designated PA project.

Fortunately I had little difficulty in achieving the position here in Alberta. I networked, found the contact I needed to get in touch with, sent an email and they said, “We are interviewing for these two positions, are you interested?” And within 7 days I was on the phone with two surgical staff. I am so grateful, it was quite easy. I know that if you go to Alberta Health Services, they do have a Physician Assistant jobs tab. Like Ontario, Alberta is divided into zones.

The Health Services Zones in Alberta

Edmonton zone is very forward, progressive and they also hire clinical associates (CAs). There is one gentleman who is our ‘go to’ guy for those roles. I think if you can find your way to him, and his availability, there you can find out about job opportunities that may or may not be posted.

From my experience, networking is important for finding a PA job role in Canada. It may be tough for a new PA graduate who does not know who to contact (which may be an obstacle).

With regards to Southern Alberta, Calgary may be slightly harder to penetrate and I’m not sure why. I don’t know if the zone has a different funding priorities, or if they are leaning towards a CA vs a PA. There are many different possibilities. We’re really far removed from the Calgary zone so I can’t speak to that too much. When the Calgary program comes, which I think has been stalled due to regulation, I think that will certainly help. As for not having academic contacts, that will come with time.

I was born in Alberta, my extended family is all here.  Northern Alberta is fantastic. It was cold this winter but I survived Winnipeg. Edmontonians are incredibly friendly, opportunities are great. It’s been a very easy adjustment for me. It still offers a metropolitan lifestyle but it is not the size of Toronto. I lived in Toronto for 4 years and that became a bit overbearing for me. It’s so easy, in just 45 minutes you are in the outskirts of nature. As an outdoor enthusiast is was a great fit for me. I would advocate for anyone to come and live here.

The civilian PA members are increasing. It was primarily retired military PAs working in Alberta, around the time the PA demonstration project started in Alberta. In the hospital alone, there are four civilian trained Ontario PAs. The others are retired military PAs.

I was very impressed with the presentations in Ottawa. A lot of the Physician Assistants gave the presentations, which has been a shift from our earlier conferences which were mostly physician led. It was so refreshing to see that others are taking leadership, “this is a PA, this is what I’ve learned, this is MY medicine”. If you’re a self starter, and if you’re not afraid, and you are not afraid to be curious and put yourself out there. We are supervised, its negotiating those relationships to ensure you are appeasing your supervisor but advocating for your profession. Having that judgement and having that ability to reflect.

An ideal Physician Assistant is someone who is a self-starter, someone who likes to reflect on their behaviour so they can modify it as necessary. Someone is not afraid to put themselves out there. A lot of places have not had PAs before, so you have to be flexible and willing to overcome barriers / challenges with PA role acceptance.

We have a legislature day in Edmonton that is coming up in April. I have another publication in press by the Canadian Family Physician. Maureen Taylor and I wrote a commentary piece which is pending. Embracing my role, we do it everyday. Being present at work and contributing, that is advocacy as well.

I look at how the practice was before a PA was present, and then how can I measure how the practice has changed since a PA was added. What am I doing as a PA that is improving quality of care, improving physician work-life balance and come up with measures to prove that, ideally quantitatively or qualitatively if you have to. Coming up with a research question (e.g. PICO).

Mentorship is always great. If you have an idea, speaking to your supervising physician(s). Look at previous articles in JAAPA, which is a great publication that we have access to as CAPA members. And we can even mimic some articles, and reference their study protocol. I do think it is quite simple. You can’t expect to be compensated. It does have to be your own intrinsic motivation.

I do have some PA colleagues that say, “I do want to do this, but there are no means to do it”. I come 45 minutes early in the morning to work on research.

I’m doing a clinical trial right now actually, coming up with the ideas, the proposal, the ethics application for that. That is what I do before I start the day. I don’t think it’s difficult. Be creative, find ways that you can measure your contribution, seek mentorship, measure those outcomes. Analysis is always exciting, hopefully you can find a difference.

Put in a poster. I did a poster about changing specialties several years ago. It wasn’t mind blowing or profound, but it was a way to articulate my thoughts in a more academic way. It’s a different style of writing. You get practice presenting it in front of colleagues. I think it’s quite simple. I’m happy to help anyone if they have any ideas, and they don’t know where to get started.

Maybe you can find funding, but I think it has to be from within.

CAPA Poster Presentations in Ottawa, ON

Statistical Analysis. There are two great resources. We have a physician mentor in our Edmonton Journal Club who has provided two great statistics books. Apparently they’re easy reads and awesome. If you know what test you want to do, variables you want to compare, start there:

• 1) How to Read a Paper – the basics of evidence-based medicine, 3rd edition.  By Trisha Grennhalgh
• 2) Using and Understanding Medical Statistics, 4th edition.  By D.E. Matthews, V.T. Farewell

For the trial I am doing now, the statistics are complex. I have approached one of the residents who is completing a PhD. He’s going to help me out with that and of course I would provide him co-authorship if it gets published. That can be daunting, that is where mentorship becomes helpful.

If you are doing qualitative research, measure things on a likert scale (e.g. 1-agree, 5 – disagree). There are ways to measure those. You can keep it simple. If a paper was turned down because of poor statistics or the way the data was analyzed, then maybe you could re-assess things and get help from someone. I’ve sought mentorship from someone that knew more than me, and said, “this is the equation is you have to do, here are your variables, punch in the data, and here you go”. Using SPSS or Microsoft Excel you can get away with it.

One of the PAs has done a fantastic job (Cindy!) who has arranged an Edmonton PA journal club which is accredited through the Royal College. We meet once a month.  We’ve had two meetings now. Our next one is Thursday. We have an opportunity to present, review articles and critically acclaim them. She has done a great job in unifying us. Active military members are coming to this journal club.  There are at least 8-10 of us who are now connected.

The clinical trial I’m doing, I’m seeing if I can improve the discharge process. I need to recruit 32 patients, and I’ve recruited 8 so far. I’m 25% of the way in my patient recruited. By late Spring or so I hope to have data I can start looking at and getting a publication on the go.

Me presenting at the CAPA Conference in Ottawa, ON

I’m still generating podcasts every two weeks, that’s my goal. I am actually going to an ENT conference for PA, so niche, in Arizona at the end of April 2018. I’m starting to look for the States for subspecialty CME opportunities. I’m looking forward to CME that is geared to what I see on a daily basis. CAPA is in Victoria as its my hometown so I can visit my nieces, sister and mom. It’ll be good to see the CAPA community, and just enjoying my summer here, camping every weekend  in Edmonton because my schedule allows it and the city does too.