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:

• Adding a PA Dwayne Lyall to her Barrie Family Health Team practice allowed Dr. Darlene Bilawski to increase her roster by 500 patients and offer same day appointments.
• In Winnipeg, Manitoba, PA Scott Naherniak and Dr. Permack  share a panel of patients, round on patient in the hospital, work together in clinic and perform home visits.
• In a busy downtown Toronto Clinic, Dr. James McNally added PA Chris LeBouthillier to his practice and has been able to “increase appointment availability, shorten wait times, and expand a larger patient roster. With PA Chris onboard, Dr. McNally is able to spend more time on complex patients, while Chris is able to help keep the patient queue going without falling behind.” Adding a PA to his has practice has been able to help decrease physician workload and assist in prevention of physician burnout.
• Introduction of a PA into an infectious disease service at Toronto East General Hospital decreased time from consultation to 21.4 hours to 14.3 hours, decreased length of stay by 3.6 days, with no change in mortality in either cases or controls.
• In surgery, surgeons can delegate pre-op evaluations, orders, investigations to the PA. PAs can also act as surgical first assists.

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

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.
• 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.
  • In Ontario, they can prescribe medications under established medical directives. In Manitoba, PAs are regulated and do not require medical directives to prescribe.
  • 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.

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.

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.

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.

• 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.

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.

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.

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.

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.