Natalie, Otolaryngology, Head & Neck Surgery PA
Natalie Dies, a McMaster Physician Assistant graduate who works in Otolaryngology, Head and Neck Surgery. She discusses how she stumbled upon the PA profession in Canada, working in different specialties, and life as a PA in Alberta.
What is Otolaryngology, Head & Neck Surgery?
Natalie currently works in Otolaryngology, Head and Neck Surgery (OHNS). This was formerly known as “ENT” (Ears, Neck and Throat) but the medical field is moving away from use of that term.
OHNS as a field is quite subspecialized. Natalie previously worked in cardiac surgery for one year, 3 months in Geriatrics which was a little stint just to get her toes wet into primary care. Prior to that, General Surgery with a focus on colorectal and surgical oncology.
A Typical Day in the Life of a PA in OHNS
Natalie works Monday to Friday, 7:30 to 3:30 PM.
6:45 AM: She arrives 45 minutes early, as this has allowed her to work on outside projects including a podcast, reading journal articles, or working on research.
7:30 AM: She then attends a teaching session where residents or staff give lectures in Otolaryngology and Head and Neck Surgery.
8:30 AM: The OHNS team runs the list and disperse, that is when the patient care starts for herself.
9:30 to noon – Natalie spends her time on the ward, managing 20-30 patients on the floor. This allows for residents to attend clinic and the operating room. If there is time, she goes to clinic 2-3 times per week or help the on-call resident manage issues that come through the pager including nose bleeds, tracheostomies, or acute airways.
The procedural care on the ward can include tracheostomy changes, decannulations, pulling any percutaneous drains, writing orders, following labs, replacing electrolytes, etc.
“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).”
Natalie also occasionally first assists in surgery if the residents are spread out.
At the end of the day she runs through the list again. She then sends a summary of handover over secure email and goes home.
Common Conditions Seen in OHNS
OHNS is divided into further subspecialties:
Rhinology
Facial Plastics
General ENT
Head and Neck
Paediatric OHNS
Natalie is allotted to head and neck, which deals primarily with Oncologic presentations. This includes 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, she will see patients with epiglottitis and neck abscesses.
Rare Conditions in OHNS
“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.”
Natalie does see unusual penetrating traumas that are rare (e.g. “I fell onto the knife and now it is in my neck”). She has also seen Neck Necrotizing Fasciitis, and profound sepsis from pharyngitis requiring intubation and surgery.
Working in a Multidisciplinary Team
Natalie works on the OHNS team, which is a smaller department compared to other surgical services. She works alongside four staff surgeons. Some of the staff surgeons are more hands on while others are hands off when working with a PA. Her practice is influenced by the department’s understanding of the PA role, as well as educating and teaching staff about what PAs can do.
Natalie works well within teams, and as a PA she manages the lower-level decision making on the ward. However, acute issues go directly to the chief resident. She cares for a broad range of patients including palliative care and active patients.
Natalie enjoys working 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. I see how hard these individuals work and to better themselves in this specialty, and I get inspired by that.”
Practicing as a PA in Alberta
Integrating a PA into OHNS
Natalie spent two weeks in each subdivision of OHNS (rhinology, facial plastics, head and neck, general ENT, paediatric OHNS, and facial plastics. At each two week interval, Alberta Health Services reviewed her performance. After six weeks, it was determined that Head and Neck Surgery required the most help, and she started on July 1 in the new academic year with the new incoming residents.
PAs in Alberta do not utilize medical directives.
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.
On April 2021, PAs came under regulation of the College of Physicians and Surgeons of Alberta.
Working in Alberta
Natalie originally completed her PA program in Ontario. She noted that there were several organizations there that communicated job opportunities, including HealthForceOntario, McMaster University and University of toronto’s PA programs. However, Alberta does not currently have a PA program, and is lacking a current provincial designated PA project.
Fortunately Natalie had little difficulty in achieving the position here in Alberta. From Natalie’s experience, networking is important for finding a PA job role in Canada.
“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.”
Growth Beyond the Clinic
The Ideal Physician Assistant
To Natalie, an ideal Physician Assistant “is someone who is a self-starter, someone who likes to reflect on their behavior 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.”
How PAs can get involved with research
Natalie is a self-starter, and has been involved in different research projects, and poster presentations presented at CAPA.
She has done various poster presentations over the years examining PA practice.
Her approach is to look at how the practice was before a PA was present, and then measures how the practice changed once 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 can help you get started in Research
Natalie suggests speaking to your supervising physician(s) if you have an idea for a research project.
“You can also 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.”
Natalie states the research process is an opportunity to be creative, to find ways that you can measure your contribution. She suggests seeking mentorship and track outcomes.
Resources for Statistical Analysis
A physician mentor of Natalie’s suggested two statistic books to get a foundation of interpreting statistics from studies in the medical literature and for quantitative research:
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 qualitative research, Natalie suggests measuring outcomes on a liert scale (e.g. 1-agree, 5-disagree).
Edmonton PA Journal Club
PAs can also participate in journal clubs. Journal clubs is a place where clinicians gather on a regular basis to discuss publications from peer-reviewed journals. Typically the publications focus on something related to clinical practice.
Natalie has been participating in an Edmonton journal club organized by a PA (Cindy). They meet once a month where PAs have an opportunity to present, review articles and critically aclaim them.
