Deniece, Family Medicine PA
Deniece is an American trained physician assistant (PA) with a Master’s Degree in Physician Assistant Studies. After graduating, she worked in a Southern California low-income family practice specializing in pediatrics and women’s health.
Deniece moved her family from California to Ontario in 2009 to accept a position as an assistant professor at McMaster University’s newly established Physician Assistant Education Program. At McMaster, she taught clinical skills and problem based learning for 4 years. Now, Deniece is currently a faculty member at the University of Toronto Campus for the Consortium of Physician Assistant Education Program. She is also working as a clinical PA four days a week with a family physician in Hamilton.
Deniece has proudly served as both the President and Vice President of the Canadian Physician Assistant Education Association (CPAEA) and is a member of the PA Integration Committee through the Ministry of Health and Long-Term Care. Throughout her career, she has been fortunate to teach and mentor many PA students and clinicians. Having spent close to 15 years in clinical practice and 9 years as an educator, she has valuable knowledge concerning the struggles facing Ontario PAs.
She is committed to working hard to build a better future for PAs in the province. Deniece enjoys advising physicians and physician assistants on effectively integrating PAs into both practice and hospital settings in Ontario.
Practicing in Family Medicine
I work with a solo physician in Hamilton who is a part of the Hamilton Family Health Team. The clinic works under a patient rostering model.
Why I was drawn to family medicine
I enjoy the variety of presentations that I see each and every day. There is so many diseases to know about, medications, community resources, and the referral process for specialists. It is challenging to stay up to date the guidelines that are constantly changing.
I really enjoy Orthopaedics, Geriatrics, Gynecology, and Dermatology, and working in family medicine allows daily exposure in all of those areas.
I enjoy the patient relationships and building rapport. Typically, I start out caring for a women in the family, and I end up seeing her children, then her husband (eventually, they are a little slow to go to the doctor’s office), then grandparents, and sometimes even her neighbors and friends. I work really hard to keep them as healthy as possible and prevent disease, which is what I am passionate about.
If a patient already has a chronic disease like diabetes, I provide education about their disease at every visit and schedule frequent visits to ensure the best management possible.
A Typical Day in the Life of a Family Medicine PA
9 am to 5:00 PM (or when we are done), where I am seeing patients four days per week.
I see 20-26 patients per day, approximately 15 minutes per patient, a little longer for physical examinations with pap smears and well baby visits.
We try to keep at least six same day appointments available for urgent visits so we can provide better access for patients.
Every day, I chart on patients as I see them (as much as possible), complete forms, review & interpreting diagnostic investigations (x-rays, ultrasounds, EKGs), refill medication requests, review consult notes from specialists, and call patients between seeing patients.
Monday, Tuesday, Thursday and Friday I work in family medicine. On Wednesday, I was working in an Orthopaedic Surgery Clinic and now will being starting another teaching contract for University of Toronto.
Currently, I do not having evening hours or weekend hours, although in the US before I came to Canada I did have one evening clinic I staffed each week. In family medicine I do not have to be on call or do hospital rounds on our patients.
Common Visits & Conditions Seen in Family medicine
Many people describe the demographic in family medicine as ‘cradle to grave’, my youngest patient is 2 days old and my oldest patient is 100. We see a wide variety from preventative health care, acute medical problems, mental health concerns, chronic diseases, endocrine disorders (diabetes, thyroid), ENT, MSK, dermatology concerns, and gynecology are very high on the list of common presentations.
Some common visits/concerns in family medicine:
Well Baby Visits
Anxiety and Depression (mental health)
Paps and Annual Physical Exams
Musculoskeletal (e.g. shoulder pain, back pain, knee pain)
Dermatological conditions (e.g. rashes, suspicious lesions, psoriasis)
Cough/Cold/Flu symptoms
Fatigue
Diabetes
Prenatal Visits up to 28 weeks
Hypothyroidism
Shortness of Breath
Hypertension management
Hyperlipidemia
Sleep Problems
Cardiac patients (CHF, Atrial Fibrillation, post MI)
Neurologic patients (post stroke, headaches, dementia, neuropathies)
Geriatrics / Internal Medicine (fatigue, falls, coordination of care, osteoporosis,)
This does not begin to encompass the scope of everything we see since everyday is very different. My scope of practice as a PA reflects my physicians scope of practice. Although, he does provide most of the care for the chronic pain patients working in conjunction with our pharmacist.
Rarer Conditions
A few of the rare conditions that I have seen include
Huntington’s Chorea
Active Tuberculosis
Ovarian Teratoma
Active Syphilis
Pituitary Tumors
Multiple Sclerosis
HIV
Active Hepatitis C
Elephantiasis
Significant plagiocephaly
Osteogenesis Imperfecta
Gangrene of the toes
Charcot-Marie-Tooth disease
Addison’s Disease
Bullous Pemphigoid
Maggots in an infected wound
Patient having a heart attack in the office
Clinical Tasks
Patient history, assessment, diagnoses and treatment
Physical Exams and Paps
Preventative health (smoking cessation, cancer screening, immunizations, weight management)
Procedures
Review Labs and Investigations
Review consults
Facilitate referrals
Phone patients and counsel on results
Filling out insurance and work forms
Coordinating Care (specialists, CCAC, long term care facilities,)
Liasing with other health care providers to coordinate care, in our office dietitians, a pharmacist, mental health counselors
Assessment and Treatment Plan:
Prescribing medications and medication renewals
Physiotherapy, massage, orthotics, chiropody, OT, compression stockings, and other nonoperative modalities
Referral to specialist/surgeon
In one visit, Deniece address patient concerns, does a lot patient education about COPD, demonstrates use of inhalers, manages blood pressure, and addresses concerns about diabetes. She also does medication reconciliation. (Photo © Anne Dang, canadianpa.ca)
How patients schedule appointments with the PA
When it comes to whether a patient sees the PA or the physician, it really is up to scheduling and patient preference. I tend to work earlier in the day, so if they want an early appointment the patient will schedule with me. The patients can also request a provider, so many times they request to see me. The other factor is that we try to keep them with the same provider if they have already had an initial visit for the same complaint to help with the follow up and coordination of the plan.
Since I provide care for any gynecologic cases and well babies visits those will be booked exclusively with me. For more complex patients I may see them for a couple of visits, then I will schedule their new visit with the physician. I offer same day or next available day, however majority are booked in advanced.
Deniece does about 40 women’s physical and PAPs each month and compliance with cancer screening tests (e.g. pap smears and FOBTs) has gone up!
What should patients expect when they see a PA?
When I enter the patient room I always introduce myself as a Physician Assistant. Sometimes they ask questions about what types of things I can help them with. I let them know the type of patients I see, the fact that we can write prescriptions through delegation from the physician, which is usually is one of their biggest question.
If there is something above my scope of practice, I am able to discuss the case with my physician and we can work together to create a plan for the patient. I function relatively autonomously within established medical directives. Each day, see my own list of patients.
At our practice, the patient can pick, whether based on availability or preference, on whether they’d like to see the MD or the PA. However, not all practices function in the same way when it comes to booking patients with the MD or PA.
My work as a PA in the United States
For my first job in California as a PA, I saw between 20-70 patients per day working in a low-income hispanic speaking clinic. I worked alone in the clinic 4 days a week and with the supervising physician once a week. There were many visits each day for sexual health counselling and screening, birth control, well baby visits, preventative health (pap smears), diabetes management and high blood pressure. I was relatively autonomous starting as a PA, with the physician available by phone. I was in charge of the staff at the clinic.
The second job in California was at a family practice with multiple offices. In our group there were 12 physicians and 9 PAs, and 1 Nurse Practitioner. At my practice location, there were 2 physicians and 3 PAs. I saw between 25-35 patients per day.This clinic was a wonderful place to work where they allowed all the clinicians (MD, PA and NP) to vote on the decisions that impacted the clinicians.
When I first came to Canada, I started at the McMaster StoneChurch Family Health Team. The clinic and physicians were not familiar with PAs. I was happy to introduce them to the role of a physician assistant and explained to staff and the patients what my role in the clinic was. This was a dramatic change from my previous practice where the clinic understood how to use PAs to their fullest potential by having PAs practice at the top of their scope. Orientation at the Canadian FHT involved shadowing, discussing tracking patients, informal discussion with EMR (we used Oscar). I enjoyed having a slower transition into the practice since this was my first job with an actual orientation. I worked part time at this practice while teaching as Assistant Professor at the McMaster PA Program.
After working there for 3 months, they realized what an asset it would be to have a PA full time. I sat on the committee to interview and help the physicians hire a full time physician assistant for our team.
Here Deniece sees a patient for a follow up visit after a trauma crush injury to the finger.
Benefits of Adding a PA to a Family Medicine Practice
Since I have started in my current practice 4 years ago, the clinic is able to have many more patients each day. Each day in the clinic is quite busy, but also very rewarding to help patients. I enjoy working with my team and caring for our patients.
There has been an improvement in the coordination of care and we are able to do much more preventative care since I joined the practice. The patients frequently tell me they enjoy coming to the clinic (which is a strange thing to hear from patients).
They do express feeling comfortable discussing their concerns and getting medical advice. Recently I have had some transgender patients open up about their care and health concerns to me. As I get to know patients and their families more the trust continues to build.
How Often I interact with my supervising physician
We see each other everyday in the clinic. We do make sure to talk about complex cases at least once per week if not more often if we need to. If there are specific questions we do have instant messaging through the EMR system, so we can use that as well. If I have a question and he is not in clinic I can call Dr Dhalla.
The PA/MD relationship is very respectful, collegial and supportive. Since I am an experienced family medicine PA, our working relationship is flexible to provide different levels of support.
Anne: I had the opportunity to interview Dr. Dhalla and ask him about what it has been like to work with Deniece, a Physician Assistant. Here’s what he had to share:
Q&A with Dr. Dhalla, Deniece’s Supervising Physician
What benefit have you noticed since adding PA to your practice?
Dr. Dhalla: A great benefit of having our PA, Deniece, join us is increased access. We see more patients, perhaps more importantly, the quality of service for each encounter is also enhanced. Patients often present with multiple complaints, we must triage the more important ones, while maintaining a patient centered approach. With Denice, both access to care and quality have improved. In addition, she adds preventative care aspects to the patients care.
In my 15 years in practice, I realize that good communication is the foundation of great care. We follow guidelines and interpret tests, and implement recommendations. Sometimes, in the routine, we lose focus of the patient’s viewpoint. When we both see or review patients, we can better reframe our (clinician and patient) goals..
With our PA Deniece, we have better access for same day appointments. This reduces unnecessary ER visits, or walk in clinic use and allows early intervention in the course of an illness. More often, patients benefit from reassurance and counselling, along with health education.
As other physicians are retiring in our community, we have been able to take on new patients and provide care for those who would otherwise not have a family physician. In addition, having Deniece in my practice allows some patients to open up a little bit more than they would to a physician directly. Patients have a connection with Deniece and they feel they can confide their health concerns and worries, trusting that she will listen and help them.
How is it determined whether the patient gets to see a PA or MD?
Dr. Dhalla: It all depends. If a patient is in for a follow-up visit, then every attempt is made to follow-up with the same provider. For well women and children’s care, Deniece has developed a niche, to be able to care and counsel them comprehensively. Over the years, it’s wonderful to watch her connect and interact with the families.
Can you speak to the PA/MD working relationship?
Dr. Dhalla: I am proud to say that we work very well as a team for the last four years. After hiring Deniece we arranged a few days per week for her to shadow me to appreciate my clinical style of practicing medicine. Currently, we schedule a half hour once a week, dedicated time, to review cases. This includes complex case discussion where we work together to create a plan for these challenging cases. It is my role to mentor and support her in the clinic. As practitioners, all of us can continually learn and improve from giving and receiving feedback. One of the things which I have supported is a scope of independence and self-reliance for my physician assistant.
Deniece and I have both work on continually finding ways to improve patient flow, dividing clinical tasks and paperwork since the workload in a family practice is intensive and demanding. We are usually the patients first point of contact in traveling through the healthcare system.
Any suggestions for MDs working with PAs?
Dr. Dhalla: Based on my experience in working with a PA, the training that physician assistants receive in school is excellent. They are trained in the medical model to assess, diagnose and treat patients. In addition, they are also trained to work in teams and evaluate how in each area of medicine they can best help contribute within their scope of practice. It is important to know the areas of need in your clinic before hiring a physician assistant. Then once the PA has started schedule frequent meetings and check ins to ensure you develop trust and a similar clinical style. I encourage other physicians to learn more about this new role in our Ontario healthcare system and determine for yourself if your team may benefit from hiring a physician assistant.
Deniece meets once per week with her supervising physician. In addition, they see each other on a daily basis in the clinic, each taking their list of scheduled patients.
Deniece with her core family practice team includes Inga, office manager (L), Deniece (center) and Dr. Dhalla, Family Physician (R).
Q&A with Office Manager Inga
What changes have you noticed as an office manager since adding PAs to the practice?
Inga: Deniece is very loved and respected by the patients. Our compliance rate for cancer screening such as PAPs and colorectal tests has greatly improved since she joined the practice. After hiring Deniece we were able to offer early morning appointments and additional appointments each day. Patients are grateful when they call in the morning and she has same day appointments to care for them. The kids enjoy coming to the office for their exams and seeing Deniece. Frequently patients comment on their experience in the clinic stating that she really listens and connects with them during their visit. They feel comfortable expressing their health concerns and understand the simple way she explains their disease.
What do you enjoy about working with Deniece?
Inga: Deniece is fantastic! She is easy going and is able to help out in so many ways in the clinic each day. She will ask for additional work when she has a few spare minutes during the clinic and help out wherever there is a need in the clinic. Patients comment that she is very approachable and the allied health care team members enjoy collaborating on cases with her. Deniece is very up to date on the last changes in family medicine. When there are challenges in the clinic she steps in to help problem solve and create a solution. She loves to teach and is frequently teaching physician assistant students, patients and staff about many different aspects of medicine. During our staff meetings, Deniece is able to provide valuable insight with regards to clinic improvements. I am very proud to work on a team with her as our physician assistant.
As a third person observing, what is the PA/MD relationship like?
Inga: They have an excellent working relationship and they frequently learn from each other. Together, they reflect on ways to improve patient care and provide a positive working environment. Each day, I see them work as a team to provide compassionate care for our patients.
PA Practice in the US vs. Canada
It’s quite a bit different, mainly with regards to the scope of practice, funding model (lack of a sustainable model), and understanding and acceptance of PAs by patients, other health care providers and government. It is difficult because you are comparing the United States that has had Physician Assistants for 50+ years, to another Province – Ontario that has had PAs practicing for 10 years. There is such a small number (around 80) PAs graduating from Canadian Universities and the Military DND program each year.
The challenge is making a huge impact with such small numbers. That being said, historically it was a slow process for the United States as well. I imagine if you spoke with those around at the beginning of the PA profession in the US the stories and struggles would be similar.
US vs Canada PA DIFFERENCES
In the United States PAs can apply for DEA numbers which allow you to prescribe narcotics, which is a big difference between Ontario and California specifically.
The medical directives are different in Ontario versus more of a practice agreement for delegation of services in California.
The reimbursement is one of the other biggest concerns. Physician Assistants have billing numbers in California for insurance companies, Medicare and Medi-Cal whereas we don’t have a good funding model yet here in Ontario.
Here in Canada, there has been more team interaction because it is a newer role. As the physicians here in Canada are understanding the PA scope of practice, they have taught me about the nuances of practicing here in Ontario. For example, you cannot get an MRI tomorrow for a shoulder rotator cuff tear, which was one of the fun things I learned in my first week of clinic here in Hamilton. It was a matter of learning how to navigate a different health care system.
For example, I wasn’t used to Orthopaedic Surgeons doing only shoulders or only doing knees, in the practice that we used for patients in California the surgeons all did a wide spectrum of Orthopaedics.
Last but not least, there is more teamwork here in Canada. I have the privilege of working with dietitians, mental health counsellors, pharmacists, and Nurse Practitioners. It’s more diverse collaborative care for the patients which I enjoy.
US vs Canada PA Similarities
I would say it is quite similar how I function daily. At the practice in California I was fairly autonomous. The physicians were in the office most of the time but they were running with their own list of patients. If I needed them I could ask them a question at the end of the day or the end of the week, but there wasn’t a lot of interaction.
Finding work in Canada as an American PA
I had a unique experience because I was hired and moved to Ontario to teach for the PA program. I had a specific visa to teach in the program. I am not sure how easy or challenging it is for other Americans to come up to practice in Canada, however I do get contacted quite frequently by Americans that are interested or have family here in Ontario.
If they are Canadian citizens it is much easier. If they were an American citizen that wanted to move up to Canada to practice they would need to get some type of work visa, and work would need to sponsor them to come up, which would be possible but would be expensive and a lengthy process. Another point to consider if that Ontario PAs are frequently looking for work. With the requirements of the work permit you need to prove that a Canadian is not able or willing to perform the job as a physician assistant.
Tips & Resources for PA Students
Recommended Books for PA students and Clinical Clerks
Advice
Be flexible and learn something new from everyone you meet
Find what area of medicine you are passionate about and pursue it with your heart
Become an advocate for yourself and your profession
PA Advocacy
My roles outside of clinic include:
Ontario PA Chapter President
Teaching – McMaster (Assistant Professor) and UofT (Guest Lecturer, and Clinical Course Director)
CPAEA Vice-President, President and Board Member
Past CAPA Conference Planning Committee Member
Ontario PA Integration Group
Research & Survey Projects about Ontario PAs
Advising hospitals and clinicians in regards to hiring and integrating PAs
Presenting at conferences on the Value of Physician Assistants
