Maggie, Physical Medicine & Rehabilitation PA

Maggie is a Physician Assistant currently practicing in Hamilton working in Physiatry. She works in a busy Physiatry practice both at the Hamilton General Hospital and at McMaster University Medical Centre.

About Maggie

I absolutely love my role as a Physician Assistant. I find that I am able to provide quality care to patients while also impacting the clinical experience and life of my supervising physician.

I really get to do that dynamic role of being a part of a larger team that is able to work together to work efficiently. And really in the end it’s about that patient centred care – having the ability to make a difference to provide patient centred care to all of our different types of patients has been very rewarding for me.

I really enjoy my role as a PA and the diverse patient population that I see and also the many different roles that I have in clinic as well as looking at where to go in the future.

Background before PA School

I did my undergraduate education at McMaster University in Kinesiology, and that was a four year Bachelor of Sciences degree. After that I took a gap year and worked in research focusing on, Multiple Sclerosis and Physical Activity. And that was when I figured out what I wanted to do with my career. After that year of research, I applied to the PA program and started my PA journey in 2015.

Contemplating other careers in health care

Since a very young age, I knew I wanted to be in medicine. I just didn’t know what capacity that was. So doing kinesiology was kind of natural for me – I had a history and background in sports and physical activity and was very interested in that kind of profession.

And naturally after kinesiology, there are a few things that you can focus on:

• Chiropractic care

• Physiotherapy

• Occupational therapy

• Being a kinesiologist

• Medical school,

• and a couple of other different career paths.

I always thought that I was going to go to medical school. So I actually wrote my MCAT, applied to med school a couple of times until I found out about the PA program.

It was in that gap year that I met a PA and was able to shadow her and thought, wow, this career is really excellent and I think it’s something that I’m quite well suited to. So that’s what led me to the PA profession and I’m so happy that I ended up here.

Maggie’s Experience in McMaster’s PA Program

1st year PA School

I found the McMaster program amazing. I wasn’t sure what problem based learning (PBL) would entail. Coming from McMaster’s Kinesiology Program, we did a lot of tutorial small group work. So I already had that experience, but I wasn’t sure how I was gonna feel in full problem based learning.

The first couple of months was very difficult. You really had to adjust a lot of independent, self-learning- but I found that when you figured out how to do that, it was exponentially better than, my undergrad experience, which was typically just didactic, lecture style learning.

I really enjoyed PBL because I found that everyone was able to bring something different to the table.

Once you learn how you can study and what you can give to your peers in a small group, I found that I came out with the knowledge and skills that were kind of lifelong, and beneficial for my career.

2nd year PA School

In clerkship, well, I was all over – I did a few rotations in Hamilton, but I also was in Whitby for Psychiatry; in Toronto for ER; Cambridge for Family Medicine and Hamilton for General Surgery.

For my electives I went back to Toronto for an ER elective, , did an elective at my current workplace in Hamilton at the Regional Rehab Centre.

I also went abroad as well over to India for an elective.

After graduation, choosing where to work

I knew what specialty I wanted to work in. I was always interested in Orthopaedics, Neurosurgery and Physiatry.

I also had early exposure to Physiatry in my undergrad; I worked at the McMaster Wheeler Spinal Cord injury Rehab Centre and all of the people that I worked with had physiatrists. I had early exposure to that and it was in keeping with my kinesiology degree and things that I was interested in. I was debating between the three specialties.

And then when I was able to do placements in Physiatry, I had my heart set on from the beginning.

Securing a PA Position

I did a longitudinal placement (LP) at the Regional Rehab Centre in the Amputee and Prosthetic Division with a Physiatrist and we set up four half days.  I ended up going for about eight half days because I was so interested in it, and really enjoyed the clinical experience.

I then set up a four week elective [in 2nd year PA School] at the Rehab Centres. In that rotation I ended up working with seven different physiatrists.

I got experience in:

• Acute brain injury ward on the spinal cord injury ward

• Amputees and prosthetics

• Sports medicine and general and

• Musculoskeletal medicine.

I got to know a number of the different practitioners there.

And at the end of my elective essentially one of the physiatrists approached me and said, “You know, I’m interested in a PA, is this something that you think we could talk about?“

What is Physiatry?

A lot of people have not heard of Physiatry, also known as Physical Medicine and Rehabilitation

“Physical medicine rehabilitation is a broad specialty that can encompass a number of different subspecialties within it. You can focus on sports medicine, general musculoskeletal medicine, spinal cord injury, acute brain injury, amputee and prosthetics, or spasticity management.”

Physiatrists tend to pick a few of those domains and then specialize in them. It depends on who you’re working with, what you will see.

How Practice Physiatry differs from Other Specialties

Physiatry is a nonoperative specialty. People often come to me and say, “You’re going to do the surgery!“. I have to make it very clear that we are a conservative management, or non-operative.

In Physiatry we work quite closely with the Orthopaedic Surgery service, and we actually manage their patients conservatively – either prior to  or after surgery. However, we would not do a surgery ourselves.

“Physiatry is like a combination of nonoperative Orthopaedic management and Neurology mixed together. We focus on both the neurological system and the musculoskeletal system combined and look at the person as a whole presentation. We can see multiple different types of patients because of the broad scope of Physiatry.”

Common Conditions in Physiatry

We see a wide variety of patients. In terms of our musculoskeletal patients, we’re seeing a lot of:

Hip pathology, whether that’s osteoarthritis, labral pathology or extra articular involvement. So gluteal tendinopathy, bursitis, and other kinds of muscular conditions around the hip.

In terms of shoulders, we see rotator cuff injuries, labral tears of the shoulder and then we’re looking at other tendinopathies of the knee, ankle, elbow, really, really everything. We tend to treat those with a wide range of modalities depending on the patient.

In the sport population we do more acute injury management and return to play from those injuries.

In our spasticity population, we see a number of different diagnoses, but try to provide them with an overall approach to care that will allow them to improve and, and function better in their setting.

Rare Conditions in Physiatry

Well, both in our MSK population and in our spasticity population, I often come across things that I’ve never seen before and they’re rare and wonderful and I find it very challenging and interesting to see those patients.

We see anything from genetic disorders that are causing, muscle hypertrophy to neurodegenerative conditions for example, Friedreich’s Ataxia, or other diagnoses that are very rare.

We sometimes see in it’s a good challenge for us to manage them and communicate with the other providers that are on the team to really be able to manage these patients.

Treatment Modalities in Physiatry

In our Physiatry Clinic, we do a lot of interventional medicine. All of our injections are image-guided. We do:

• ultrasound guided intra-articular injections

• tendon fenestration,

• and other types of procedures to manage joint complaints or other musculoskeletal complaints non-operatively.

We also make recommendations for physiotherapy, occupational therapy. Any rehab recommendations essentially is, is what we would be looking at speaking with the patient about.

“In Physiatry we can coordinate patient care with other specialists that we think should be on the team – so we work closely with Neurosurgery, Orthopaedic Surgery and Neurology to manage our patients with a whole team approach.”

Medications Prescribed in Physiatry

In our practice, we don’t do a lot of overall pain management. We will prescribe short term analgesia for our patients such as NSAIDS or Tylenol, but we do not prescribe opioids mainly because we find it difficult to follow up with the patients.

I’ll often make medication recommendations and start the medication, give them a two or three week course and then have them follow up with their family physician or another attending provider, whether they are enrolled in a chronic pain program, to have that medication followed closely and titrated as needed.

So we will prescribe Gabapentin or Pregabalin for neuropathic type pain.

We will also look at spasticity management with certain types of medications.

We do Botox injections as well for specificity management.

So again, with the medication piece, we will start the medications but often ask them to follow up with their primary care provider to titrate or make any adjustments.

What I enjoy about Physiatry

I really enjoy everything about Physiatry – and I really enjoy this patient population. I find it challenging, I find it interesting, I find it ever changing and I look forward to learning more in the future and see where physiatry goes. It’s still quite a new and growing specialty and there’s lots of research and evidence based medicine coming out around certain conditions that we see – that part is exciting to me to know that I’ll be involved in that in the future and continue to learn more and  be excited about my work.

Challenges in Physiatry

What I find most challenging is the patients that we can’t make a difference for.

In this specialty we often have complicated patients and after exhausting a number of different treatment modalities, sometimes we have to have that conversation that we’ve done all that we can. And I find that very difficult because they are coming to you as the specialist as their last resort, last hope, last intervention.

That can be a burden on us to provide that care and have the answers. And sometimes we don’t. So I find that piece difficult and often I’m left feeling like I wish I could do more. And that just motivates me to continue to be educated and, and do provide the best care I can to my patients.

Working in Physiatry – PA vs. MD Path

• Path to becoming a Physical Medicine & Rehabilitation Physician – When you go to medical school and get accepted into physiatry residency that’s a five year residency. Within their five years they’re doing rotations in a number of different specialties and locations. They get a lot of training and experience in rehab specific medicine, whether that’s with oncology,  cardiac rehab,  spinal cord injury or a stroke rehab. So the residents spend five years getting to do and learn all of those things.

• Path to becoming a Physical Medicine & Rehabilitation PA – As a PA, you’re trained as a generalist after two years of education in the Mac PA program. , when you’re being didactic, when you’re being clerkship, you are out in the workplace and working. So in those first couple of years, the scope is quite small because especially with a limited background in a certain specialty, it’s going to take a little bit to understand the common presentations and the different treatment modalities out there. I found that coming from my background in kinesiology and sports and spinal cord injury, I had a very good base going into my role as a physiatry PA and I was able to pull from my previous education and experience to allow to really fully engage immediately with our patient population. Now if you are coming from a limited background, it’s still doable and really it comes from the support of your supervising physician or team to allow you to continue to learn and be integrated into the practice

Working as a PA in Physical Medicine & Rehabilitation

As a Physiatry PA, I work with one supervising physician. Our practice focuses on a few different things – so we have a sport medicine patient population where we’re seeing high-performing athletes on a regular basis.

We see general musculoskeletal medicine, focusing primarily on hips – as that’s just where the the practice has led that. We do a lot of hip injections but also manage extra articular soft tissue hip diagnoses.

We will also see shoulders, elbows, ankles.. your general MSK presentations.

We also do some inpatient work on the Spinal Cord Injury unit about three to four months of the year.

I find that really interesting and rewarding.

We do a Spasticity Clinic for our patients with spinal cord injury, cerebral palsy, other neurodegenerative disorders, and we do Botox injections and other, allied health care team management for those patients.

(Note: Spasticity comes from the upper motor neuron insult and it can be in patients with a number of different diagnoses. This includes cerebral palsy, spinal cord injuries, stroke, and neurodegenerative disorders.)

PA Role in Physiatry

My role as a Physiatry PA is quite dynamic. Depending on the day I’m doing different things in clinic.

I will see both new consults and follow up patients:

• For a new consult, I will typically see patients, review all of the imaging, do a physical exam, come up with an assessment and plan and then review with my supervising physician so that patient gets to meet him and, review what we had talked about. If there’s any further questions patients are able to ask us at that time.

• In terms of followups – I tend to know the patients quite well. I’m seeing many follow ups that we’ve either done intervention for. And we want to see how that’s going a few months later or followups from diagnostic imaging and reviewing that with the patients and again, coming up with a plan and reviewing with the team what the options are. I do interventions as well, so I’m doing ultrasound guided injections.

We have specific injection days where we see many patients. I’ve added musculoskeletal injections to my scope of practice after working with doctors and being trained by them as well as others who are doing these types of procedures. So I’ve become quite comfortable with ultrasound guided procedures and I enjoy that part of the practice.

Otherwise I’m managing patient flow throughout the clinic.

I’m liaising with the allied health team a lot of the time and trying to provide that comprehensive care for our patients.

Oftentimes I get feedback that the patients enjoy seeing me because we get to spend a lot of time together and talk about their options. And they often feel that things had been explained quite well. Whether I am going through a model of the knee and showed them exactly where their injury was or writing down the plan patients to go home with, which I enjoy giving that to the patients and having them leave feeling good about their appointment.

PA Orientation to the Physiatry Service

My onboarding process was pretty quick because I had done an elective there as a second year PA student – it actually was quite a seamless transition. I already knew how the hospital worked, how things worked from the administration side, and I knew what clinic flow looked like. So I was just up and running when I was hired.

“After the first couple of months working as a new PA grad, I settled into my role and figured out where I could be beneficial to the clinic and to my supervising physician.

We continue to make changes in the clinic in terms of how things are organized and what type of role the PA is playing. Every four to six months we meet and come up with next steps in terms of what we want to accomplish with my role specifically and review what has been going well and what we still need to work on.”

-MAGGIE HITCHON, CCPA, CANADIAN PHYSICIAN ASSISTANT WORKING IN PHYSICAL MEDICINE & REHABILITATION

Physician Guidance & Mentoring During PA Orientation

It was quite a steep learning curve because physiatry is so specialized. Coming from my background, I did have a good base of knowledge coming in. But, at the beginning we worked really hand-in-hand and I was reviewing every patient with him. Oftentimes I would sit in on his appointments with patients and just understand what his decision making process was like and learn more about the different types of patients we were seeing.

The first six months was a lot of learning. We would often debrief after clinic, review any questions that I had and any new diagnoses that we saw that day as well as do some formal teaching sessions on specific conditions that we were seeing. I also attended Physiatry rounds when I am able to, which helps in my ongoing learning.

And I find that physiatry conferences are excellent in continuing to engage in education and working with the residents and students that come through our clinic is always a good way to continue to broaden my scope and, and move forward.

Conferences in Physical Medicine & Rehabilitation

Some CME events that I have attended/am planning to attend listed below

• Canadian Rheumatology Ultrasound Society (CRUS) – MSK Ultrasound Course – highlighted the use of MSK ultrasound in a clinical setting

• Neuromuscular Electrical Stimulation in Neurorehabilitation

• Ultrasound guided injection of botulinum toxin in spasticity – Clinical and Anatomical Concepts

• OMA Sport Med Conference (yearly)

• CAPMR Annual Conference

• MacHand Day

• Fundamentals of Musculoskeletal Ultrasound, San Diego (upcoming April 2020)

• Clinical updates in the management of rheumatological conditions, osteoarthritis, stroke, ABI, spasticity etc.

What its like to work with a PA

Is working with a PA similar to working with a resident?

I think describing us as “permanent residents”, does have some truth to it in the early stages of your career, which I still consider that I’m in. I’ve been working for two years and our scope continues to broaden the more that you work in a specialty and with a specific supervising physician.

“Much like residents, Physician Assistants are able to see patients alongside the physician. We’re reviewing cases, we’re always engaged in education and learning. Mind you, residents are there for a very short amount of time and then they move on. Having a physician assistant in your practice is, is much like having that permanent resident and we are able to cater to the clinic’s needs specifically.”

As a Physiatry PA, I having worked with one supervising physician for the last two years, I’ve found that I very much molded and moved my practice in a way that will help the clinic – whether that’s administration or seeing certain types of patients and taking that workload and burden off of the physician.

The residents often there to learn and much like the resident, PAs are learning, but we’re also providing  that offload of work from the physician and taking on some of the patient load, some of the other workload off to allow physicians to provide more quality care to their patients, but also have a better work life balance in their practice.

Benefits of Adding a PA to a Physiatry Practice

I think there are a number of benefits for any specialty specifically in Physiatry because it’s so specialized and so busy. It’s quite easy to integrate the role of a PA into the clinics.

I do a number of different roles within our clinic, whether that’s procedural, whether that seeing new consults, seeing followups, and that’s able to offload the pressure on my supervising physician. 

We work very well as a team (PA and MD). We look at our day and say, “Where can we or what can we accomplish in this day and how can we make it beneficial for, for both of us for time management and efficiency?”

“I think that’s really what a PA can offer is efficiency within the clinical role. We have changed the way that clinics have ran since I’ve started. Whether that’s changing the length of appointments or the number of patients that are being seen in a day or the type of patients that are being seen to allow the clinic to run a little bit smoother and allow my supervising physician to do the work that needs to be done during the day and not have to stay late afterwards.”

My Practice in Physiatry

I’m primarily outpatient based and we do short stints of inpatient management on the spinal cord injury ward as well.

I feel that a PA would be very beneficial on an inpatient rehabilitation unit, whether that’s with a spinal cord injury, brain injury, amputees and prosthetics. We could function much like that point person for the ward.

Similar to an internal medicine PA or an Orthopedic surgery PA where you’re managing those inpatients and then liaising with the Most Responsible Physician (MRP). I think a PA would be very valuable in that role to allow to offload some of the burden on the physicians to be there every day and rounding on patients and managing all of the medical co-morbidities that come with certain rehabilitation diagnoses.

Our patients are medically stable, but they’re often quite complicated and require a lot of work and management as well as following them through their rehab process and getting them discharged home in a safe and effective manner.

Offloading Admin Work off of the Physician

I’ve taken on dictation, medical documentation, medical legal forms, return to work forms, etc.

Oftentimes I’m the one that’s liaising with patients or families or allied health care team members to get things done. That is often something that I take on to take that burden off of my supervising physician, which he quite enjoys because as we know, forms are not always our favourite things to do – but it is a way that a PA can be beneficial in their role.

And because I know the patients quite well, it’s often easy for me to fill out those forms or make the call to someone to, you know, figure out what needs to be done. So I am doing quite a bit of that in clinic, which comes naturally when you do take on the patient load.

Working with PA Medical Directives in Ontario

Anne’s Note: PA Practice varies between provinces. At time of Maggie’s interview, PAs are not yet regulated in Ontario and function under direct or indirect physician supervision. Medical directives allow PAs to function with a relative amount of autonomy, without requiring physician participation in every single patient encounter/order. Other provinces that use PAs may or may not have formal “medical directives”, but have documents outlining PA scope of practice (e.g. what a PA can and cannot do with patients, medications they can prescribe, investigations they can order, procedures that be performed, etc.)

Maggie: I’ve implemented PA medical directives in my place of work and was able to pull from the current medical directives in different areas such as ICU and other outpatient locations to make my own medical directives.

It was quite a process and took a number of months to implement. But now that the PA medical directives are in place, it’s very helpful to have that written scope of practice to be able to refer back to both in my ability to do documentation within the clinic, but also order prescriptions, order diagnostic imaging , etc. So the health care team is aware of what I’m able to do because its in the PA medical directive – so I find that helpful.

Maggie’s Practice as a PA

Teaching

I am involved in teaching/precepting PA students and other medical learners. I’ve had a number of longitudinal placement students come and observe for the half day.

“I always recommend Physiatry as a placement, whether it’s a half day or a full elective to any PA’s that are interested in Family Medicine, Emergency Medicine, Orthopaedic Surgery, Neurology, because we really see it all.”

-MAGGIE HITCHON, CCPA, CANADIAN PHYSICIAN ASSISTANT WORKING IN PHYSICAL MEDICINE & REHABILITATION

I find that our musculoskeletal teaching in the PA program and in the medical program is quite limited.

Anytime you’re able to get that experience in a clinical setting whether that’s review your history, taking your differentials, your physical exam – I find that that can be very helpful for students going forward.

I enjoy having students and teaching and imparting what I’ve learned as well as my PA journey – showing them how a PA can work in this type of clinic I find is rewarding for me.

Looking into Quality Improvement (QI) Projects as a PA

I am not currently involved in quality improvement projects or research right now, but that is something that my supervising physician and I talk often about  – its something that I’m looking to pursue in the future.

Specifically looking at the implementation of a physician assistant in physiatry and how that’s changed our practice, – whether we’re looking at time to follow up time to consult or number of patients seen.

That’s something that I’ve been working on gathering that information as well as research in our clinical population. So I’m looking forward to being involved in that in the future.

How I see my PA role evolving

The last two years has been quite dynamic and we often have been changing my role every four to six months implementing new types of clinics or have me seeing new types of patients.

I will say that I’m constantly looking for the next step and how to continue to improve things.

“As a physician assistant, you’re rarely stagnant and you shouldn’t really ever be just comfortable in one place because you’re always looking at improving the patient experience, improving the efficiency of clinic and how to continue to grow in your role.”

Physiatry Resources for On-the-Job Learning

I use a number of different resources in my current role, a lot of it being online resources as well as textbooks that have actually been recommended to me by residents and my supervising physician, other people that I’ve worked with, whether that’s guidance on ultrasound guided procedures and referring to the text or online resources.

I find that the conferences and educational opportunities are great at both enhancing my learning, but also you come out with a number of different resources and options for going forward.

I really have a large collection of things that I use on a daily basis to reference.

Final Notes

Tips for Students contemplating PA vs. MD

I do have students who ask me if they should apply to medical school or the physician assistant program.

I try to explain the difference between the two. And I say to students that if you think that you want to be a practicing physician and that’s your passion, then absolutely follow that goal.

The physician assistant program is not a stepping stone and it is not an alternative to being a physician. It truly is a different profession and a different role in healthcare.

I think you really have to do a lot of exploring in terms of what that means.

I advise students to talk to practicing physician assistants, shadow them if you can, to understand what the role is in clinical practice – now that can vary across different specialties.

PAs are doing a number of different things in their clinical practice. The options are broad, but I recommend that they really explore what that, what that difference is in the clinical role and, and figure out what’s, what’s best for them and what they want in their future.

Tips for PA students interested in pursuing Physiatry

If you’re a student and your interest in physiatry get as much exposure to it as you can, whether that’s doing longitudinal placements, setting up a clerkship elective or just speaking to physician assistants who are involved in the specialty or other health care providers that work in physiatry to truly understand, what the different types of physiatry are, the divisions there are and how you think you would be implemented into that practice.

I found that the best thing for me was doing that elective and placement there to understand what it was all about.