LEARN ABOUT PAs
Clarifying the PA Role
When trying to explain what a Physician Assistant does, there’s usually an elevator pitch I like to use:
A Physician Assistant (PA) is an advanced practice health care provider. PAs perform histories, physicals, order and interpret investigations, diagnose, and formulate treatment plans. They also perform diagnostic and therapeutic procedures, reduce fracture, cast and splint, perform biopsies, and assist in surgery. They educate and counsel patients preventative health. They work under the supervision of a physician.
However, sometimes it’s helpful to understand what does not fall under the PA scope of practice.
Many Canadian PAs have come across PA jobs on indeed.ca, and based on the salary listed and job description it’s clear the employer did not post a true “PA” position.
What can PAs do? Canadian PA Scope of Practice Explained
PAs can perform 12 Entrustable Professional Activities (EPAs). Canadian EPA-PAs outline the tasks or responsibilities that can be entrusted to a Physician Assistant once they have attained sufficient specific competence (AFMC 2016).
In other words, Canadian EPA-PA answers the question: “What can a PA do when they see a patient?”
EPA #1: The PA practices patient-focused, safe, ethical, professional, and culturally competent medical care across the healthcare continuum.
EPA #2: The PA obtains histories and performs physical examinations, demonstrating the clinical judgement appropriate to the clinical situation
EPA #3: The PA formulates clinical questions and gathers required clinical evidence to advance patient care and communicates those results to the patient and medical team.
EPA #4: The PA formulates and prioritizes comprehensive differential diagnoses.
EPA #5: The PA develops and implements patient-centred, evidence-based treatment plans within the formalized physician, clinical team and caregiver relationship.
EPA #6: The PA accurately documents the clinical encounter incorporating the patient’s goals, caregiver goals, decision-making, and reports into the clinical record.
EPA #7: The PA collaborates as a member of an inter-professional team in all aspects of patient care including transition of care responsibility.
EPA #8: The PA recognizes a patient requiring immediate care, providing the appropriate management and seeking help as needed.
EPA #9: The PA plans and performs procedures and therapies for the assessment and the medical management appropriate for general practice.
EPA #10: The PA engages and educates patients on procedures, disease management, health promotion, wellness, and preventive medicine.
EPA #11: The PA recognizes and advocates for the patient concerning cultural, community, and social needs in support of positive mental and physical wellness.
EPA #12: The PA integrates continuing professional and patient quality improvement, lifelong learning, and scholarship.
PAs do that!
Physician Assistants are Clinicians
Physician Assistants are clinicians who work to extend the services provided by a Physician. PAs can be delegated tasks that fall within their supervising physician’s scope of practice.
PAs perform patient assessments – ordering and interpreting investigations, communicating diagnosis, formulating treatment plan, managing patients, facilitating referrals, prescribing medications* and therapy.
PAs also perform procedures – These procedures can be diagnostic or therapeutic. For example, in family medicine, PAs can perform joint injections/aspiration, soft tissue injections, ear irrigation, vaccinations, skin biopsies, etc. In the ER, PAs can perform ocular pressure tests, nasal packing for nose bleeds, injections, reducing and splinting a fracture and/or dislocation.
Read more about specific procedures and details for PAs in specific specialties: Q&A with an Emergency Medicine Physician Assistant and Day in the Life of an Internal Medicine & Critical Care PA.
Physician Assistants help increase patient throughput. Two clinicians (PA and physician) are seeing patients simultaneously. For review of cases, or should the PA have any questions or concerns, the physician is available to discuss and mentor – not unlike what physicians already do with medical learners like fellows, residents & medical students.
As the PA develops experience – the PA’s knowledge and skillset grow and increase. A very experienced PA practices autonomously, requiring very little direct supervision. The physician is always available to provide direction and address complex cases.
The Impact of PAs on Health Care
On a larger health care system scale, PAs can help to save the health care system money while at the same time improving patient access to health care services. This can theoretically free up health care dollars to be spent on other necessary services.
At a family practice for example, a PA can see their own list of patients, while the physician is seeing their own list of patients. A family practice that adds a PA to their practice can expand the number of patients seen, increase number of appoints available while simultaneously decrease wait times to see a primary care provider.
At a specialty practice, a PA can help a specialist physician increase the number of patients seen, decrease the wait times to be seen by a specialist, while simultaneously increase the fee-for-service billing that comes to the practice **
**In Canada, a physician must have “meaningful participation” in order to bill for the patient encounter at 100% of the physician code (Source: OHIP Schedule of Benefits). An example of how this can work:
- Step 1: This means the PA can start the encounter (history, physical, review of investigations)
- Step 2: PA leaves the room & case presents with provisional diagnosis & management plan (or MD reads PAs note on EMR or paper file). The physician then confirms or modifies the plan (or the clinic note)
- Step 3: Physician enters the room to finish off the encounter, (primary assessment and plan, although there may be a quick check of specific history or physical exam points). During this time the PA has started another patient encounter (Step 1).
This model in a fee-for-service setting allows the physician to bill for 100%, with the PA having done 85% of the work in the patient encounter. PAs in Canada cannot independently bill provincial health insurance plans. The above model allowed my supervising physician to triple the number of patients seen, while simultaneously reducing the length of the clinic (6 hours instead of 8), and the physician subsequently did no medical dictation for the clinic afterward as the PAs completed the dictations between the next patient.
In the United States, PAs have billing numbers and do not require physician participation to bill third party insurers. They bill at 85% of the physician fee. The “Incident to” billing is when the physician steps in and participates in the patient encounter, the practice can then bill at 100% of the physician fee. The steps outlined above may occur for PAs that are fresh out of school, but as PA builds competency, it may transition into a more indirect supervision method (MD available in building or by phone if PA needs to consult).
Physician Assistant Education
There are four Physician Assistant schools in Canada. This includes 3 civilian programs, and one military program. University of Manitoba Master’s of PA Studies, McMaster University PA Education Program, University of Toronto (PA Consortium) and Canadian Forces PA Program
Each PA program has their own admission criteria (e.g. undergraduate education, health care experience, letters of reference, etc.) and curriculum. Each of the programs however follow the same general outline: year 1 is didactic learning where medical foundations and clinical skills are established, and year 2 is clinical rotations in various mandatory, core rotations (i.e. family medicine, internal medicine, surgery, emergency, psychiatry, pediatrics, OB/GYN) and elective rotations (i.e. orthopaedic surgery, dermatology, urology, nephrology, cardiology, anesthesia, cardiovascular surgery, etc.).
At present each of the 3 civilian programs in Canada use the MMI as the interview style of choice.
Read the post on How to Excel at the MMI.
Programs in the United States rely on three different methods depending on the school: traditional interview, group interviews, or MMI.
Read our post on PA Admissions in the United States.
What PAs are not
Physician Assistants are not doctors in training
A question I often get asked by patients after introducing myself as a Physician Assistant, “So when are you done your training?” I take this as an opportunity to do some PA advocacy and explain that I am a PA that has been working for 6 years, and that I finished my training. I quickly go through my PA elevator pitch, and explain my scope of practice.
It may be confusing to some because the role looks almost identical to what physicians do – patient assessment, investigations, diagnoses, treatment plans, and performing procedures. However we also work with a supervising physician, which is where the confusion comes to thinking we are somewhere in the medical education pathway to becoming a Physician.
Unlike a medical learner who will go onto become a physician, we will not independently open up our own clinics. Nurse practitioners are able to do this. However, our role as PAs is tied to the PA/MD relationship.
Physician Assistants are not Nurses
PAs are trained under the medical model, nurses are trained in the nursing model. Nurses may choose to pursue PA school or Nurse Practitioner (NP) school. There are some of my PA colleagues who were registered nurses before becoming Physician Assistants.
Read The Differences between Nurse Practitioners and Physician Assistants.
PAs do not compete for nursing jobs, as PAs do not do the same clinical duties as nurses. PA scope of practice is very similar to Nurse Practitioners more than it is to Registered Nurses. In the United States, there are some practices that advertise for a PA or NP for the same position.
Nursing duties can be divided into four major categories:
- Assess patients’ physical, mental and emotional health status. This includes taking history & performing basic physical exams and ensuring appropriate medical documentation throughout the patient’s stay.
- Carrying out physician orders for ordering investigations and initiating a treatment plan. This can mean administering medications, wound care, starting an IV, and injections.
- Monitoring results of treatment and alerting the physician of any untoward outcomes.
- Patient and family education, counselling on treatment plan and preventative health.
Physician Assistants (PAs) and Nurse Practitioners (NPs) would perform detailed patient assessments (histories and physicals) and initiate orders as an extension of the physician. Nursing staff may often consult with PAs and NPs for the supervising physician’s patient (as they would consult with residents, fellows or clinical clerks). These advanced practice providers (APPs – the PAs and NPs) have medical directives and/or a document signed off by authorizing officials (e.g. hospital or department staff, supervising physician, department lead) which outline the APP’s scope of practice.
Physician Assistants are not Medical Scribes
When a physician or PA has to document an encounter with a patient, this can occur in one of several ways:
- Handwritten Clinical Note
- Recorded audio note (provider speaks into dictaphone, which records the audio and sends it to a transcriptionist to type it out)
- Typed Note (in an Electronic Medical Record)
Medical scribes allow the physician to focus solely on the patient without multitasking or spending a lot of time after the encounter recording the dictation or writing/typing out the clinic note. Patients are satisfied, and the clinical notes are always done.
Using PAs as scribes is a waste of clinical training, knowledge & skillset. PAs are able to complete and document their own patient assessments. In fact, in our practice the PAs are quite savvy with EMR, so we complete the medical documentation for the physician, which also saves time and keeps patients satisfied.
Physician Assistants are not Medical Secretaries
What’s unfortunate about the term “Assistant” is that doesn’t quite capture the knowledge, skillset and capability of the PA. There has been a movement in the United States to switch to the name “Physician Associate”.
Employers who are not familiar with the PA role mistakenly label an “Administrative Assistant” or “Medical Secretary” as a Physician Assistant.
Administrative Assistants (aka Medical Secretaries) work on administrative work and organization of the office and hospital. They book patient appointments, book surgeries, fax paperwork, book and schedule investigations such as CT scans or MRIs, submitting billing, appointment reminders, .
Education for administrative assistants include college diploma or degree in medical office administration. In these courses they learn medical terminology and anatomy, as this is necessary when dealing when working with a physician.
Full time earnings of a medical secretary range between $25,000 and $55,000 a year.
Physician Assistants are not “Medical Assistants”
Medical Assistants perform basic tasks such as greeting patients and escorting them to exam rooms, maintenance of medical office supplies, vaccine inventory and office equipment, and keeping the office clean and organized. They often share the administrative workload with administrative assistants (e.g. medical secretary).
Some job postings for medical assistants may or may not include some clinical tasks such as taking medical histories, recording vital signs, taking height and weight, performing simple laboratory tests, and explaining procedures to patients. Information collected may then be used by the physician, PA or NP.
The Physician, PA and/or NP can diagnose, and formulate treatment plans – medical assistants are not trained in clinical reasoning or diagnosing of conditions or ailments.
Education usually includes at minimum a college level degree. If clinical tasks are involved the employer may request the medical assistant have a college-level diploma or degree in medical office administration.
Salary, when last checked on Indeed.ca, was around $40,000 per year for a full time position.
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