WHAT IS A PA? • PA vs. OTHER HEALTH CARE PROVIDERS

I had the opportunity to sit down with Rachel Onishi, a stellar physiotherapist who works on the physiotherapy end of our Orthopaedic Outpatient Clinic. Prior to starting at our workplace, Rachel had never heard of Physician Assistants, after working with myself and PA colleagues, she is one of our biggest advocates! I often overhear her explaining how multi-disciplinary the physiotherapy and Orthopaedic clinic is, and how the physiotherapists communicate with the PAs and physicians.

Here I interview Rachel who talks about physiotherapists, how physiotherapists interact with Physician Assistants, and the difference between a physiotherapist and a PA working in Orthopaedics or Physiatry Practice. We were amazed at a lot of the similarities in our patient assessments, special tests, and clinical reasoning, but there are a few places where physiotherapist and physician assistants differ.

We go through what Physiotherapists do, however you can jump right to the comparison of a PA versus Physiotherapists which is near the end of the post.

Physiotherapists practice rehab medicine, which focuses on restoring of function (being able to go back to your activities of daily living). One way to think of it is a drugless treatment (exercise is medicine) of different medical conditions. They work with patients from all age groups, with a wide variety of conditions. Treatment can include health promotion and prevention, acute care and rehabilitation, to disability and disease management. Physiotherapist work with their patients to improve and maintain optimal functional independence and physical performance, and help them manage condition that causes limitations to their activities using therapeutic exercise programs and other modalities.

Physician Assistants practice the same medicine physicians do,  which focuses on assessment, diagnosing, treatment and prevention of disease to maintain good health (across different body systems). PAs may prescribe physiotherapy, however are not involved in the extensive work physiotherapists do with their patients (hands on care, modalities, etc.).  However, unlike physiotherapy there are different operative and non-operative treatments we are looking at: medications, surgery, diagnostic/therapeutic intervention (e.g. a cortisone injection), referral to a specialist etc.

Rachel went to University of Waterloo for Health Studies. While completing her undergraduate degree she was considering medical school at the time. She decided to volunteer at the physiotherapy clinic in her 3rd year of undergraduate study, and from that experience she decided that physiotherapy was the career she wanted to follow. She successfully applied to Queen’s University with a Master’s in Physical Therapy. Following graduation, she worked in private practice and community clinics.

Rachel Onishi is a physiotherapist that works on the “physio end” of the Outpatient Orthopaedic Clinic I work at! Here she demonstrates Patient Education.

I enjoy working in physiotherapy, as it is a very rewarding profession in terms of working with people and helping achieve their functional goals.

Physiotherapists are primary care providers – which means that patients can directly access physiotherapists without requiring a referral. Often patients receive a referral from a physician’s office; however, this is usually for insurance purposes to allow for coverage of the physiotherapy visit from the patient’s extended health care benefits.

This includes:

• New Assessments and Follow-up Assessments (physio history, physical, can be trained additionally to interpret imaging results)
• Therapeutic Treatments may involve:
  • Manual Therapy – hands on, mobilizations (moving a joint passively) and manipulations, soft tissue work
  • Modalities – TENS machine, Interferential current, muscular stimulation, biofeedback, heat, ice, ultrasound therapy, taping, laser therapy, shockwave which help decrease pain and/or swelling, and improve healing
  • Exercise Prescription
  • Patient Education

Description of Physiotherapy in Canada, page 3, 2012 edition

Acupuncture, among treatment modalities, manual therapy and exercise prescriptions are ways physiotherapists help to improve patients’ physical function.

Physiotherapists are regulated health care professionals, which means regulation sets out practice requirements and maintenance of their certificate of registration. Physiotherapy treatment you are receiving can be provided by a physiotherapist or working under a physiotherapist’s direction (e.g. a physiotherapy assistant). Only a registered physiotherapist can use the title ‘Physical Therapist’, ‘Physiotherapist’ or ‘PT’.

Physiotherapists are subjected to auditing by the College of Physiotherapists, which ensures physiotherapists are practicing according to the minimum standards.

Physiotherapists also have access to four controlled acts:

1. Moving the joints of the spine beyond the individual’s usual physiological range of motion using a fast, low amplitude thrust.
2.  Communicating to the individual or his or her personal representative a diagnosis identifying a disease or disorder as the cause of symptoms of the individual in circumstances in which it is reasonably foreseeable that the individual or his or her personal representative will rely on the diagnosis.
3. Performing a procedure on tissue below the dermis, below the surface of a mucous membrane, in or below the surface of the cornea, or in or below the surfaces of the teeth, including the scaling of teeth. (e.g. a Wound Care Physiotherapist)
4. Internal assessment or internal rehabilitation of pelvic musculature (e.g. Physiotherapist with additional Pelvic Health Training)

Source: Controlled Acts & Other Restricted Activities, CollegePT.org

There are different areas a physiotherapist can work in:

• Physiotherapists in respiratory rehabilitation / pulmonary rehabilitation: these physiotherapists may work with patients who are suffering from issues such as COPD, emphysema and chronic bronchitis.
• Physiotherapists in cardiovascular rehabilitation may work with patients who are recovering from a heart attack, heart surgery or other heart conditions.
• Physiotherapists in neuro rehabilitation may work with patients in hospital and in the community who may be recovering from a stroke, spinal cord injury, acquired brain injury, or suffering from conditions such as Parkinson’s, Multiple Sclerosis and ALS.
• Physiotherapists in MSK / Orthopaedics / Sports Medicine  see patients with a variety of conditions which may include such sprains, strains, soft tissue tears, arthritis, fractures, and post- operative conditions to name a few.  They may also treat people with sports injuries, workplace injuries, or post motor vehicle accident injuries.
• Paediatrics
• Wound Care
• Women’s Health
• Critical Care
• Occupational Health
• Education and research

Learning does not stop after physiotherapy school. There are many continuing education courses that physiotherapists can complete, and many different directions a physiotherapist can go in to focus their practice.

For example, these special skills workshops go beyond what is taught in physiotherapy school, some of these courses is just on a weekend, a few weeks, or some a few years. Here are a few examples of some special skills workshops:

• Acupuncture
• Manual therapy courses (i.e. Canadian Academy of Manipulative Physiotherapy: CAMPT manippt.org/)
• NDT for adults with stroke, brain injury and other neuromotor
• Pelvic Health (urinary incontinence, pelvic pain, post and pre-natal care)
• Vestibular Rehab (e.g. dizziness, vertigo)
• Active Release Therapy
• Concussion Rehab
• Golf Rehab
• Taping
• Wound Care

Rachel providing supervision and direction to Yuki, a McMaster Physiotherapy student

I work with the physiotherapy assistant, massage therapist, physicians and physician assistants in our the clinic

• Physiotherapy Assistant (PTA): The physiotherapy assistant helps me complete the treatment plan by showing patient experiences, doing gentle range of motion. I delegate the treatment plan to them and they help me to carry out. I do not have to be present for delegated work, I have to be confident that they can carry this out competently, which I have evaluated.
• Registered Massage Therapists: I refer people to massage therapy for soft tissue work. I do speak with the RMT at our clinic before she sees our initial visit, and how the patient is progressing.
• Physician: We send progress notes to physicians, or call the office if it was urgent to ask for a response. We may also ask about surgical restrictions and post-op surgical protocols.
• Physician Assistants: I basically go to the PA first prior to going to ask the Orthopaedic Surgeons. I tend to consult PAs for imaging questions, exercise restrictions post-surgery, I have helped to facilitate referrals for imaging, we reviewed imaging as entry-level physiotherapists we are not trained to read x-rays (some advanced practice physiotherapists can). We have brought up concerns to the PA about potential infections, poor progression with physiotherapy, any new problems and change in health status. Some benefits of this PA/PT communication is that continuity of care is significantly faster since the PA is more accessible than the physician at our clinic, we would have to wait long or didn’t hear back.

As a physiotherapist, Rachel often collaborates on patient care with other health care providers. Here she is speaking to Steve, a physiotherapy assistant and Sylvia, a registered massage therapist.

Pros to being a Physiotherapist: 

• In private practice I have a lot of autonomy
• Some physiotherapists open their own independent clinics
• Schooling is 2 years (24-25 months) depending on the program, and then you go straight into practice
• Job security is good, many physiotherapists are usually hired from a pool of already employed physiotherapists
• I get to develop rapport with patients, 30 minutes 2-3 times per week for whatever duration, 6 months you get to know people really well.

For me, a reason I decided to go into physiotherapy (instead of medicine) was because of the length of schooling and that that physiotherapists are “drugless practitioners”, they prescribe exercise rather than medications.

Cons to Being a Physiotherapist: 

• Not all of your patients are covered by OHIP – and often you come across patients that would benefit from physiotherapy but do not have third party insurance or extended benefits to cover
• You may work evening hours in a private practice setting
• The job can be physical and you need to take care of yourself

Rachel working on medical documentation after seeing & assessing a patient. 

Philosophy of Care:

• Physiotherapist: Exercise and movement is medicine. Physiotherapists are involved in “Rehab” medicine which involves returning a person to optimal physical functioning.
• Physician Assistants:   PAs practice the same medicine physicians do,  which focuses on diagnosing, treatment and prevention of disease to maintain good health (across different body systems).

Education:

• Physiotherapists: Physiotherapy education is 24-25 months in duration, and you can apply once you have completed 4 years of undergraduate studies. Upon completion of a physiotherapy program, you graduate with a Master’s and become certified after completing a licensing exam. You get 66 weeks of classroom learning and 30 weeks of clinical placements. You have to complete clinical placement hours in Orthopaedics, cardiorespiratory, and neurology.  When you are done you obtain a Master’s Degree.

• Physician Assistants: Physician Assistant education is 24-26 months in duration, and depending on the school, you can apply after completing 2-4 years of undergraduate education. There are 12 months (~52 weeks) of clinical rotations, ranging from 4 weeks to 12 weeks in different areas of medicine. Core (mandatory) rotations include Family Medicine, Emergency Medicine, Internal Medicine, General Surgery, Psychiatry, Paediatrics, OB/GYN, etc. Then elective (optional) rotations can take place in other specialties, such as Orthopaedics, Neurology, Neurosurgery, Endocrinology, Physiatry, Urology, Dermatology,  etc. PAs graduate as generalists and can work in any area of medicine (any physician, department, clinic that is looking to work with a PA). Depending on the school, you may have a Master’s or Bachelor’s Degree in PA Studies.

Getting Licensed:

• Physiotherapists: There are 15 universities that offer Physiotherapy programs across Canada. Successful graduates get to write the Physiotherapy Competency Examination (PCE) which is required to register and work as a physiotherapist.
• Physician Assistants: There are 4 Canadian Physician Assistant programs in Canada, 3 are civilian one is military. Upon completion of the PA Program (whether a Canadian or American school), PAs are eligible to write their PA Entry to Practice Exam, and register as a CCPA (Canadian Certified Physician Assistant).

Role:

• Physiotherapists: Can see patients with physical ailments, without referral from a physician, and are independent healthcare practitioners.
• Physician Assistants: PAs can practice in area of medicine (e.g. family, ER, cardiology, internal medicine, neurosurgery, nephrology, dermatology, urology, etc.).

How similar are Physiotherapists and Physician Assistants

• Physiotherapists are most similar to PAs that work in MSK Specialties such as Orthopaedic Surgery and Physiatry, when it comes to assessments, physical examinations, and patient education. They do differ in terms of investigations that are ordered and treatment.
• Advanced Practice Physiotherapists are very similar to the PA role. However, a Family Medicine Physician Assistant is more similar to a family physician and nurse practitioner, than they are to a physiotherapist.

Settings:

• Physiotherapists: can be found in the community at private clinics, home care services, retirement residences, occupational health, nursing homes/long-term care facilities, prisons, rehabilitation centres, research facilities, senior centres/residences, worksites/companies, sporting events, sports medicine clinics,  child development centres, health clubs/fitness centres, hospices,  and in the hospital (cardiac rehab, seeing patients post Orthopaedic Surgery, etc.). Physiotherapists can also work on sports teams and events.
• Physician Assistants: can be found anywhere in the community where you’d normally find a physician. This includes hospitals, private physician offices and clinics, community health centres, family health teams, specialists’ offices, military bases, correctional facilities (more common in the United States), and long-term health care centres. PAs can also work on sports teams and events.

Specialties:

• Physiotherapists: can specialize within different areas of rehabilitation – this includes cardiac rehab, pulmonary rehab, neuro rehab and MSK/Orthopaedics. There are also different “subspecialties” of rehab where Physiotherapists can further specialize.
• Physician Assistants:  can specialize in any area of medicine.

Lateral Flexibility (switching specialties):

• Physiotherapist: can switch areas of practice as long as they feel competent in those specialities.
• Physician Assistants: can switch from any area of medicine at any time without “formal further training” (i.e. physicians would have to go back to residency in order to switch specialties), although they can participate in further Continuing Medical Education workshops, seminars and courses.

Referral:

• Physiotherapist: To see a physiotherapist, patients often receive a physiotherapy prescription from their physician (or PA!), however this is not necessary to obtain treatment from a physiotherapist. A prescription helps in terms of coverage for insurance. A physiotherapist may delegate some aspects of care to a Physiotherapy Assistant (PTA), however they are in charge of initiating or making changes to the treatment plan
• Physician Assistants: Patients are not “referred to a PA”, instead, you may encounter a PA if the PA is working in a physician’s practice, or in a hospital department. For instance: in some multi-disciplinary ERs, the provider you may see in the ER may be a Physician, Physician Assistant or Nurse Practitioner. At some family health teams, you will either see the Physician, Physician Assistant or Nurse Practitioner. Each have different wait times, and see their patients independently. The PA may consult the physician if there are any untoward outcomes or complex cases, however they can all autonomously treat patients in collaboration with the physician.

• Canadian Physiotherapy Association: https://physiotherapy.ca/
• Canadian Alliance of Physiotherapy Regulators: http://www.alliancept.org/becoming-credentialled/
• Canadian Academy of Manipulative Physiotherapy: http://manippt.org/
• College of Physiotherapists of Ontario https://www.collegept.org/
• Ontario Physiotherapy Association https://opa.on.ca/