Episode #4: Natalie, PA in ENT
Natalie is a McMaster-trained CCPA with clinical experience across Ontario, Manitoba, and Alberta. Her career has spanned General Surgery, Cardiac Surgery, and Geriatrics, leading to her current role in Otolaryngology – Head and Neck Surgery (OHNS) at a major academic center in Edmonton. In this high-volume surgical environment, she is often the sole PA managing a ward of 20 to 30 oncology patients. This role requires close coordination with resident teams and the ability to triage complex consults flown from as far as the Northwest Territories.
WHAT YOU’LL LEARNWhat working on an academic surgical resident team looks like for a PA, including scope, consult flow, and OR access
How to start a research project without a formal research background or funding
What characteristics Natalie believes make someone well-suited to practicing as a PA in the Canadian healthcare landscape
GUEST BIONatalie grew up in Victoria, BC, completed her undergraduate degree in the United States on a tennis scholarship, and later earned a Master of Science in Kinesiology in St. Catharines, Ontario. She stumbled upon the PA profession on the day she defended her master's thesis, when a serendipitous conversation with a colleague who had just been accepted to the McMaster PA program changed her direction entirely. She graduated from McMaster's PA Education Program in 2012 as part of an early cohort, at a time when civilian PAs in Canada were still a rarity.
Since graduating, Natalie has practiced across three provinces and four specialties — general surgery and surgical oncology in Toronto, cardiac surgery and geriatrics in Winnipeg, and now Otolaryngology, Head and Neck Surgery at a major academic centre in Edmonton.
Outside of clinical practice, Natalie hosts a PA-focused podcast, has co-authored publications in the Canadian Family Physician, and is currently running a clinical trial examining discharge processes in her department. She is also an active member of the Edmonton PA Journal Club, a Royal College-accredited initiative that meets monthly to critically review current literature.
ON PA LATERAL MOBILITY “Each time I started a new role, it was a steep vertical learning curve. But each time I brought experience with me. That's what's so great about being a PA — the flexibility.”
— Natalie Dies, CCPA, PA in Otolaryngology, Head & Neck Surgery
ON GETTING INTO PA RESEARCH“Reflect on what you bring to the table. How did things change since the PA role existed? How can you measure that? Put it on a poster. It's really that simple”
— Natalie Dies, CCPA, PA in Otolaryngology, Head & Neck Surgery
ON FULFILLMENT IN HER ROLE“I'm working with the best of the best in academic centres. Job satisfaction is a huge part of my life. When my job is happy, everyone in my world is happy.”
— Natalie Dies, CCPA, PA in Otolaryngology, Head & Neck Surgery
ON PA ADVOCACY“Just being present at work and contributing every day — I feel like that's advocacy too.”
— Natalie Dies, CCPA, PA in Otolaryngology, Head & Neck Surgery Author
ON THE ACADEMIC RIGOUR OF PA SCHOOL“It was the toughest two years of my life — harder than my master's thesis. For those going in, just be ready. The sky is the limit”
— Natalie Dies, CCPA, PA in Otolaryngology, Head & Neck Surgery
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Natalie's Path to PA and Background
Natalie [0:05] I did my undergrad in the United States on a tennis scholarship and then found my way to Ontario. I grew up in Victoria, BC. I did my master's in St. Catharines and loved that experience, gained a lot, but knew I wanted to leave the academic world.
Natalie [0:22] I really just haphazardly stumbled upon the PA program and applied, and being in Ontario, it was easy enough to head to Hamilton. I did the training there, graduated in 2012, and it's hard to believe we've been working that long.
Natalie [0:41] I've worked in Toronto, Winnipeg, and now Edmonton.
Anne [0:45] Excellent. I think you're one of the few CCPAs who have worked in three different provinces in Canada, which is very impressive. So what specialty do you work in right now?
Natalie [0:59] Currently I'm in Otolaryngology, Head and Neck Surgery — formerly ENT, but the surgeons are trying to move away from that term. OHNS is more widely used now. It's quite subspecialized. Previously I was in cardiac surgery for about a year, geriatrics for about a three-month stint just to get my toes wet in primary care, and before that general surgery with a focus on colorectal and surgical oncology.
A Day in the Life in OHNS
Anne [1:33] Can you walk us through a day in the life in Otolaryngology, Head and Neck Surgery?
Natalie [1:40] My shifts are Monday to Friday, 7:30 to 3:30. It's a great 8-hour workday. I always arrive about 45 minutes early, and for me that's key. That's when I work on outside projects — I'll work on my podcast, read journal articles, or write journal articles. It gives me about 45 minutes to start my day intentionally.
Natalie [2:14] Then there's teaching from 7:30 to 8:30, which I'm very fortunate to have. Residents or staff give a full 60-minute lecture in Otolaryngology, which is fantastic.
Natalie [2:30] Around 8:30 to 9:00 we run the list. I don't round with the residents. The residents start their rounds at about 6:00 AM. I'm fortunate to stay in bed or come in early as I mentioned. After we run the list we disperse and patient care starts for me.
Natalie [2:47] We try to get residents to the operating room or clinic as soon as possible. Procedural care on the ward includes tracheostomy changes, decannulation, pulling percutaneous drains, making orders, following up labs, replacing electrolytes, and so on. That's roughly between 9:00 and 11:30 or noon.
Natalie [3:05] Then of course there's putting out fires as they come. With fresh tracheostomies on the ward, there's always things that can go wrong — desaturations, patients requiring readmission to the ICU. So dealing with those acute issues as they arise.
Natalie [3:30] I try to get to clinic maybe about two times a week. Otherwise the ward is pretty demanding. Our resident team only has three residents at a given time and we cover two hospitals. Sometimes I find myself alone on the ward managing 20 to 30 patients depending on how many we have. If there's time I get to clinic, and if there's time I also help the on-call resident.
Natalie [4:06] One of those three residents is always on call, and there are a lot of issues during the day — nosebleeds, tracheostomies, acute airways, things of that sort.
Navigating OHNS Team Dynamics and Patient Conditions
Natalie [4:20] I serve as the first contact point from the attending surgeon who takes all the consults from the emergency department. Our catchment area in Edmonton is huge. We take patients from Northwest Territories, Yukon, British Columbia — basically anything west of Winnipeg comes to us, and anything east goes to Toronto. The surgeon contacts me with new emerg consults, I recognize how urgent it is, find the junior resident on call, and alert them. If I can get started on the consult while we wait as they're coming in through STARS — which is the Alberta equivalent of the ORNGE helicopter transport — I do that.
Natalie [5:23] At the end of the day I run the list again if I can, or if not I send a handover note via secure email. Then my 8 hours is done and I get to go home.
Anne [5:28] It sounds like you do handle some call responsibilities during your hours, but not on weekends or evenings, right?
Natalie [5:35] I wouldn't even call it call. It's more like a medical student model who's learning with the resident. I'm happy to start the consult and happy to pre-admit people. Really, because I'm the continuity, it's easy for the surgeon to contact me and I disperse the consult from there, as opposed to the surgeon having to track the call schedule, which changes constantly with the residents.
Anne [6:04] Is the surgeon reviewing every case with you? What does that relationship look like?
Natalie [6:08] Honestly, I rarely see the staff unless I'm in clinic with them. The chief resident and the two junior or intermediate residents I work with are really my team day to day. I'll review a consult first with the junior resident I've been helping, or if it's straightforward I'll skip that loop and go straight to the senior. It's still that hierarchical model we learned, and I enjoy that. It's a great relationship. It's a small program — about two to three residents per year over five years, so 10 to 15 residents total. We're all close and we only get plastic surgery residents as off-service. Otherwise it's always the same people, so there are really nice bonds formed.
Anne [7:05] You really get to know them after a few months to years.
Most Common Conditions in Head and Neck Surgery
Anne [7:08] What are the most common conditions you see in OHNS?
Natalie [7:16] Because I'm specifically on the head and neck team, within otolaryngology we have different subspecialties — rhinology, facial plastics, general ENT, and head and neck. I'm allocated to just the head and neck, which is the oncology side. The most common things we see are malignancies from the nasal cavity and pituitary down to the larynx and hypopharyngeal area. Laryngeal cancer, tongue cancer, oropharyngeal cancer are the bread and butter. On call we'll also take patients with epiglottitis and neck abscesses.
Anne [8:05] Any rare conditions that you come across from time to time?
Natalie [8:10] There are always interesting trauma cases — penetrating neck trauma, for instance. We've seen a few cases of necrotizing fasciitis in the neck area, which are pretty wild. I also saw one really severe case of profound sepsis from pharyngitis, which required intubation and an operation. Just from pharyngitis. So I'm fortunate, in a twisted sort of way, to see the severe end of what primary care colleagues usually see as benign presentations.
Anne [9:01] Do you see a pediatric population as well?
Natalie [9:06] Pediatrics is another subset of otolaryngology. We have four fantastic pediatric surgeons. I don't do pediatrics. I did have about two weeks of introductory exposure across all the subsets of the division, which was a great introduction to the role and I really appreciated that. But during the day there's a pediatric day call resident who handles all of that.
Getting Started in the OHNS Department: Onboarding and Medical Directives in Alberta
Anne [9:31] How did they start you off in the head and neck surgery department? Did they know what to do with you when you arrived?
Natalie [9:43] Not really. Everything was flying by the seat of the pants, which I actually think was a blessing because they were really flexible in defining the role. They knew they needed help in head and neck, so that was going to be my destination. I had two weeks rotating through everything, and then Alberta Health Services wanted a review of my performance every two weeks. So for the first six weeks I had a lot of feedback, which was great.
Natalie [10:16] After that six-week rotation I started July 1st with the new academic year, which was good timing with the incoming residents. Some residents had junior experience without me and now they were still juniors but had experience working with me — so they were really able to comment on how the role helped and how we could change it to make it better. The introduction was actually quite smooth. We have one dedicated otolaryngology ward, so I got familiar fast with everyone.
Anne [10:59] Do you require medical directives in Alberta to practice?
Natalie [11:03] It's different. I signed what I believe was called a "statement of supervision" — a one-page document from Alberta Health Services outlining what I can and can't do. It's certainly not as exhaustive as medical directives in Ontario. It's a fairly vague directive, and it hasn't been updated since I started. I think because regulation in the province is in progress, there hasn't been urgency around modifying it. The College of Physicians and Surgeons has said we'll be regulated, so no one is pressing hard on requiring more documentation. There is a document that all parties signed, but it's a different process than what I went through in Ontario.
The Challenges and Rewards of Changing Specialties as a PA
Anne [12:03] We have a question from Becky who runs the podcast Meet the PA. She's curious about what it's been like changing specialties — you started in general surgery, moved to cardiac, then geriatrics, and now OHNS. Is it like starting from zero every time?
Natalie [12:29] Sort of, yes. The most difficult transition was actually from general surgery into geriatrics. Going from an academic resident team to a quite different model was challenging. I went from surgery to primary care, and that shift is broad and more superficial in terms of knowledge depth. Through that I learned about myself that I really like knowing a lot about one specific thing. That's why I've gravitated toward surgical subspecialties — I like surgery, I like that patient population, I like acute care.
Natalie [13:01] Each time I've started a new role it's been a steep vertical learning curve. But I carry experience with me each time, so the adjustment has been less than if I had just started with no background. This role in OHNS is actually quite similar to my role in Toronto at Mount Sinai in general surgery — resident team, similar daytime hours, ward management. Lots of crossover. Of course, the anatomy and disease processes are completely different, but that's what's so great about being a PA. The flexibility.
Anne [13:59] It's almost like switching rotations every four to six weeks during clerkship.
Natalie [14:03] Yeah, exactly. Brand new every time.
Working and Living in Alberta as a PA
Anne [14:06] We have a few questions about living and working in Alberta. Pre-PA student Brandon wants to know — what were some of the obstacles involved in getting employment as a PA in Alberta? He understands there aren't as many positions available there as in Ontario. Is that a misconception?
Natalie [14:29] We don't have anything like Health Force Ontario, and McMaster and U of T aren't providing job postings. Alberta lacks a PA education program and a designated PA project like Ontario has. That said, I actually had little difficulty finding a position. I networked, found the right contact to email, and they said they were interviewing for two positions — was I interested? Within seven days I was on the phone with two surgical staff. It was quite easy for me, though I know I was fortunate in that regard.
Natalie [15:25] If you go to Alberta Health Services and look through the career dropdown, there is actually a Physician Assistant tab. Like Ontario, Alberta is divided into zones. The Edmonton zone seems very progressive and they do hire Clinical Associates and PAs. There's one person within HR who's the go-to for those roles. Half the battle is knowing who to contact. That can be tough for a new grad who doesn't know anyone yet. Postings are scarce, but it is possible. Calgary seems a bit harder to penetrate — different funding zone, possibly leaning more toward CAs. When a Calgary PA program eventually opens, that will certainly help.
Anne [17:18] What do you love about living and working in Alberta?
Natalie [17:30] Extended family is here, which is great. Northern Alberta is fantastic. It was cold this winter, but I survived Winnipeg winters so I survived here. Edmontonians are incredibly friendly. Opportunities are great. It still feels metropolitan but it's not the size of Toronto, which after three years became a bit overbearing for me. You can be 45 minutes from the city and be in nature. As an outdoor enthusiast, that's wonderful. I advocate for anyone to come live here.
Anne [18:16] What's the PA community like in Alberta?
Natalie [18:25] It's fantastic and growing. Historically it was predominantly retired military when the PA demonstration project started here. Now I think there are about four of us civilian-trained Ontario PAs who have come over, which is a little wave. The others are retired or active military. A colleague, Cindy, has done a fantastic job — she organized an Edmonton PA Journal Club, got it accredited through the Royal College, and it meets monthly. We get to present and review articles critically. Active military members are attending too. It's unifying us. I'd say there are about 8 to 10 of us connected in Edmonton alone right now.
Advantages of Working in an Academic Centre as a PA
Anne [19:38] Was there anything else you wanted to mention about working with residents or working as a PA in Alberta?
Natalie [19:48] It's just a blessing. Early in my career, I don't mind being in a somewhat hierarchical setting — we're still a team, but I manage the ward at the lower decision-making level. For the bigger decisions, that still goes through the chief resident. The opportunities that come from being in an academic centre on a resident team, you would not find in a community position. The rounds I get to attend, the range of illness from palliative to acute, working alongside residents who are keen and studying hard — it all encourages me to keep learning too.
Natalie [20:56] When I'm in an environment where people are quizzing each other, where the chief residents are stressed studying for exams, that energy is contagious. I absorb it just through being there. I love working with them. And since I'm under 45, I can still fit in with a team of 22-year-olds.
Anne [21:27] Are you in the OR, or is that primarily the residents' domain?
Natalie [21:33] Definitely the residents. I want to get them to the OR to develop their surgical skills. I had more OR time in Toronto and that was fine. My role here is quite procedural on the ward, so I try to negotiate with the respiratory therapists — can I do that tracheostomy change so I can keep my skills up? I do get to operate occasionally if there are multiple rooms running or the residents are stretched, but it's far and few between, and I'm okay with that.
PA Advocacy and Research as a PA in a Surgical Subspecialty
Anne [22:04] Have you been involved in PA advocacy recently?
Natalie [22:10] We have a data legislature day coming up in Edmonton in mid to late April, which I'm excited about. I also have another publication in press in the Canadian Family Physician — Maureen Taylor and I wrote a commentary piece that's pending. My podcast on a biweekly schedule promotes PA advocacy too. But honestly, just embracing my role and being present at work every day, contributing and doing good work — I feel like that's advocacy as well.
Anne [22:57] Every year at CAPA you always have a poster or some research you're presenting. How can PAs with no research experience get started?
Natalie [23:26] I think it's quite simple. First, reflect on what you bring to the table and how your contribution differs from what existed before the PA role. How can you measure that? What are you doing that's improving quality of care or physician work-life balance? Try to come up with measures — ideally quantitative, but qualitative if needed. Use a PICO framework. Seek mentorship from your supervising physicians. Look at previous articles in the JAPPA. It's a great publication. See what other people are doing and even mimic their study protocol as a starting point. Then reference it.
Natalie [24:26] The main thing is you can't expect to be compensated for it. It has to come from within. That's why I come in 45 minutes early — I use that time for generating a protocol, writing an ethics application, whatever the current project needs. I don't think it's difficult. Just be creative, find ways to measure your contribution, seek mentorship, and put it on a poster. Even a simple piece, when you articulate your work in an academic way, is a different style of writing and a valuable experience. Presenting in front of colleagues matters. I'm happy to help anyone who has an idea and doesn't know where to start.
Anne [26:05] We have a lot of data stored in our electronic medical records already. But I get intimidated by statistical analysis. What's your suggestion — is it worth contacting a statistician, or are there simpler ways to get started?
Natalie [26:33] There are two great statistics books I can send you — our physician mentor at the Edmonton journal club recommended them and said they're easy reads. For the clinical trial I'm running now, the stats were more complex and I just asked a resident who's doing an MD/PhD to help me out. In exchange, if it gets published, they'll receive co-authorship credit. For qualitative work it's quite simple — a Likert scale, one to five, agree to disagree. You can keep it pretty manageable. And if a paper gets rejected because of poor statistics, you can reassess at that point and get help. I've never approached a professional statistician. I've just sought mentorship from people who knew more than me.
Navigating Team Dynamics and Working Relationships
Anne [28:13] As a PA, what are the possible obstacles or benefits in team dynamics? How are your working relationships with other team members?
Natalie [28:38] There are always personality differences. Our chief residents change over every three months, so in a given year I'll have about four different leadership dynamics to adjust to. Having a small residency program makes it easier — I can accommodate to each person's preferences. Whereas in a larger program with lots of turnover, I could see that being more challenging. The staff I work with — four male staff — we all get along well. I'm fortunate to be in a prestigious academic centre where the criteria for working there means the staff are themselves considerable leaders. Their CVs are incredibly impressive, and I'm just lucky to be working alongside them.
Natalie [29:43] It does get challenging. It depends on the leadership style of each person — some are more hands-off and some aren't. Knowing them well now means I know when I can make a decision independently and review later, versus when I need to go to them first. It's just understanding your role as a PA and knowing how to navigate decisions without stepping on toes.
How Natalie Found the PA Profession and Decided to Apply
Anne [30:17] You were class of 2012 at Mac. At that time there weren't many civilian PAs in Canada that we had access to as pre-PA students. How did you decide that PA was the right career for you?
Natalie [30:40] It was really just stumbling upon it. Literally on my graduation day from my master's, I bumped into someone who would become our program director. We were in the same master's program — she'd applied and gotten into the PA program. I asked what it was, and that was it. I'd written the MCAT that year, performed poorly — it was the same time as my dissertation. I found out I had gotten into medical school abroad, but I wasn't ready to take that step. I thought, let me try one more thing and see if medicine is really what I want to do. So I stumbled upon the PA program.
Natalie [31:50] The admissions process is much more challenging now than when we were getting in. But was it the right choice for me? Absolutely. I still have an active lifestyle. I'm practicing in awesome specialties, working in academic centres with the best of the best. Job satisfaction is a huge part of my life. I don't have children — I have three dogs and a better half. When my job is good, everything in my world is good. I'm just happy right now.
Pre-PA Preparation: What Natalie Would Tell Her Past Self
Anne [32:29] A lot of our followers have questions about how you prepared as a pre-PA student. What did you do to prepare for PA school admissions?
Natalie [32:59] At the time I was still finishing my master's thesis, so there was a lot going on. Honestly, I'm not sure I prepared extensively. Looking back, the one piece of advice I'd give to incoming students is to get solid on your anatomy and physiology. Coming from kinesiology, I had some MSK knowledge and cardiovascular physiology, but reading a straightforward anatomy and physiology textbook just to get that foundational medicine in your head would help a lot before you start PBL. I can't say I did that, but I would now recommend it.
Natalie [34:02] You have the summer before you start — use it. The internet has a lot of great flashcards and resources. Try to make it fun, even if you're on the beach. An overall systems review would be useful because PBL is organized around those same systems. But I won't pretend I over-prepared. I just accepted that it was going to be a challenge. And it was the toughest two years of my life — harder than my master's thesis. For those going in, just be ready. The sky is truly the limit for your learning and it's really what you make of it.
What Makes an Ideal PA in the Canadian Context
Anne [34:56] Given all the challenges we have in Canada — being clinicians, doing advocacy, navigating regulation and funding — what would you consider the ideal characteristics for someone becoming a PA here?
Natalie [35:21] I was really impressed at CAPA in Ottawa — a lot of PAs were giving the presentations, which was a shift from conferences typically being physician-led. It was so refreshing to see PAs taking leadership and saying, this is what I've learned, let me teach you about my medicine. So first, be a self-starter. Don't be afraid to be curious and put yourself out there. That said, it's a fine balance — we are supervised, so it's about negotiating those relationships. You're still appeasing your supervisor while advocating for the profession. That takes judgment.
Natalie [36:03] Someone who likes to reflect on their behaviour so they can modify it as needed. Someone who's willing to create a role because a lot of places haven't had a PA before. You have to be flexible and you have to accept that there will be challenges. Those would be the key characteristics.
What's Next for Natalie
Anne [37:13] What's next for you?
Natalie [37:21] I'm excited about the clinical trial I'm running — small measures, but I'm trying to improve the discharge process. I need to recruit 32 patients and I'm at 8, so I'm 25% through. Hopefully by late spring I'll have the data to analyze and maybe another publication on the go. I'm also generating a new podcast episode every two weeks — that's my goal. And I'm very excited about attending an ENT conference with four PAs in Nishi, Arizona at the end of April. I asked if a Canadian could come and they said absolutely, you'll be our first. It'll be CME literally geared toward everything I see on a daily basis, which is great.
Natalie [38:30] Of course, CAPA in Victoria — I won't miss it, it's my hometown. An excuse to see my nieces, sister, and mom. And just enjoying my summer in Edmonton, camping every weekend because my schedule allows it and this city does too.
Anne [38:47] Fantastic. You've got that beautiful scenery and landscape right at your doorstep. I know you're fairly active, so it must be a dream living there.
Natalie [39:00] I can drive 10 minutes and go cross-country skiing. It's a great country. This is such a vast nation and we've done such a good job unifying it. Each province has its own little gem. I love it here.
