The PA experience in Manitoba – Primary Care and Beyond

We had a session on Primary Care in Manitoba, presented by Sheldon Permack, MD, FCFP, and Scott Naherniak, CCPA , a PA-MD team who work together in Primary Care in Manitoba. They spoke about their experience, and the difference in patient care once a PA was introduced into practice.

Although I feel very well versed about how PAs function in Ontario, how PAs practice in Manitoba has been somewhat of a mystery to me. Questions like “Why does PA regulation happen in some provinces and not others?” or “Why has Ontario been slow to integrate PAs the way that other provinces have”?

This session was a great opportunity at the CAPA conference to understand these differences and more between PA integration in Ontario and PA integration in Manitoba. One key in these differences lie in what provincial legislation is in place which may or may not recognize  PAs in that province and therefore affect their scope of practice and level of autonomy, the cooperation of PAs and their respective College of Physicians and Surgeons, etc.

Manitoba’s role in proving the utility of PAs outside of the Canadian military has been important. The Doctors of Manitoba have been supportive of PAs in Manitoba as practitioners who extend the health care system’s ability to improve quality of care, increase access and improve a physician’s ability to service more patients (1).

Rural Manitoba does have a shortage of physicians. Physicians who are retained in local hospitals and clinics often practice there for 1-2 years before going to bigger cities like Winnipeg. This shortage has resulted in shut downs of ERs. There is a huge opportunity for PAs to step in and improve access. In the United States, some Nurse Practitioners and PAs work in rural and remote areas, with physician supervision. “Supervision” usually means they are accessible by phone or other means.

Doctor shortage shuts ERs in western Manitoba

ERs have had to shut down ERs due to a lack of providers. Source: CBC

• They are part of the inter-professional health care team
• developing services to ensure people are more informed
• improved access to primary care for all Manitobans
• Demonstrating quality and safety in primary care
• increasing focus on patient and patient-centered care
• Provide seamless transitions (office –> home, hospital –> office –> home)
• Enhancing efficinecy in primary care and supporting sustainability of the health systems, PAs can help prevent hospital re-admission.

University of Manitoba’s Education Program has expanded their program to meet the high demand for their graduates in Manitoba’s health care. Many of the graduates have stayed within Manitoba after completing the PA program.

“Physician Assistants are part of the solution to improving health-care delivery in Manitoba,” said program director Ian Jones. “We have increased the class size from 12 to 15 students to address the demand for PAs, whose work with physicians provides a successful patient-centred model of care. With the support of the government of Manitoba, our graduates have made a difference in communities such as Brandon, The Pas, Thompson, Dauphin, Steinbach, Morden and Winnipeg.” – Winnipeg Free Press

• In 1984 Canadian Forces named Senior medics as “Physician Assistants”
• In 1999, Manitoba introduced legislation allowing military PAs to practice in civilian settings, and they were called “certified clinical assistants”.
• In 2008, University of Manitoba launched one of the first civilian PA Education Programs in Canada (the other being McMaster University in Ontario), offering a Masters in PA Education, currently the only civilian PA program in Canada to do so
  • Training programs in UofT and McMaster offer Bachelor’s Degree. I feel it would be beneficial to offer a Master’s as the capstone project and having a “research” component to the degree would be invaluable for PAs who practice in a world of evidence based medicine. It might also encourage Ontario PA graduates to pursue PA research after graduation.
• In 2009, Manitoba changed its legislation to recognize the title and training of PAs. Tge legislation from 1999 was ammended under Regulation 183/99 and was called “Clinical Assistants & Physician Assistants Regulation” as registered under the Manitoba Medical Act (3).
  • Ontario does not currently have legislation to recognize title & training of PAs, we wish to be included in the Regulated Health Profession’s Act. (See key features of RHPA, 1991).
• In 2010 the University of Manitoba Masters of PA studies graduated its first class of PAs

Manitoba has been a leading example of how PAs have been integrated into their health care system successfully. Other provinces have followed suit with PA integration on a legislative level, and I think Ontario could certainly benefit by taking example from this leadership. If you google, “Manitoba Physician Assistants” an excellent 2014 summary on the “Introduction of PAs into Primary Care Implementation Evaluation” pops up. The Winnipeg Regional health Authority, under the direction of the Introducing Physician Assistants into Primary Care Steering Committee  put together a robust evaluation of how PAs could be utilized effectively, as there was very little in the way of experience of PAs in primary care in Canada. These action committees have led to the successful implementation of PAs in Manitoba who practice at the top of their scope of practice.

Unlike Ontario, Manitoba PAs are regulated, and they have legislation in place recognizing the training and title of Physician Assistants (Ontario PAs wish to be regulated and are working towards this).

“Regulation has proved to be a substantial barrier. In Manitoba, where Rhule works as a PA in cardiac surgery, PAs can write prescriptions and orders for diagnostic tests without the need for a doctor to co-sign. His counterparts in Ontario don’t have the same scope of practice.” – Joanne Laucius, The Ottawa Citizen

“PAs in Manitoba are employees of the RHA [Regional Health Authority] and most work in hospitals. PAs are not currently employed by physicians,” said Omichinski. Presently there are no funding options available to help fee-for-service physicians hire PAs besides the undesirable option of paying a PA’s salary from their own fee-for-service profits.  – Vandehoef, D. Doctors of Manitoba

Therefore they are salaried PAs who are able to substitute for the physician and perform delegated autonomous work. Currently there is no solid funding structure for fee for services.

PAs are salaried employees in primary care allowing them freedom from volume based billing

1. Care of the vulnerable
2. Home Visits
3. Telephone care
4. Quality improvement work
5. Supporting patient self management
6. Flexibility to meet needs of the patient population and the health care team

Chronic Disease Management National Parameters: Creation of workflows incorporating PAs to improve chronic disease management parameters, which includes: CHF, CAD, Asthma/COPD, HTN and Diabetes. PAs may have a large role in helping family practices meet their targets in preventative health.

Authors: Sarah Bowen MSc PhD, Ingrid Botting PhD, Lori-Anne Huebner MEd, Brock Wright MBA FRCPC MD, Beth Beaupre LLB, Sheldon Permack MD CCFP, Ian Jones MPAS, Ainslie Mihlachuk MD CCFP,  Jeanette Edwards MHA, and Chris Rhule MHSc

This study was mentioned during the session, and followed the introduction of Physician Assistants in 6 sites of Manitoba who started in 2012-2013. PAs that were successfully implemented at sites in Manitoba had a few commonalities, provincial planning, appropriate site preparation such as having the culture supportive of innovation, and characteristics of PA/MD team. The most important factor was identified as a good relationship and fit between PA and the supervising physician.

Facilitating Factors & Potential Challenges when integrating a PA

Clinical Assistants in Manitoba are health care professionals who have experience/education outside of another medical field (often international/ medical graduates)  who work under supervision of physician who delegates responsibilities.

Physician Assistants are formerly trained as “PAs”, they may or may not have foreign medical graduate experience but must go through PA training regardless of PA education (there is no way to “skip” the didactic or clinical year because of previous experience). Learn more about PAs a University of Manitoba’s What is a PA?

• PAs in Manitoba work across different medical and surgical specialties (1).
• PAs are regulated in Manitoba, allowing them to practice at the top of their scope of practice.
• PAs are tracked via registry through the College of Physicians and Surgeons of Manitoba.
• Physician Assistants are recognized in Manitoba Legislation as per the Manitoba Medical Act (this does not exist for Ontario PAs yet).

References: 

1. Physician Assistants: The Growing Profession of Doctor Extends by Diana Moes VandeHoef
2. Physician and Clinical Associates of Manitoba
3. CAPA-ACAM: Legislation of PAs