6. Impact of a PA in Radiation Oncology
How I work with 39 physicians in the department
What’s great about my department I have constant access to all of my physicians. We’re all on the same floor and most of them have an open door policy. I can just walk into their office and we can chat about whatever we need to, whether it’s patient care or clinic concerns.
My supervising physician is the one who is in charge of my entire schedule, and that is Dr. Richard Singh. We will sit down every 6-8 months and think about where I am needed most. I tend to go clinics that are very busy or full.
Over the years we have known that when a staff Radiation Oncologist leaves there is a gap that needs to be filled, and I end up covering those clinics.
For example, we had a radiation oncologist who moved out to British Columbia, and he had a big prostate practice. One of the other staff and I took over that clinic for a while. That would tend to be my role in how I interact with the physicians. Unfortunately, I have not had the opportunity to work with all 39 of them over the 4 years, as that is a lot to go through, but I have worked with a lot of the senior staff.
Patient Experience with a PA vs. MD
In clinic, there is not a lot of difference in whether a patient sees myself (PA), a fellow, a resident or the staff physician. Our practices are pretty similar for new patients. It involves history taking, physical examinations, communicating about the diagnosis, obtaining consent, going through side effect profiles, and talking to patients about the anticipated future timeline.
The biggest differences in patient care is what happens behind the scenes.
Behind the scenes, the radiation oncologist including the residents and fellows are involved in creating an individualized, personalized plan for each and every patient – because we are all anatomically different.
All of our organ sizes are different and how we are structured is different. We can’t just use one plan for every breast patient, for example, it has to be carefully designed so that you are not giving toxicity to the nearby organs.
I don’t have any training in that aspect, so I am not involved in that part of patient planning aspect, which is where the radiation oncologist can dedicate more of their time if I can help them clinically.
How I work with a NEW physician team member
Anytime I am starting off a new clinic with a physician that I have not worked with before, I usually sit down with them, and I ask them about what their expectations of a PA is.
This is because I am the first PA to be working in the Radiation Oncology Department at UHN, and it is likely they have not worked with a PA before.
Although, we do have some American staff Radiation Oncologists who have had opportunities to work with PAs in the United States.
“Most physicians, in fact, would expect me to do everything they are doing, which is being able to see a patient, discuss treatment plan, obtain consent, walk them through their entire cancer journey that the patient would expect to go through.”
Every now and then there are physicians who are either part of clinical trials and I may not be aware of all the clinical trials they are apart of, or trying to recruit patients for. It tends to be a learning and teaching opportunity for both myself and the physician.
Once I get started with the physician, and I am in a routine, we know exactly what we are doing. I see all the new patients for the clinics I am part of. If there is a resident, then the resident will see new patients and physicians will dedicate a little bit of extra time to do the teaching.
For example, I’ve been going to the endocrine clinic for the past four years. I can determine the dose to give to the patient for the radioactive iodine. We would go through the treatment plan, and for residents it ends up being the first time they are introduced to the concept of radioactive iodine treatment. Subsequently, there is a teaching component for staff physicians when they work with residents, as opposed to working with me as a staff PA.
Our radiation oncology residents are shared between Princess Margaret as well as Sunnybrook Hospital, and they do have some rotations they either have to do uptown or in rural areas. They will rotate through different site groups and we will go months without having a resident because they are doing their rotation at Sunnybrook.
Impact of having a PA work in Radiation Oncology
Benefit #1 – PAs help with reduced staff coverage on holidays
The feedback that I have received is, “its nice to have one person who can essentially cover any Radiation Oncology site group”. For example, during the week of Christmas, a lot of the staff members are away and we can get urgent consults from anywhere or patients who drop in. This may be difficult if you can’t find a covering physician and resident.
But if you have a PA who can attend to any of the patients for any of the staff it makes the process a lot easier. For example, on Remembrance day weekend, which is technically a stat holiday, our clinics were cancelled. We had a radiation oncology patient who bleeding fungating mass and they needed to be attended to.
The patient would have to go to the ER and wait a long time, but since the Radiation Oncology department has a PA – I was able to attend to them, and update the physician about what my plan of action was, and allow physician take over the care the next day.
“It makes the transition smoother for the patients, for the physician in charge and I hope it is reducing the load we are having to put on our Emergency departments and our inpatient beds.”
Benefit #2 – PAs can help take on the Physician workload
In the first year that I was there, we did collect data of PA use. We are keeping track of those numbers still. We have noticed reduction in two full time staff physicians, we were able to compensate for that reduction by hiring a PA. I was able to see the same number of new patients that a staff would see.
For example, there is two radiation oncologists who treat endocrine malignancies, so both pituitary and thyroid cancers. When I was introduced to the practice I was seeing 1/3rd of the patients.
“I was contributing just as much as a staff physician in terms of the number of new patients and follow up patients I was seeing, which made it financially feasible to keep me around, as well as improve our access to care.”
Benefit #3 – PAs can help increase # of patients seen while reducing wait times
One huge thing we noticed, is that we only have one neuroendocrine clinic per week, and like I said we only have two radiation Oncology physicians that are in charge of it. We also cover a wide catchment area, so our wait times at one point were up to 2-3 months, and although thyroid cancer tends to be slow growing, and it is safe to wait that long and pituitary tumors tend to be benign more often than not.
“When I was introduced, we were able to see a lot more consults and a lot more follow up patients. Our wait times is now 3 weeks, decresaed from an initial wait time of 3 months.”
The multiple site groups have had that opportunity, that’s why they’ll put me in a site group where there is a lack of a staff physician or where there are more consults than anticipated for that time frame.
The idea that “PAs replace physicians” is a misconception
PAs are NOT replacements for Radiation Oncologists. Like I said, there is a lot that happens behind the scenes that only the radiation oncologists can do, which I absolutely cannot help with. But what I can do is help Radiation Oncologists with their clinical workload, which is seeing patients. This frees Radiation Oncologists to perform treatment planning so that these patients can actually be planned and tee-ed up for their treatment, and treatment can then be delivered in a timely manner.
Cancer Care Ontario (CCO) mandates that we see our new consults within two weeks of the referral being sent to us. Radiation Oncology is not like other specialties where we can just hold on to these referrals and say ‘Oh we’ll see when we can get to you’.
These are cancer patients, and time is of the essence. We have to get to them sooner rather than later, and if I can help see extra patients in clinics, it frees up that much more time for the radiation oncologist to work behind the scenes, both for resident and fellow teaching, as well as being able to plan the radiation treatment plan for the patients.
I would not say that I am replacing them, I would be better described as an extra pair of hands that helps radiation oncologists cover the clinical load that we have.