PA PRACTICE • BY NATALIE DIES, CCPA

Natalie Dies is a graduate of the McMaster PA Education Program, Class of 2012 and is one of the few PAs in Canada who has worked in 3 different provinces for her PA career.

Her journey started in Ontario. Natalie completed many of her elective rotations in surgical subspecialties, knowing that she had a strong preference for perioperative medicine. She “created” a general surgery position after completing an elective, working in a large academic tertiary care centre in Toronto from November 2012 to January 2016. She worked on surgical resident teams in colorectal surgery and surgical oncology. She wrote a paper demonstrating improved late patient discharge rates and reduced resident workload, which was published in the American PA Journal JAAPA in January 2016.

In February 2016, Natalie joined a PA team at the Geriatric Outreach Service of Ontario, performing geriatric consults at long term care facilities. The model of supervision was very unique as she worked remotely and communicated with her supervising physician through Telehealth. She also helped the group establish their medical directives.

In Winnipeg, Manitoba, Natalie joined a well-defined group of 6 Physician Assistants and Clinical Assistants in cardiac surgery and cardiology in July 2016. Her role involved 100% ward coverage, no intraoperative role. She presented data at the Société Française de Chirurgie Thoracique et Cardio-Vasculaire (SFCTCV) annual congress in Marseille, France June 2017 about the utilization of PAs in cardiovascular surgery.

Canadian PAs Francois Cameron and Natalie Faye Dies were invited to present the role of PAs s Universities in France are looking at different strategies to cope with decreased resident working hours (from CAPA/ACAM).

In April 2017, Natalie became the first PA in otolaryngology, head and neck surgery (OHNS) at University of Alberta Hospital in Edmonton, Alberta.  She has been rotating through the entire OHNS department, but will ultimately be working on head and neck surgery team where patients undergo major reconstruction after massive ablative cancer resections. She is currently working on developing a PA curriculum and optimizing the PA role in Alberta.

Natalie with her supervising physician in the outpatient procedures clinic.

Natalie gives us some insight in the differences of how PAs practice between the different provinces.

I re-situated to Manitoba in search of stable funding in a hospital/surgical PA position. The relocation also suited my common-law spouse’s professional needs. The lifestyle in Winnipeg was more affordable than Toronto, and easier to get out of town and into the wilderness.

The hospital shifts in Winnipeg were 10 hours and included weekends and home call. Home call was an interesting experience. I did have a slight underlying anxiety of having to go back into the hospital at anytime.

I had to work 80 hours over a 2 week period in any format. For instance, I would work 60 hours in one week, then work 20 hours the following week. This allowed days off during the week, a counterculture schedule, and time to work on side businesses during weekdays.

Supervision & Registration

• PAs in Manitoba require a contract of supervision and registration with College of Physicians and Surgeons of Manitoba (CPSM). These two documents allow for PA practice.
• In Ontario, PAs are not registered with the College of Physicians and Surgeons of Ontario (CPSO). Rather a registry of PAs has been recommended by HPRAC but has yet to be developed.

Introduction for PA Role

• In Manitoba, there is little introduction for the PA role that is required. The PA role is already well defined and accepted. However, my experience may have been slightly biased given I joined a team of PAs who had been at the practice for more than 5 years already.
• In Ontario, many physicians have heard of PAs, and there is an increasing number that have worked with one. Most PAs and PA students often have to help supervising physicians, allied health they work with, and patients understand the PA role. We are always advocating for the PA role.

Level of Supervision

• In Manitoba, there were immediate expectations to practice autonomously, especially given my experience in a surgical position.
• In Ontario, PAs operate under delegation. PAs are able to see patients independently. However, in a fee for service setting, if a physician wishes to bill for a patient encounter they must have meaningful participation. This does not apply in a fee-per-patient/capitation model where a practice will still be compensated for patients a PA sees in a roster setting, even without physician participation (e.g. A PA may help a practice expand its roster by 500 patients, and that practice will be able to receive a fee-per-patient)

Requirement for Medical Directives

• In Manitoba, there is no need for medical directives . All orders are immediately accepted and implemented by nurses, radiology technicians, etc.
• In Ontario, there are requirements for medical directives if PAs wish to order investigations, imaging, blood work, perform procedures, communicate diagnoses and prescribe medications without direct physician supervision or physician co-signature. Medical directives help define scope of practice of the PA.

Working with medical learners

• I occasionally worked along side residents, however there seems to be more direct interaction with staff surgeons in my Manitoba position than I did previously in my general surgery position in Ontario.
• In Ontario, Physician Assistants learn alongside 3rd, and 4th year medical students and residents. As staff, PAs do work with medical learners.

Unions

• In Manitoba, PAs who are part of the Winnipeg Regional Health Authority (WRHA) have union representation and defined contracts. PAs within this region receive same salary and benefit schedules with no negotiation possible. In Manitoba, WRHA PAs are unionized. Manitoba physicians may also opt to hire PAs privately, however certain rules must be covered in order to bill for PA services rendered in a fee for service setting, and PA is able to negotiate salary and benefits.
• In Ontario, PAs may or may not be unionized depending on their employers (i.e. whether or not they are employed by a hospital). PA salaries also vary throughout the provinces, with some working within pay scales and others having the option to negotiate for higher pay.

Employment Involvement

• In Manitoba, I found there is greater involvement of the government (i.e. the regional PA director) that dictates PA employment, and less involvement from supervising physicians about the overall PA role. Unless the PA is privately hired outside of government funding (e.g. solo physician or group practice) there is a more direct role for physicians.
• In Ontario, PA employment is dictated by several sources of funding. This may include include physician funding (physicians pay out of pocket for PAs), Career Start (usually at 50% of PAs salary), LHIN funding, Hospital Department funding, Hospital Funding or a combination of previous.

A video still of Natalie as part of the Department f Surgery at University of Toronto’s official campaign video. (Source: UofT)

Initially, I was primarily supervised and trained by veteran Physician Assistants and Clinical Assistants. Later, I conducted rounds independently and patient care progressed based on the assigned PA/Clinical assistant care plan.

Supervision from surgeons depended on the staff surgeon. Some surgeons rounded daily while others did not. Every clinical decision was definitely not discussed with the supervising physicians. Surgeons could read progress notes and orders on EMR remotely; direct supervision is not necessary.

More often, PAs would initiate care and surgeons would later request changes to the care plan if necessary.

Sometimes PAs shared patients with residents if they were on-service. Residents could also provide supervision or intervention if required.

I believe the funding model recently discontinued in July 2016 prior to graduation of the 2016 University of Manitoba class with a change of provincial government. Previously, permanent funding was automatically allocated to certain PA positions demonstrated (this is similar to the Ontario Career Start Grants, but greater than 1-2 year duration).

I am unsure if it is easier or harder to find government funding for 12 Manitoba PA graduates each year compared to the >50 PA graduates each year in Ontario programs. I am assuming it is easier to allocate money for fewer positions  given the funding stability that Manitoba had between 2010-2016. This is only my opinion however, and could not reflect the situation at all.

At this point moving forward, I am uncertain about the stability of funding. However I do note job postings for PA positions in Manitoba (through WRHA) are ongoing. Hiring has not completely stalled without automatic fund allocation. I believe all graduates from the 2016 class found positions.

Manitoba health care is divided into regional authorities. Most PAs are working in the Winnipeg Regional Health Authority.

Health authority boards are accountable to the Minister of Health, Seniors & Active Living and are responsible for the mandate, resources and performance of the health authority.

Manitoba PAs do work in various areas of medicine like PAs in Ontario. The ones I do know of include:

• ICU / Critical Care
• Cardiac Surgery
• Cardiology
• General Surgery
• Oncology
• Internal Medicine
• Primary Care
• Thoracic Surgery
• Otolaryngology
• Emergency Medicine

Despite government fund withdrawal. I think the value of Physician Assistants are better understood in Manitoba, which leads to some job market instability. I found my position in surgery informally, so networking opportunities also exist.

I don’t believe, however, that opportunities are abundant in Manitoba. The job market is going to be competitive everywhere in Canada. If you are considering finding employment in Manitoba as an Ontario-trained PA, you just have to ask if your life circumstances allow relocating to another province and at the time it did for me.

I think we should all make a habit to check the CAPA website for job opportunities and fill out the annual census to stay better informed of the hiring climate / job market across the country.

Keep in mind each province has its own challenges with PA implementation. I’m now experiencing challenges in Alberta more similar to those in Ontario – for instance, definition of the PA role.

I certainly believe I have a unique view of the profession having worked in 3 different provinces (for better or worse!).

Like any PA position, ensure the fit is good for you and develop rapport with your supervising physicians.