Position Statement - Physician Assistants
The Registered Nurses’ Association of Ontario (RNAO) is committed to supporting change within the Ontario health-care system designed to meet the needs of citizens, when those changes are evidence-based, support continuity of care and continuity of caregiver, and enable full scope of practice for regulated health professions. On the basis of those principles, the Registered Nurses’ Association of Ontario (RNAO) has fundamental concerns regarding the introduction of physician assistants (PAs) in Ontario. As currently defined in Ontario, physician assistants have relatively limited education, training and experience. They are unregulated providers who are not accountable to a regulatory body responsible for ensuring that those physician assistants practise to acceptable and safe standards. Introducing PAs has the potential to fragment patient care within interprofessional teams, significantly increase costs to a system that is struggling to achieve financial sustainability and confuse the public understanding of roles within the health-care system. There are better, safer, more cost effective alternatives. For over 30 yearsi, nurse practitioners have had the knowledge, skills and competencies to provide access to essential health services in the community, long-term care and hospital settings, yet they continue to be under-utilized in Ontario and face barriers to being able to practise to their full scope.
What are physician assistants?
A physician assistant (PA) is an unregulated health- care provider who, under the supervision and delegation of a physician, can perform such acts as to: take client histories, conduct physical examinations, write orders, interpret test results, diagnose and treat illness, counsel on preventive health care, write prescriptions and assist during surgery.
PAs in the Canadian Forces have a long history and it is not the RNAO’s intention to question the fine and valuable service they continue to provide.
Unlike their military counterparts, civilian PAs in Ontario have limited education, training and experience, and are not subject to consistent standards of practice and supervision. Physician assistant education in Ontario
By the time a soldier commences the Military PA course they have had at least 12-15 years in the military working as a medical assistant, and have likely served on several missions at home or overseas. Soldiers enter the Military PA program with a great deal of experience in the medical fieldii.
The same protections do not exist for the civilian PA model.
RNAO is concerned both about the quality and length of civilian PA education. Unlike nurse practitioners (NPs) who need to have completed a 4 year Baccalaureate of Science degree in Nursing, and a minimum of two years in clinical practice prior to applying to the NP program, the limited prerequisite requirements for application to a PA program in Ontario do not build on a health care or scientific background.
Applicants to the McMaster Universityiii and the University of Toronto/ Northern Ontario School of Medicine/ Michener Institute collaborativeiv (U of T/ NOSM/ Michener Institute) programs need only have finished two years of a general four-year undergraduate degree program. This education can be in any discipline (e.g. arts, engineering, or journalism). No preference is given to one program over another, though the U of T/NOSM/Michener Institute requires completion of courses in human anatomy, chemistry and physiology. A complete undergraduate degree is not required.
In addition, the requirement for prior clinical work experience varies. Whereas McMaster does not have any prerequisite clinical requirements, the U of T/ NOSM/ Michener Institute requires only one working year (equivalent to 1680 hours) of patient contact in a professional setting.
In contrast to the post-baccalaureate level education that Nurse Practitioners receive and the baccalaureate or additional education of registered nurses and advance practice nurses, PAs are educated at the undergraduate level in Ontario and start assessing and treating patients after only one year of general didactic (classroom) education, and one year of general clinical exposurev,vi. Given the growing acuity and complexity of the health-care needs of Ontarians, RNAO believes the current Ontario PA education to be inadequate. There has been no evidence that PAs in this education model can support their practice safely. The insufficient level of education and narrow clinical experience may compromise recognition of the limits of expertise and may, as a consequence, jeopardize client safety.
No autonomy or accountability
Physician assistants in Ontario are not accountable to a regulatory body, as nurses, physicians, pharmacists and other health-care professionals are. These bodies ensure that regulated health professionals practise to acceptable and safe standards, an expectation not in place in Ontario for PAs.
PAs do not work autonomously as independent practitioners, and will not bring greater efficiency to the health-care system. All work performed by a PA must be supervisedvii by a physician who is legally responsible for all the PA’s client care. However, there is no legal requirement or assurance that the supervising physician will actually be physically present. The primary supervising physician needs only to be accessible for verbal consultation at all times, and does not need to be on site. PAs describe themselves as practising medicine with physician supervision.viii
As physician assistants in Ontario work in an intra-professional role within the scope of medicine, they are not subject to the high standards of interprofessional practice governing regulated health professions under the Regulated Health Professions Act (RHPA). Unlike other health professionals, their competencies and skill sets are not monitored or enforced by a regulatory college. It remains unclear whether PAs will engage other professionals’ expertise, or connect strictly with their supervising physicians, thereby exacerbating the silo effect that is antithetical to interprofessional collaboration.
NPs on the other hand, treat patients independently, and work in interdependent practice to add new perspectives to team-based practice. NPs bring a background in nursing and its strong emphasis on health promotion and disease prevention, in addition to restorative and curative care.
Physician assistants and the attendant requirement for physician supervision add a significant cost burden to Ontario’s health-care system. PAs enter the workforce with earnings comparable or higher than substantially more educated and experienced nurses at the top of their rangeix. In 2009, registered nurses with up to five years of experience earned $64,623, and those with 25 years of seniority or more were earning only $78,000 a year. The salary for a graduate NP working in primary health care ranges from $74,038 to $89,203x. The salary range for PAs reflects differing levels of experience, with PA base salaries ranging from $75,000 to $86,700 per annumxi.
Currently, Ontario’s Ministry of Health and Long-Term Care (MOHLTC) has committed to pay 75 per cent of the total PA’s remuneration for the first year and the PA’s employer pays 25 per cent, with funding moving to 100 per cent by hospital employers in 2010. This is in an environment of ever more constrained hospital budgets.
Besides the base salary and benefits, the MOHLTC also reimburses prospective PAs up to $500 per person per employment interview (with an average of three interviews per hospital) for travel costs, and $4,000 for relocation expenses, in order for a PA to undertake employment in Ontario. This includes household utility connections, professional moving company fees, gasoline, temporary hotel accommodation, food expenses, and any fees for Canadian work permits or Canadian work visas. In contrast, very few organizations cover exam, liability or registration fees for other regulated professions because of potential conflicts.
In addition to having the full-time services of a physician assistant at their disposal, each primary supervising physician in the demonstration project is paid a stipend to “encourage participation”, as well as to “compensate for potential lost earnings and productivity”. This stipend is currently up to $72,000 over two years per physicianxii. Supervising physicians in the demonstration project also receive a $5,000 completion bonus for supervising their assistants.xiii
Finally, when the need for consultation arises, the physician would also receive compensation for his/her attendance or services. Overall, the cost of introducing just one physician assistant to the Ontario health-care system averages just over $150,000 per year.
RNAO is committed to interprofessional collaboration with a view to improving the public’s access to safe, high-quality and universally accessible health services. Evidence shows this can be done effectively and efficiently through expanding the scope of practice of existing self-regulating health professions in accordance with their education and competencies. For example, expanded roles for registered nurses to enable them to work to their full scope of practice will maximize health-care resources and improve access to services. Registered nurse first assists (RNFAs) with additional certification in surgical assistance have been shown to reduce wait times, facilitate continuity of care and have a positive impact on patient outcomes.xiv Clinical nurse specialists (CNSs) are advance practice nurses who have made a significant contribution since being introduced in the early 1940’s.xv Nurse practitioners have the knowledge, skills and competencies to provide access to essential health services in community, long-term care and hospital settings.xvi xvii Yet NPs, like RNs, are still not being fully utilized in Ontario and face barriers limiting their ability to practise to their full scope.xviii It is in this context that the RNAO does not support the introduction by the government of the new category of unregulated physician assistants (PAs).
PAs are not the answer to the need to provide access to high-quality, client-centred, cost-effective health care utilizing all health professionals to their full scope. Physician assistants have the potential to promote fragmentation of patient care rather than interprofessional collaborationxix that the evidence saysxx is in the best interests of patients and the efficiency and cost-effectiveness of the system. They fail at the primary objective of the HealthForceOntarioxxi initiative, namely to improve access to health services and quality of care, and decrease wait times.
i Nurse Practitioners’ Association of Ontario. (2009). History of NP Role Development in Ontario. NPAO. Retrieved from: http://www.npao.org/history.aspx
ii Ozon, P. (2003). Canadian Forces Physician Assistant Program. Canadian Medical Association. Retrieved from: http://www.cma.ca/multimedia/CMA/Content_images/Inside_cma/Accreditation/Physicians_Assistant/1_2_ozon.ppt.
iii McMaster University (2008). McMaster University > Physician Assistant Education Program > Prospective Students. Retrieved from: http://www.fhs.mcmaster.ca/physicianassistant/prospective_students.html Hamilton, ON.
iv University of Toronto (2009) Physician Assistant Education Program. Faculty of Medicine. Retrieved from: http://www.paconsortium.ca Toronto, ON.
v Faculty of Health Sciences. (2008). Mac pioneers Physician Assistant Program. McMaster University. Retrieved from: http://fhs.mcmaster.ca/main/news/news_2008/physician_assistant_program.html . Hamilton, ON.
vi University of Toronto (2009) About the program. Faculty of Medicine. Retrieved from: http://www.facmed.utoronto.ca/programs/PAEducation/About_the_program.htm. Toronto, ON.
vii Mikhael, N, Ozon, P., and Rhule, C. (2007). Defining the Physician Assistant Role in Ontario: Ontario Physician Assistant scope of practice statement and Ontario Physician Assistant Competency profile. HealthForceOntario: Toronto. p 6.
viii Hughes, N. (2008). Letter to the editor: Physician Assistant Role Clarified. MEDSURG Nursing, 17(2). P. 142.
ix Ontario Nurses’ Association (2009). Frequently Asked Questions: How do salaries compare based on expertise and education versus seniority? Retrieved from: http://www.ona.org/faqs.html#f16
x Ontario Ministry of Health and Long-Term Care. Effective April 1, 2009. (updated November 2009).
Ontario Ministry of Health and Long-Term Care
xii Ontario Hospital Association and Hay Group Health Care Consulting. (2009). Physician Assistant Demonstration Project Compensation for Hospital Emergency Department expansion sites. Toronto, ON.
xiii Hellyer, D. (2008). Physician Assistant Project. Funding Models: An Ontario Perspective. Ontario Medical Association presentation to 2nd National Symposium on Physician Assistants. Ottawa, ON. Retrieved from:http://www.cma.ca/multimedia/CMA/Content_Images/Inside_cma/Advocacy/Physician_Assistants/2008_symposium/Ontario-funding-models.pps
xiv Ontario Ministry of Health and Long-Term Care. (August 2009).Registered Nurse: Surgical First Assist (RN-SFA) Pilot Project Update. Toronto: Author.
xv Lewandowski, W., and Adamle, K. (2009). Substantive Areas of Clinical Nurse Specialist Practice: A Comprehensive Review of the Literature. Clinical Nurse Specialist. 23:2. 73-74.
xvi Cowan, M., Shapiro, M., Hays, R., Afifi, A., Vazirani, S., Ward, C., et. al. (2006). The effect of a multidisciplinary hospitalist/physician and advanced practice nurse collaboration on hospital costs. Journal of Nursing Administration, 36(2), 79-85.
xvii DiCenso, A., & Matthews, S., (2005). Report on the Integration of Primary health care Nurse Practitioners in the province of Ontario: Executive Summary (revised). Hamilton: IBM & McMaster University.
xviii DiCenso, A., & Matthews, S., (2005). Report on the Integration of Primary health care Nurse Practitioners in the province of Ontario: Executive Summary (revised). Hamilton: IBM & McMaster University, 19.
xix Registered Nurses’ Association of Ontario. (revised 2006). Client Centred Care: Nursing Best Practice Guideline. RNAO: Toronto. p. 21.
xx Health Professions Regulatory Advisory Council. (2008). An interim report to the Minister of Health and Long-Term Care on Mechanism to Facilitate and Support Inter professional Collaboration between Health Colleges and Regulated Health Professionals. HPRAC: Toronto.
xxi Ministry of Health and Long-Term Care. 2009). Ontario’s Physician Assistant Initiative. Health Force Ontario: Toronto, ON. Retrieved from:http://www.healthforceontario.ca/Work/OutsideOntario/HealthProfessionalsOutsideOntario/OntarioPhysicianAssistantInitiative.aspx
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