Ask Dr. Brian Show: Question About Physician Assistants

A few weeks ago, we asked for your good questions about the hows and whys of getting what you need from the health care system.  As usual, you didn't disappoint us.  Here's a sample of the many questions we received.   Lisa Seib of Winnipeg sent us this question:  "I'm curious to hear your opinion on the introduction of Physician Assistants to the Canadian healthcare system. Do you see a future for this profession? In your career have you worked with any PAs and how would you compare their scope of practice with that of Nurse Practitioners? In your opinion are there specialties that are better suited to each respective profession?  Most of all, do you see potential for PAs to work in family practice medicine in the future?"  See the answer below.  And join us for our season-ending 'Ask Dr. Brian' edition of White Coat, Black Art Saturday June 25 at 11 am (11:30 am NT) and Monday June 27 at 11:30 am (3:30 pm NT) on CBC Radio One.

Lisa, let me begin my answer with a bit of background.  Physician Assistants (PAs) have a long and storied history as battlefield medics.   Currently, they serve in the Canadian Forces mission to Afghanistan.  PAs have been used widely in the civilian sector in the US since the mid-1960s when severe shortages of family physicians meant looking for a new type of professional to fill the gap.  Many PAs returning stateside from military missions wanted to find a way to use their considerable skills in civilian health care.  An estimated 200,000 PAs work in the US.  There are numerous accredited PA programs in the US; in Canada, there are Master's Degree programs at the University of Toronto, McMaster University in Hamilton, and the University of Manitoba. 

PA's are often equated with Nurse Practitioners (NPs).  However, there are fundamental differences between the two professions.  NPs by definition have an independent scope of practice.  That means they function independently of MDs.  By contrast, PAs must practice under the direct supervision of a physician.  For that reason, PAs are sometimes referred to as 'physician extenders' because they enhance but do not replace the physician.  Under the current system in most provinces in Canada, the PA can't issue orders, perform invasive physical examinations or carry out procedures such as stitching cuts and setting broken bones without direct physician supervision.  That may change if and when PAs become a regulated health profession.

I believe that PAs can play a substantial role in Canada's health care system.   I work with a PA in my own ER.  He sees patients under our direct supervision, puts in stitches and does other procedures.  He helps us see patients more quickly and helps us meet our provincial targets for timely care.  I have also seen or heard of PAs assisting internists, surgeons, critical care specialists and family medicine. 

Three years ago, I visited Concordia Hospital in Winnipeg.  There, I witnessed a pilot program in which PAs assisted orthopedic surgeons doing hip and knee replacements in the operating room.  Having PAs enable the surgeons there to run two operating rooms at virtually the same time.  As a result, surgeons at Concordia Hospital have been able to double the number of hip and knee replacement operations performed there. 

By the same token, I also work with a NP in our ER who is extremely bright and capable.  Recently, I worked alongside her resuscitating a critically ill patient and found that the two of us functioned better than either of us individually. 

I think PAs and NPs can enhance the work of family physicians as well as specialists.  I suspect that PAs may be more effective than NPs as surgical assistants because in the operating room, the surgical assistant takes orders from the surgeon.  By contrast, since NPs have an independent scope of practice, they may function better than PAs providing anesthesia in the OR, since the person who functions in that role is not under the direct supervision of the surgeon. 

Given an aging population plus the growing complexity of modern health care, I don't see physicians by themselves being able to look after the needs of every patient.  Therefore, I see a bright future for PAs and NPs alike in family medicine and virtually every specialty of medicine.

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