Physician Assistants: an idea whose time has surely come
                                                                         

Doug Thomson, CEO
Canadian Orthopaedic Association

Physician assistants (PAs) have been giving surgeons a helping hand since those epic times when Britannia ruled the waves and Napoleon, the battlefields of Europe - wherever casualties were likely to come in great numbers.

Indeed, World War II and the Korean War gave further impetus to creating the first formal PA training programme at North Carolina's Duke University in 1965, which remains to this day a leader in developing regulatory models for physician assistants. Widespread support from American physician groups led to spectacular growth in the PA profession; from 1992 to 2000, the number of PAs in the United States doubled. Currently, there are more than 70,000 physician assistants currently working throughout the US.

By contrast, Canada has lots of catching up to do, if it is to integrate PAs into its health care delivery system. At present, you have to be in the military and have had at least a decade of experience as a medic to receive PA training at Canadian Forces Base Borden in Ontario. Between 20 to 24 PAs are trained there annually under the auspices of the Canadian Forces Health Services School. In 2003, there were 130 PAs working in the Department of National Defense. The Canadian Association of Physician Assistants (CAPA), a military governance structure, provides membership representation on PA professional issues.

Unfortunately, with the exception of Manitoba, there is currently no legislative framework that allows physician assistants to practice in a civilian clinical context and, as a result, this valuable resource dissipates to other jurisdictions or other lines of work. But things are changing and picking up momentum.

An important milestone in turning the situation around came in 2003, when the Canadian Medical Association recognized physician assistants as bona fide health-science professionals in Canada. The CMA's recognition of the profession was contingent on development of a national occupational-competency profile for a civilian, general-practitioner physician assistant. According to Tom Ashman, a pioneering PA and founding member of CAPA, who now works as a consultant helping to transition the fledgling profession from army drab into civilian scrubs: "In order to achieve the recognition of the profession within Canada, we put together a board of governors - consisting of many physicians, a nursing officer and pharmacist, as well as some people with influence - that really acted as an advisory board. Together, we developed the national competency profile that was part of the prerequisite criteria for CMA recognition. I really wanted to make sure that my profession within the military could develop to its fullest potential and have verifiable, outside, evidence-based practice standards."

Now the challenge is to make contact with stakeholders such as federal government departments, provincial ministries of health, provincial Colleges of Physicians and Surgeons, provincial medical associations, regional health authorities, medical schools and so on. And that's where Tom Ashman comes in. During the summer of 2007, he received the letters of patent to incorporate a not-for-profit organization known as the PA Development Foundation of Canada Inc. (Ashman asked his mentor in the military, Dr. Ken Jenkins - now a VP Medical Services for Western Health in Newfoundland and Labrador - to become the Chair of the Foundation's board.) "The people on our board," says Ashman, "have a long history of working on PA development in Canada. We also have advisory people from both sides of the border who have been involved in some of the fundamental PA development in the US." The Foundation will provide consultancy services to stakeholders, as well as act as an information clearing-house and repository of the profession's acquired wisdom. "A one-stop resource," says Ashman, noting that he'd "like to see national standards developed that are transportable, whether you were trained in Newfoundland or BC or in between."

And Ashman has absolutely no doubts about who should be the profession's chief allies and most vocal supporters. It's built right into the professional designation: "You can't be a PA without a physician. Because our scope of practice is completely physician-dependent, I believe that the deployment of PAs in public clinical practice should be physician-led and physician-driven. One of the reasons PAs have been so successful throughout the last 30 years of development in the US is that physicians convinced other physicians that PAs were a good thing."

Data from Manitoba's experience with PAs, assembled by Dr. Eric Bohm of Winnipeg's Concordia Hospital, indicate that physician assistants freed up the equivalent of four, 50-hour work-weeks per year for their supervising orthopaedic surgeons. Similarly, in his analysis for his MBA thesis, plastic surgeon Lief Sigurdson's data demonstrated that a PA could increase surgical productivity by 36.7%, and he noted: "However, much greater discounted incremental cash flows, internal rates of return (IRR) and return on investment (ROI) were achieved when PA hiring allowed one surgeon to run two ORs simultaneously."

If all goes as planned, The University of Manitoba will launch the first PA training programme outside the military in 2008. In the meantime, Ontario has launched a number of PA pilot programmes, after considering the Canadian Medical Association's endorsement of the PA model and the research evidence from the US. British Columbia, Alberta, Nova Scotia and Newfoundland and Labrador have all expressed interest.

And the COA is on board. The National Standards Committee has endorsed physician assistants as an effective way to respond to Canada's health human resources crisis and make meaningful headway against patient wait times. "Professional associations and medical associations will be key partners in moving forward," says Ashman, who would like to see "PAs in practice in all jurisdictions in Canada within the next several years."

[If Bulletin readers would like to learn more about the PA Development Foundation of Canada and perhaps lend their support, they can contact Tom Ashman at This e-mail address is being protected from spam bots, you need JavaScript enabled to view it   or Dr. Ken Jenkins at This e-mail address is being protected from spam bots, you need JavaScript enabled to view it .]