International development of the physician assistant profession

Introduction

The PA profession has continued to grow and develop in the Canadian health care system over the last few decades. PAs were introduced in Canada for a variety of reasons. They were first introduced in the Canadian Armed Forces (CAF) to augment the medical services provided by a small number of physicians across a vast geographic region. In Manitoba, they were implemented to address rapid turnover of fellows in specialty services. Specialties such as neurosurgery, cardiology, bone marrow transplantation, and plastic surgery were early adopters and continue to be the primary employers of PAs in Manitoba. In Ontario, they were introduced to address a shortage and maldistribution of primary care providers in rural, remote, and other underserved areas. Canada is the second largest country in the world by land mass. There are over 35 million people living in Canada, with approximately 90% living within 100 miles of the southern border. This leaves large swathes of Canada with low population density and difficulty providing medical services to widely scattered people.

According to the 2019 Canadian PA census, as of July 2019 there were over 870 Canadian Certified Physician Assistants (CCPAs), representing a 41% increase since 2016. Geographically, approximately 42% work in Ontario and 10% in Manitoba, with the rest spread among different provinces and territories. Almost half work in urban or metropolitan areas; 46% work in communities of less than 250,000 people, and of these, 11% work in communities of less than 5000. Finally, 6% work at military postings.

Canadian PAs work in over 30 medical or surgical subspecialties. Many PAs report working in primary care, with 24% in family practice and 14% in emergency or urgent care. 18% work in hospital medicine and 14% in hospital surgery. 11% report working in the CAF.

Scope of practice

Similar to their American counterparts, Canadian PAs are “medically educated clinicians who practice medicine within a formalized agreement with physician(s).” Canadian PAs work in collaboration with physicians in a wide range of settings and clinical roles, often in interprofessional teams. The PA scope of practice is determined by a formalized agreement with one or more physicians and by the laws of the province or territory. PAs must practice within the scope of practice of their collaborating physician. The specific role of an individual PA is determined by the practice setting and by the physician–PA relationship.

The Occupational Competency Profile for civilian PAs was developed in 2001. This professional competency profile was updated in 2009, and again in 2015, to mirror the widely accepted Canadian framework for physician training, CanMEDS, which was developed by the Royal College of Physicians and Surgeons of Canada in the late 1990s. The PA Competency profile, now known as CanMEDS-PA, defines the roles and competencies that a generalist PA should possess on graduation. It is the accepted standard in Canada for PA education, certification, continuing professional development, and program accreditation.

Certification

To obtain PA certification in Canada, candidates must graduate from an accredited PA program and pass the National PA Entry-to-Practice Certification Examination, administered by the Physician Assistant Certification Council of Canada (PACCC) since 2005. Additionally, to maintain certification, PAs must log continuing professional development hours annually.

Graduates of both Canadian and American PA programs are eligible to take the Canadian entry-to-practice exam; however, Canadian-educated PAs are not yet eligible to write the American National Commission on Certification of Physician Assistants (NCCPA) exam. Practically, this means that Canadian-educated PAs are not eligible to become certified in the United States, whereas U.S.-trained PAs are eligible to become certified in Canada.

Education

There are four accredited PA educational programs in Canada. From 2004 to 2018, these programs were conjointly accredited by the Canadian Medical Association (CMA) and CAPA. At the time of this writing, CAPA is engaged in a search for a new accrediting body, after CMA’s divestment from its conjoint accreditation services. The CAF PA program has been delivered by the Canadian Armed Forces Health Services Training Center in Borden, Ontario since 1984 and is open only to qualifying members of the Canadian Forces. There are three civilian university PA programs that opened between 2008 and 2010. The Consortium program is housed at the University of Toronto and is delivered in collaboration with two other institutions, the Northern Ontario School of Medicine and The Michener Institute of Education at UHN. The Manitoba program offers a master’s degree, whereas McMaster, Toronto, and the CAF programs offer a bachelor’s degree. The CAF program began awarding a bachelor’s degree in 2009; the degree is granted by the University of Nebraska Medical Center, with which CAF maintains a formal agreement. All programs are approximately 24 months in duration and deliver curricula aligned with CanMEDS-PA ( Fig. 6.1 ).

History

Like the American model, the Canadian PA profession has its roots in the Canadian military, evolving from earlier roles similar to PAs. In Canada, PAs were first educated and employed by the CAF to support and extend medical services beyond the capacity of the relatively small number of physicians serving the military. Before World War II, these assistants were called “sick berth attendants.” After WWII, they were known as medical assistants, and with more advanced training, they could become medical technicians. In 1984, the title “physician assistant” was adopted, and in 1991, the role of senior medical technicians was formally changed to PA. For many years, PAs in the Canadian Forces were the only PAs in Canada.

The PA national organization, the Canadian Association of Physician Assistants (CAPA), was formed in 1999, with support from the CAF. In 2003, CMA recognized being a PA as a health care profession. In 2010, CAPA and CMA collaborated to create a national PA Toolkit as a resource for physicians and other stakeholders considering hiring PAs. The same year, on November 27th, a funding agreement allowed CAPA to incorporate as a civilian agency, removing the CAF’s fiduciary oversight role. Therefore November 27th is National PA day in Canada each year. In 2016, CAPA commissioned the Conference Board of Canada to research and create a detailed review of the impact of PAs in Canada to date. Three reports and a final briefing were published between 2016 and 2017, highlighting the positive impact of PAs on the Canadian health care system.

Canadian armed forces

PAs in the CAF provide medical services under some of the most extreme conditions, often in austere settings with only remote physician supervision. The National Defense Act stipulates that the CAF has the legal authority to provide and manage its own health care professionals. Accordingly, CAF PAs work on military bases located in all provinces and territories, even those in which civilian PAs cannot work under current provincial legislation ( Fig. 6.2 ).

Until recently, the pathway to becoming a CAF PA was through advanced training for noncommissioned officers who had been previously trained and were experienced as medical technicians. A significant advance came in 2016 when PAs transitioned from their status as senior enlisted noncommissioned officers to the newly identified commissioned officer occupation within the CAF. This is the first time in CAF history that a military occupation has gone from noncommissioned member to commissioned officer. This change will favorably address a number of challenges for military PAs. There will be better alignment between the level of education PAs receive and their status as commissioned officers. This will further improve teamwork with other Health Services officers, such as nurses, and justify potential clinical leadership opportunities for PAs. Additionally, the change to commissioned officer will address pay disparities between CAF PAs and their civilian counterparts. This will further enhance CAF recruitment opportunities, allowing the CAF to compete fairly with civilian employers and improve retention by mitigating the incentive for military PAs to leave the CAF for higher paying civilian jobs.

Provinces

Each province or territory has its own medical act that delineates the degree of delegation and supervisory requirements for PA practice.

Ontario

The highest concentration of PAs in Canada is found in Ontario. In Ontario, PAs practice under the Delegated Medical Authority of the Medical Act. In 2007, Ontario’s Ministry of Health and Long-Term Care (MOHLT) launched its PA demonstration project as part of its human health resource strategy, HealthForceOntario, to determine the impact of PAs on the provincial health care system. The demonstration projects also included a bridging program for international medical graduates to work as PAs.

In 2012, CAPA submitted an application for PA regulation to the Health Professions Regulatory Advisory Council (HPRAC). In a significant setback for Ontario PAs, HPRAC decided to recommend against PA regulation, citing insufficient risk of harm to the public, based on the relatively small number of PAs in the province and the physician supervisory model of practice. A mandatory PA registry under the Ontario College of Physicians and Surgeons was recommended, which would at least provide some form of title protection for an unregulated profession; however, this has not yet been implemented ( Fig. 6.3 ).

Additional barriers for PAs in Ontario are the absence of a billing structure for PA services and the lack of a steady source of employment opportunities. Although most physicians bill the provincial health system directly, there is no equivalent structure for PAs. Most PAs are paid salaries from their institutions, such as hospitals and clinics, whereas others are paid directly by their supervising physician, or from other, sometimes creative, funding sources. PA program graduates are offered employment under the Health Force Ontario Career Start Program, which is subject to annual renewal. These contracts generally only last 1 to 2 years in duration, with many PAs finding themselves back in the job market when the contract expires.