Guide to working with Physician Assistants (PA)
What is a Physician Assistant (PA)?
Physician Assistants (PAs) are highly skilled health care professionals educated in the medical model who practice medicine. Canadian Certified Physician Assistants (CCPAs) are trained in the same medical model as physicians. PAs graduate from a Baccalaureate or Master’s Degree program that may be affiliated with a medical school and ultimately, work to extend physician services and can work autonomously, but are not independent practitioners.
PAs practice medicine under the supervision of a licensed physician within a patient-centred health care team. While PAs are relatively new to Canada, they may work in just about any clinic setting and can help to extend physician services, complement existing services, and aid in improving patient access to health care.
They are able to conduct histories/physical examinations, order and interpret investigations, prescribe non-controlled substances, diagnose and treat illnesses, educate patients on treatment options, and counsel on preventative health.
In this setting, PA/MD teams help to improve patient access to high quality care,saves the health care system dollars, improves practice efficiency, improve continuity of care, reduce wait times, increase physician time savings, reduce physician workload and burnout and expand a practice’s flexibility to provide after hour services & accommodate more same-day appointments.
What is the role of the supervising physician?
PAs can work independently, but are not completely autonomous.
In Ontario, medical directives are strongly recommended to allow PA to carry out treatment, interventions & procedures. PAs can work with multiple supervising physicians, and one supervising physician can work with multiple PAs.
Supervising physicians should also be aware of what PAs cannot do, which include prescription of controlled substances. PAs cannot practice independently of a supervising physician. However, supervision can be direct or indirect.
The foundation for a successful PA/MD working relationship requires mutual respect and trust, open communication, and freedom to ask questions and seek guidance for complex cases or issues related to practice.
Defining Supervision in PA/MD Relationship
Direct supervision involves the physician being physically present in the patient encounter.
Indirect supervision means the physician is available by phone or by electronic means (secure internet network, or EMR messaging) to review patient cases and answer PA questions.
The supervising physician is responsible for ensuring that the PA is adequately supervised, which means access to the supervising physician is reasonable should the PA wish to consult the physician.
An example of inadequate indirect supervision includes when the physician is not accessible by phone, the physician is not in the country (and cannot come in to intervene, or be available to discuss the case should an issue arise). As per the CPSO, the responsibility of the delegated acts falls ultimately on the delegating physician.
SUPERVISION BY PRACTICE SETTING
In a family medicine / rostering model, it is not uncommon to have Physician Assistants seeing their own patients, without the physician physically stepping in. The PA would consult the supervising physician for difficult or unusual cases, and the physician would review the PA’s chart, and sign off on those charts and/or each case without having to be physically present in the room to interact with the patient. This supervision is considered indirect, since the physician is available in the building or via phone but not directly in the patient encounter.
In Ontario, a physician in a specialty or general setting that uses a fee for service model requires direct PA supervision if they wish to bill for the services (patient assessments, and consults) rendered by a PA. Outlined in the OHIP Schedule of Benefits, a document that outlines how physicians are paid in Ontario, it states that physicians cannot bill for delegated tasks (assessments) performed by a PA unless they actively participated in the patient encounter. This rule is not the case for PAs in the United States, or other Canadian provinces.
SUPERVISION BY PA EXPERIENCE
When a PA first begins working, the supervising physician may consider starting with direct supervision first.This helps establish a working relationship, the physician can gauge first hand the PA’s knowledge and competency with assessment, ordering relevant investigations, assessment and plan, patient communication. It’s also a great opportunity for the physician to provide feedback and guidance on how they prefer assessments and procedures be performed as well as how they prefer their medical documentation for patient encounters. Feedback on observed PA performance can be given in the beginning, and this method is not uncommon for integration of a PA into a new practice (i.e. in the ER, family medicine, etc.).
With time, as the PA becomes more accustomed to the practice and patient population, a more indirect approach may be taken with supervision where a physician is on site, available by phone, EMR messaging or electronically.
For PA/MD relationships that are more well established, or perhaps where the PA is more experienced, the PA in many practice settings performs delegated tasks autonomously in an environment of mutual trust and understanding of the strengths and skills that benefit patient outcomes and practices.
Billing for PAs in Canada
In Canada, PAs DO NOT have billing numbers and do not independently bill for services rendered.
The Canadian Medical Protective Association (CMPA) has a document on working with Physician Assistants. The CMPA also provides medical-legal assistance and advice for CMPA members, including billing audits and inquiries. MDs can seek medical-legal advice or consult the CMPA at 1(800) 267-6522 if they have questions.