By now, most Canadian physicians will have some familiarity with physician assistants (PAs). Physician assistants are physician extenders who are trained under a medical model. They are not independent practitioners, but instead complement physicians by practising within the supervising physicians’ scope of practice. This occupation is being actively piloted in Ontario, and Manitoba has regulations in place for clinical assistants and PAs.1 Additionally, both provinces have initiated PA training programs within their faculties of medicine; the first class was scheduled to graduate in 2010. It is well known that the PA role originated in the US and Canadian militaries; although the genesis of civilian PAs in the United States is well documented, this is not the case in Canada. This article will summarize the origin of the civilian PA movement in Canada.
Backstory
The Canadian Forces (CF) has been training and employing military physician extenders since the 1960s, initially named 6B Medical Assistants and later renamed Physician Assistants in 1984. As a separate health jurisdiction with medical support needs unlike those of any other jurisdiction in Canada, the CF has greater flexibility to develop its health human resources (HHR) strategy, including the establishment of health occupations and scopes of practice to meet unique military requirements. It has never been feasible to place physicians in all places where military personnel must be engaged and medically supported. For deployments to such places as the Canadian Forces Station Alert (a very northern outpost), on board ships, and in small or dispersed locations in Canada and abroad, it is neither practical nor feasible to send medical officers to provide day-to-day medical support. To overcome this, the CF has employed superbly trained PAs to leverage and extend the role of physicians and to provide valuable primary and emergency health care, including emergency dental care.
Until the mid-1990s, the CF had its own military hospitals. All CF PAs were trained for their role within the CF hospitals using their unique training systems. However, with the cessation of the Cold War, the desire for a financial “peace dividend,” and the consequent reduction in the size and budget of the CF, all military hospitals were closed and all domestic inpatient care was contracted out to the civilian community. This created meaningful challenges in the continued training and development of military PAs. To ensure ongoing training, it was necessary to contract out the clinical internship to civilian hospitals. This was not an easy process as, up until this point, few medical personnel in Canada had even heard of PAs unless they had had previous exposure to the US medical system.
Owing to this unfamiliarity, much effort was required to inform and educate our civilian partner hospitals and their staff about PAs and the kind of training they required in order to fulfil military functions. The cooperation of our civilian partners was outstanding, but the lack of clarity and familiarity in matters of liability, scope of practice, competency, etc, meant that constant effort was required to maintain this partnership. When key positions turned over in any given hospital, the educational and informational campaign had to be restarted—clearly not a sustainable method and far from ideal.
Coincidentally, while the CF was managing this challenge, there was growing pressure to demonstrate accountability; having non-accredited or uncertified health care practitioners in the CF became problematic. This led to the following question: how do you regulate, license, or certify a profession that has no civilian equivalent in Canada?
Accreditation of civilian PAs
Two interrelated and concurrent efforts were relevant to addressing the matter of PA accreditation and certification and to resolving the training challenges of military PAs in the civilian sector. To address deficiencies in our ability to train and accredit PAs, the CF Health Services commissioned the Standing Committee on Operational Medicine Review to recommend solutions. The recommendations of this committee2 were to develop a civilian-accredited military training program for PAs and to support the creation of the Canadian Academy of Physician Assistants, which was later renamed the Canadian Association of Physician Assistants (CAPA).3 The second effort in particular arose from a grass-roots desire among military PAs to establish an entity that promoted the values and professionalism of PAs in Canada based on the US model. These 2 initiatives came up in parallel in the spring of 2000, and a decision was made to aim for civilian recognition and accreditation using CAPA as a vehicle to achieve this end.
After examining potential approaches to achieving civilian accreditation, there was only one sensible option: the Canadian Medical Association’s (CMA’s) Conjoint Accreditation process, which provides “a leadership role to ensure national standards for the education of about 40 000 health care practitioners who perform diagnostic and therapeutic services to support physicians in the clinical setting.”4 After 3 years of preparatory work by the CF Health Services and CAPA, the CMA Board of Directors unanimously endorsed the profession of PA in Canada in May 2003. The CF Medical Services School in Borden, Ont, was thus the first PA educational institution in Canada to achieve accreditation by the CMA in August 2004 and to graduate PAs with bachelor’s degrees (through the University of Nebraska) in 2009. All graduates were then eligible to write the PA certification examination under the auspices of the Physician Assistant Certification Council of Canada. This approach was validated in a review by the Office of the Auditor General,5 which confirmed and concluded that the CF should not have health care providers who were not regulated or certified by a competent external civil authority.
The CMA’s Conjoint Accreditation process required that the PA program developed by the CF be relevant to the pan-Canadian health care landscape. This meant much consultation with the civilian sector to ensure that the PA educational and training programs and CAPA were able to account for the potential that the PA occupation could one day primarily comprise civilians. The CMA’s engagement, leadership, and consultative efforts greatly contributed to the awareness and legitimacy of the PA as a health care profession in Canada as well as to the development of another option with which to address ongoing physician shortages and general HHR challenges in Canada.
Although the origins and early phase of the PA movement in Canada are rooted in the CF, the movement continues to grow and develop in the Canadian civilian sector. Given the success that the CF and the US health care systems have enjoyed over many decades through the employment of PAs, the early successes of the various pilot projects in Canada, and the need for innovative solutions to address HHR challenges, the future of Canadian PAs is looking bright.
Footnotes
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This article has been peer reviewed.
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Competing interests
None declared
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The opinions expressed in commentaries are those of the authors. Publication does not imply endorsement by the College of Family Physicians of Canada.
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La traduction en français de cet article se trouve à www.cfp.ca dans la table des matières du numéro de mars 2011 à la page e81.
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A Clinical Review of the role of the physician assistant in Canada appears on page e83.
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