# Nurses cautious about expanding role of physician assistants



## Armymedic (26 Jan 2009)

My comments to follow:

http://www.cbc.ca/health/story/2009/01/23/physician-assistants.html

Nurses cautious about expanding role of physician assistants
Last Updated: Friday, January 23, 2009 | 6:10 PM ET CBC News 
Several provinces are looking at physician assistants as a way to shorten patient wait times, but a nursing group says there is no place for them in the Canadian health care system.

Physician assistants have been used in the military for decades, and they work in many hospitals and clinics in the U.S. They work under a doctor's supervision, doing everything from filling out paperwork to prescribing medication to surgical procedures.

Manitoba came up with a plan to fast track surgeries using physician assistants in 2003. One surgeon works on overlapping operations in two rooms, with two teams of anesthetists, nurses and physician assistants.

Jose Araneta is one of 55 clinical assistants, as they are known in Manitoba. Araneta said when he started working, they were doing three knee replacement surgeries a day about twice a week, and the waiting list was about 28 weeks.

Now, "we usually get seven, eight cases done by 3:45," Araneta said.

Pilot project in Ontario
Officials at Ontario's health ministry saw what was happening in Manitoba and started a pilot project to see how physician assistants could fit into its system.

"This is another way that they can get highly qualified care when they need it, where they need it, as part of receiving care from a team," said Dr. Joshua Tepper, an assistant deputy health minister in Ontario.

The idea is meeting with resistance, however, from the Registered Nurses Association of Ontario. The group said Ontario should be training more nurse practitioners instead, because they are better educated and have more autonomy than physician assistants.

Physician assistants will have to turn to nurses or call physicians to act on medical directives when a patient's situation changes, said Doris Grinspun, executive director of the RNAO.

Grinspun said she is especially worried that some physician assistants are doing surgical procedures, which she says puts patients at risk.

I would say to my family, friends, colleagues, to the public: don't let them touch you," said Grinspun. "Make sure to ask who is taking care of you."

In Winnipeg, Ian Jones, vice-president of the Canadian Association of Physician Assistants, bristled at Grinspun's view. Jones works in neurosurgery.

"If I was drilling into somebody's skull by myself, I would be nervous too, but I don't," said Jones. "I work with a physician. I'll have the drill on my arm, he'll be standing right there .… When you need an extra set of hands, my hands are there. So I can make the neurosurgeon a lot more effective and efficient. And that's my job."

Alberta is also looking at allowing physician assistants to take some of the workload normally done by doctors.


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## Armymedic (26 Jan 2009)

Here is the comment by the head of the Registered Nurses Association of Ontario:


> Grinspun said she is especially worried that some physician assistants are doing surgical procedures, which she says puts patients at risk.
> 
> I would say to my family, friends, colleagues, to the public: don't let them touch you," said Grinspun. "Make sure to ask who is taking care of you."



They also say that Ontario should be training more nurse practitioners instead, because they are better educated and have more autonomy than physician assistants.


Wow, there is no empire protection there. I am certain Mrs Grinspun has never dealt with a PA nor seen one work outside of a training environment. 

Nurse Practitioners are highly trained nurses, and have their role in health care. They excel in areas where long term patient care, counseling, and monitoring are needed, like adult diabetes.

PAs are trained in the medical model (same as doctors) and not in the nursing model so that they think and problem solve in the same way doctors do. Hence the also speak the same language. Doctors prefer the "assistance" and ability to extend their services that PAs give them. For doctors, time is money, and for patients time wasted is money. So if a PA can spend more time with a patient doing things that take time, and a doctor can see more patients in the finite amount of time they have, then everyone benefit.

The reason the Winnipeg Surgeon/PA model is working is because the surgeon is no longer wasting time on prep and post procedures which are easily done by his assisting PA, and can now have 2 or 3 surgical teams doing operations in rotation where the surgeon comes in, does what he needs to do and moves on. Versus before, where they had do do each surgery one at a time.

And the PA is responsible to the surgeon for all pre- and post-surgical care of the surgical patient. Giving more intimate care than the surgeon alone.
More surgeries completed per day means less time on shorter waiting lists.


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## Blackadder1916 (26 Jan 2009)

I would say it is not so much "empire protection" as growing pains for two occupations (both NPs and PAs) that are only just raising their heads in Canada.  Both look south and see the opportunities available for individual practice and hope that Canada adopts the model(s).  

While in Canada, it can easily be said that NPs are raised and practice in a "nursing" model, it is not so cut and dried in the United States.  You may find that many are working in situations that we would associate with a PA, often side by side and sometimes interchangeable (mostly in primary care/family practice).  You can find an example (personal experience of mine) where NPs and PAs do the same job here.  At one time (10+ years ago) the PA and NP program at Stanford University was intermingled (actually the same program in name).  There were one or two additional things NPs had to do, but at the end of a two year program the PAs left with an Associates degree and the NPs left with a masters.  I don't know if they still follow the same model.

For both NPs and the few PAs, employment in Canada is still mostly restricted to being a salaried employee, usually for a public entity.  The opportunity (like in the US) for "independent" practice in a private clinic where one bills a provincial health plan on a fee for service basis (just like a doctor) is very, very far away.  This article  gives an impression that (for services rendered and billed) NPs and PAs are more similar than different south of the border.


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## Snakedoc (27 Jan 2009)

Is there a similar sentiment among NPs within the military environment towards PAs?  Or are there too few NPs to tell?


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## Civvymedic (27 Jan 2009)

I worked as an Advanced Care Paramedic in a Toronto ER during a pilot project at the Hospital for Sick Childrens ER and St. Josephs Health Centre ER a few years ago. Clinically and Practically it worked very well! Politically it was a nightmare for the Hospital CEO's because of this type of approach from some members of certain Nursing organizations. Much fear mongering was put forth, and much effort was put on having this practice stopped by the same organizations even though the Paramedics were IN ADDITION to existing Nursing staff. Eventually the program was cancelled and finally Ontario is bringing in PA's.

Health Care has changed, new delivery methods are needed to augment existing programs and PA's work well elsewhere and will work well in Ontario we just have to get past some old thinking, cliches and "empires".

It's too bad because it was a good thing for the patients and the system.


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## DartmouthDave (27 Jan 2009)

Hello, 

On White Coat Black Art had a podcast on PA, NP and if I remember correctly expanded scope Paramedics (on Long Island, NS).  It is quite good.

As for Civvymedic.  It is too bad that the ER program fell flat.  But I can see why.

Turf protection is strong in all professions.  I am sure, ORNGE would welcome nurses (NICU notwithstanding) with open arms?  Or, BC Ambulance would let NICU nurses take on the role of ITT paramedics? No, there would be serious 'fear mongering' by paramedics, I am sure.  It is only natural to protect ones turf.

Speaking for experience, it is amazing how cooperation between RN and ACP turns to a mass extention of nursing once the power balance shifted.  My experience from the side of the fence.

LOL....I guess that makes it a tie. =)

This of course kills new methods of care delivery.


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## Civvymedic (27 Jan 2009)

Dave,

I see your point. I know it's true all professions protect there turf. I just think that we can all work together as a team and get along. IT CAN BE DONE. Patients and the ailing system come first. I should point out that the Nurses we worked beside in the ER I was at (St. Joe's) were more than happy to have us there. They looked specifically for people who would work hard and make themselves very useful in the ER and everyone who was actually in the arena seemed to appreciate the program. It was the outsiders, staff from other floors and other organizations created the "issues"

Actually my partner today on the Ambulance is an RN, never went to Paramedic school just challenged the exam. No one is complaining.


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