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Physician Assistants, Legal and Ethical Use in Practice

September 4, 2020

The response to my previous opinion piece regarding the legal and ethical use in practice of Physician Assistants [PA] demonstrates, in my opinion, the inappropriate utilization of these extremely beneficial individuals by some physicians in the delivery of healthcare that has gone on since the introduction of the PA program and continues to go on in private practice.

The point of my opinion piece in the use of PA in medical practice is not to suggest for a moment that PAs are not desirable, qualified or are not an important resource in the delivery of care model. The point of my piece is to bring to the attention of the medical profession that the manner in which many, [ not all,] physicians are utilizing PAs in private practice is not in accordance with acceptable professional practice. PAs are “assistants” to the physician. Many physicians appear to believe that they can be a “substitute” for the physician.

The standards of practice of the medical profession are Regulated by the College of Physicians and Surgeons of Ontario. [Or the Province in which the physician practices]. Regardless of what training PAs have, regardless of what the educators indicate the PA is competent to perform and carry out, and regardless of what they may have actually been exposed to in training, the physician cannot permit any delegate to perform any task or procedure that would generally be regarded by the Regulator as contrary to or falling outside of the generally accepted standards of medical practice.

It is a fact, while it might be unpopular to hear, that PAs are not permitted to;

a] Engage in a patient encounter in the absence of the supervising physician being on the premises and immediately available to intervene if necessary; Moreover, with a few exceptions, a physician-patient relationship must be established first.

b] PAs may not do everything a physician by education training and experience and is permitted to do pursuant to his or her independent practice certificate even if their own educators vouch for the competence in specific services or procedures;

c] some procedures are not generally delegated to non-physicians whether or not the delegate is trained or competent to perform the procedure.  An International Medical Graduate who may have been a consultant specialist and in practice for several years as a registered physician in the country of qualification simply cannot do certain things in assisting an Ontario physician in practice. It is no different for a PA. and the most important key to the entire situation is that the delegate is “assisting” the physician;

d] a PA may never bill the Ontario Health Insurance Plan [OHIP] on the physicians billing number for a service that was wholly performed by the PA.

The CPSO policy on delegation is not a direction or a license for physicians to delegate those services and procedures that the standards of practice of the profession expect and anticipate will actually be carried out by the physician. The overriding requirement when delegating is that in every instance the primary consideration must be the best interests of the patient. Controlled acts must not be delegated solely for monetary or convenience reasons and quality patient care must not be compromised by the delegation. “… Delegation must only occur in the context of an existing physician-patient relationship, unless patient safety and best interests dictate otherwise. This will usually mean that the physician has interviewed the patient, performed an appropriate assessment, made recommendations, obtained an informed consent to proceed and ordered a course of therapy.” The policy goes on to direct that “in some instances, the  patient’s best interests will be served by having the controlled acts performed prior to assessment by the physician [in a hospital emergency room for example, where it is common for some tests to be ordered before a physician has seen the patient]. In such circumstances, the delegation may take place pursuant to a medical directive. When this happens, it is expected that a delegating physician under whose authority the controlled act has been performed, will meet and assess the patient as soon after it has been performed as possible.”

The delegated task or procedure must be one that is accepted by the profession at large and thus by the Regulator to be generally delegated to a non-physician. Breast examinations, internal examinations, anal examinations and full body general assessments are not generally accepted by the profession at large to be within the standards of professional practice to delegate.

 As a matter of law, a PA has no independent practice authority. Cannot make a diagnosis or order treatment plan for patient. The PA can communicate that information to the patient on behalf of the physician. The PA has no independent practice authority.

Admission requirements for the PA program are a minimum of two years in a University undergraduate program and an additional 24 months of clinical training. 

Testimonials

Ms. Tremayne-Lloyd was the keynote speaker at the Medical Staff Association 2011 meeting on June 20, 2011. Her presentation was titled: “Hospital Governance: An Indispensable Joint Venture of Medicine and Management and Rights and Responsibilities of the Medical Staff”. The presentation was well received by the Medical Staff and the topic was certainly relevant. We would recommend her and have her back for any further topics.

Hien Ta, M.D., FRCPC Past Medical Staff President, York Central Hospital

Tracey Tremayne-Lloyd Health Law