In brief
- Physician assistants (PAs) provide care to patients by performing specific medical acts delegated to them by physicians.
- To address healthcare human resource shortages, many provinces have introduced frameworks to license and regulate PAs.
- Appropriate delegation and supervision are key to the physician-PA relationship.
- CMPA liability protection generally does not extend to physician assistants who work independently of a supervising physician.
Regulation of physician assistants
While PAs are not yet regulated in all provinces and territories, many jurisdictions do have some form of regulation or will soon be regulating PAs. PAs have not been integrated into the healthcare systems in Québec, Northwest Territories, the Yukon, or Nunavut.
PAs are currently regulated by the Colleges in Alberta, British Columbia, Saskatchewan, Manitoba, New Brunswick, Nova Scotia, and Prince Edward Island. In these jurisdictions, PAs must meet specific registration requirements (e.g. hold certain qualifications) and must practice under physician supervision. There is also pending legislation in Ontario that will establish PAs as a new class of members regulated by the College.
In other jurisdictions (e.g. Newfoundland and Labrador), PAs are being integrated on a less formal basis.
Delegation, supervision, and the standard of care
Despite being regulated in some provinces, PAs are not independent healthcare professionals. Instead, they provide care to patients by performing specific medical acts delegated to them by physicians. Most PAs work exclusively under medical directives.
This means that appropriate delegation and supervision are key to the physician-PA relationship. In the event of a College complaint, hospital complaint, or civil legal action, supervising physicians will be evaluated on whether they met the standard of care when delegating and supervising tasks. Doctors who delegate tasks that are beyond an individual PA’s training and experience, or who do not properly supervise the PA, may be criticized.
Assessing a physician assistant’s competencies
When deciding which medical acts to delegate and how much supervision is appropriate, supervising physicians should first assess a PA’s competencies, skills, and experience in the targeted practice setting (e.g. emergency department, anaesthesia, or family medicine). It is important to recognize that PAs cannot perform tasks that are outside the scope of practice of their supervising physician.
Assessing whether a PA is adequately trained can sometimes be difficult for supervising physicians. The physician must ultimately exercise good clinical judgment when determining if the PA is clinically competent to perform a particular task.
Physicians should also check with their College, hospital, or health authority to see if there are relevant policies and guidelines setting out the degree to which PAs can perform certain tasks. This is particularly important in those provinces in which PAs are regulated.
Working with a physician assistant
The most common concern for supervising physicians is their potential exposure to the risk of liability for the PA’s clinical duties. A supervising physician remains responsible for the medical care provided to the patient, including any care delivered by the PA as delegated and supervised by the physician. Delegation should therefore only occur in appropriate circumstances. In every instance of delegation, the primary consideration must be the best interests of the patient.
The supervising physician should be available to the PA to give direction. The specific requirements for a supervising physician’s availability vary from jurisdiction to jurisdiction. Physicians should consult with their College for the requirements in their area.
While PAs are not independent practitioners, they can work with a “degree of autonomy," depending on the clinical task and their skills. The degree of autonomy should be agreed to by the supervising physician and the PA.
Many PAs may work under medical directives or standing orders issued by the supervising physician(s). Physicians must keep in mind that the use of medical directives does not reduce their exposure to the risk of liability or discipline if there is negligence on the part of the PA while carrying out the order.
Physician assistants need their own liability protection
The CMPA strongly supports collaborative healthcare, including the use of PAs. However, a crucial element to the effectiveness of any collaborative care model is that all healthcare professionals practising within a healthcare team have sufficient and adequate liability protection.
CMPA members are generally eligible for CMPA assistance for medico-legal difficulties arising from their medical professional work, including from the supervision of other healthcare professionals such as PAs. However, CMPA assistance does not generally extend to non-physician healthcare providers, including PAs, who may see patients with a degree of autonomy, even when they are employed by a member physician.
In situations where PAs are employed by a hospital, health authority, or institution, liability protection might be available to the PA through the employer’s insurance provider. When PAs are employed by individual physicians or private group practices, they must obtain their own liability protection from a commercial carrier. Professional liability protection is not only a regulatory requirement for PAs but is one of the necessary elements for physician-owned clinics to be eligible for CMPA assistance if the clinic employs PAs. This protection, which can be obtained through the Canadian Association of Physician Assistants, should address all aspects of the PA’s employment and must be adequate and appropriate for the work they do.
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