TORONTO - Susi Schoeley knew she wanted to work in medicine, but nursing didn't appeal to her and becoming a doctor would require too much of a time commitment, both for earning her credentials and after entering the workforce.
So when she heard about a program to train practitioners who seemed to bridge the gap between the other two disciplines, she jumped at the chance.
Schoeley is on her way to becoming a physician assistant, or PA, a relatively unknown type of health-care provider in Canada, but one that has been steadily growing in numbers over the last four decades south of the border.
One of 45 students enrolled in McMaster University's physician assistant education program -- the first of its kind in Ontario and one of only three in Canada -- the 24-year-old is preparing to become a doctor's right-hand man, as it were.
"As a PA, we collaborate with our supervising physician all the time," the first-year says between classes at the Hamilton university. "We do everything from history-taking, examinations, reading lab results and basically being proactive with the patients -- being a good communicator, facilitating, advocating, managing."
"So we play a huge role along the side of the physician."
Dr. John Cunnington, assistant dean of the McMaster program, says applicants must have at least two years of university education for acceptance. And while a science background is preferred, it is not a prerequisite.
"The background can be varied and is varied," says Cunnington. Students range in age and experience, with some having left other jobs to embark on a second career following graduation from the program, which runs 24 straight months.
In first year, PA students learn anatomy and the science that underpins medical care, including how to investigate, diagnose and treat the various ills the human body and mind are prone to. That includes recognizing symptoms, knowing what tests to order and even learning to suture wounds or cast a broken bone.
Second year involves honing those skills while working under the supervision of practising physicians as "clinical clerks in the real world," says Cunnington. Rotations include weeks-long stints in a family doctor's office, hospital emergency, surgery, medicine and psychiatry.
"So by the time they finish, you have a person with a broad general education, knowledge and skills," he says.
McMaster introduced its course in September 2008 at the behest of the Ontario government, which has launched a two-year demonstration project placing PAs in hospitals, community health centres and doctors' offices with the goal of reducing patient wait times. The University of Toronto welcomed the first students to its new 24-month program in January.
The discipline isn't entirely new to Canada: the Canadian military has trained and employed PAs for years to care for members of the Armed Forces and their families. Civilian doctors' assistants have been licensed in Manitoba for almost a decade. The University of Manitoba has also instituted a new PA degree program, and like McMaster will graduate its first students at the end of the summer.
Cunnington believes adding PAs to the care-provider picture will be a boon to patient care.
"A physician can only do one thing at a time, so a physician can only see one patient at a time," he says. "If you have an assistant, two people can be served at the same time. The physician's still in charge of both, responsible for both, but you're doubling the productivity."
Doctors groups, including the Canadian Medical Association and its Ontario counterpart, have welcomed the addition of physician assistants.
But not everyone is on board.
The Registered Nurses' Association of Ontario argues that the level of education to earn a PA degree in the province is inadequate for the tasks graduates will be expected to perform once they enter the health system. And unlike doctors, nurses and pharmacists, Ontario physician assistants are not regulated by an oversight body, the organization says.
"And that's where we see the risk for the public," says RNAO executive director Doris Grinspun.
As well, charges Grinspun, PAs will cost the health system more than their closest counterparts, nurse practitioners who are trained to perform similar jobs. While salary and benefits for nurse practitioners and physician assistants will be roughly equal, she says educating a single PA will cost the system tens of thousands of dollars more in compensation to the doctor who supervises their training.
"If we need extra access, you can expand (nurse practitioners') scope of practice," she says. "Why do you need a new type of health-care professional that the public doesn't know and that you will be spending all this money on educating?"
Ian Jones, president of the Canadian Association of Physician Assistants, calls the money issue a "bit of a red herring."
"There's a lot of obvious turf war issues that are coming out, that perhaps the RNAO is worried that the generalist nature of a PA's training better suits the needs of health care and it may become more popular," says Jones, who trained and worked in the United States before returning home to practise in Winnipeg a few years ago.
Grinspun denies that the RNAO's is protecting nurses' traditional territory.
"What we want is to increase access to the public through regulated professions without creating new roles that only serve to confuse the public, and in the case of physician assistants, in our view, compromise the public in the long run."
Jones says his organization strongly supports regulation by an oversight body: in his province, for instance, PAs are governed by the College of Physicians and Surgeons of Manitoba. In Alberta, which recently authorized PAs, the college there will oversee practitioners.
There are about 200 civilian PAs practising in Canada, but their numbers are sure to grow, says Jones, who works with neurosurgeons at the Winnipeg Regional Health Authority. Nova Scotia employs PAs under delegated medical authority and New Brunswick is drafting legislation to add them to hospital emergency departments.
Schoeley, who was raised on a farm in Thedford, Ont., eventually wants to practise where she believes extra pairs of hands are most critical -- outside the urban centres.
"The question is where the jobs will be," the first-year student says. "But I would really like to go back to the rural area because there's such a shortage of health-care professionals and there's such a need."
As to the RNAO's concerns, Schoeley says PAs aren't out to "step on anyone's toes," but to stitch together the gap between doctors and nurses.
"We're only there to endorse the care of the patient. And that's the exact same thing as the nurses want."
