Organization
[October 18, 2023 11:23 AM]
Office of the Fairness Commissioner
Response in PDF format:
PA Regulation_OFC Response_20231018_Redacted.pdf
Organization
[August 15, 2023 3:30 PM]
Ontario Medical Association (OMA)
Response in PDF format:
PA Regulation_OMA Response_20230815.pdf
Organization
[August 15, 2023 7:00 AM]
Professional Association of Residents of Ontario (PARO)
We have reviewed the proposed regulation amendments for the Medicine Act, 1991 and believe them to be quite comprehensive and reasonable. We do have two areas for clarification.
 
We suggest that the regulation explicitly define the relationship between medical learners (medical students or residents) and Physician Assistants (PAs) and whether PAs are able to supervise and delegate tasks. The Consultation Backgrounder’s subsection on Clarifying No Sub-delegation states:
 
“The draft enabling regulation bars a PA from sub-delegating a controlled act that has been delegated to them. This does not preclude PAs and other health professionals from working collaboratively throughout the continuum of care under the supervision and direction of physicians, vis-à-vis a direct order or a medical directive. Moreover, it does not preclude PAs from being involved in training or performing aspects of care that are not controlled acts.” (Section 1)
 
The CPSO policy on Professional Responsibilities in Medical Education, point #3, provides that “A postgraduate trainee may also be a supervisor. (Endnote 3)” and we believe that PAs already do play an important role on some services providing training to residents.
 
We believe there are opportunities for PAs to supervise learners, and if PAs were to teach or supervise residents in the absence of an MRP, this could be beneficial for demanding services where senior staff are not immediately available or have time to supervise certain tasks. Furthermore, involving PAs in the supervision of residents would foster more learning opportunities for residents and help residents achieve Entrustable Professional Activities (EPAs).
 
We found the CPSO document to provide less clarity as to the supervisory duties expected of PAs. It was not clear to us whether PAs could be involved in training, and if so, to what extent and what degree of independence.
 
The second point of clarification is where draft regulation amendments state:
 
“(2) Despite subsection (1), a member who is a physician shall not delegate to a member who is a physician assistant the authorized act of treating, by means of psychotherapy technique delivered through a therapeutic relationship, an individual’s serious disorder of thought, cognition, mood, emotional regulation, perception or memory that may seriously impair the individual’s judgment, insight, behaviour, communication or social functioning.” (Part XII, Section 2)
 
We would like to understand if there are other areas such as central lines or other acts that are restricted under the Regulations for Physician Assistants. 
 
We ask for greater clarity within the document on these two points: 
(1) if CPSO considers supervision of learners as a delegable task for PAs and make it explicit; and (2) to elaborate on other tasks that are considered non-delegable to help provide guidance to physicians, physician assistants, and learners.
 
We once again appreciate being included in the CPSO's consultative process.
Other health care professional (including retired)
[August 14, 2023 10:44 PM]
As a Practicing Physician Assistant in Ontario I am very concerned about the possibility of regulation restricting PA practice in Ontario. I strongly think the Ontario regulation should mirror regulation in Manitoba, New Brunswick and the US. It does not make any sense with the severe shortage of healthcare providers to create many restrictions to PAs practicing in Ontario. Many other provinces are trying to recruit PAs from Ontario and more will leave if there are too many restrictions placed as barriers to practice. PAs have been functioning in Ontario for 13 years assisting physicians and medical teams in family practices, hospitals and speciality practices.

A few of the significant barriers we face daily in Ontario are 1) difficulty referring patients we have seen to specialists without a registration number or billing number, 2) inability to sign any medical forms for patients/waiting for the physicians to sign hundreds of forms each month, 3) inability to get additional certifications such as a diabetes educator without being a registered profession. It is needed to regulate Physician Assistants in Ontario to ensure patients are protected and the profession has title protection so when a physician is looking to hire a PA they can be confident that the applying PAs has been properly trained and certified. Everyday in Ontario, many of the PAs I know provide counseling and education during regular medical appointments for many mental health conditions including depression, anxiety, ADHD, grief, bipolar disorder, PTSD. It is important to clarify what is considered psychotherapy.

I also have a concern with the inability to sub delegate tasks. Many times over the last 10 years I have heard of challenges in the workforce where nurses refuse to accept orders or direction from a Physician Assistant due to the single fact the profession was not regulated. Once we are regulated, I worry the new reason will be we are not allowed to delegate any tasks to any other team members. It is critical to ensure all members of the healthcare team work together and are effective to provide excellent timely care that patient's deserve and avoid delaying care due to waiting for a physician to return to a hospital or clinic to repeat or sign the PAs order.

Unfortunately, there is still confusion with PAs and medical assistants and IMGs who all have different training and should hold different titles that are not interchangeable for job postings.. Educating the public and some physicians is clearly still needed and I am concerned by reading these posts that many still do not understand our role in hospitals and clinics. Thankfully many physicians have continued to support our progress in Ontario and have been open to learning about our role and our contributions to the healthcare teams in Ontario.
Physician (including retired)
[August 14, 2023 9:28 PM]
While I find that the instructions are clear, I feel that the overarching relationship between Physicians and PAs is absent from the narrative.I see from the Consultation Backgrounder that this is intentional to enable flexibility in the care providers with whom the PA works.
I feel that the absence of an established, mutually beneficial working relationship is required to enable collaboration to ensure safe, effective and timely patient outcomes.
In the CAF, we adopted supervising and consultant MD categories. I still feel that outlining and capturing the working relationship is critical when delegating controlled acts.

Perhaps there should be some consideration to:
1. a duration of time working together (PA + MD), either in the same location (direct) or remotely (indirect supervision), to enable a firm understanding of capabilities, strengths and expectations (both parties of the other);
2. Greater clarity in how these delegations are to be offered between the PA and MD (written, verbal).

Sorry if I missed it in the backgrounder or elsewhere but what other requirements will the PAs have to adhere to if regulated under the CPSO? While the Conduct criteria is explicitly highlighted in the amendments, is the intent to have the PAs adhere to the other regulations for MDs under the CPSO? Includes, but not limited to, Availability and Coverage, Dispensing Drugs, Managing tests, Medical records documentation, Treatment of Self, Family Members or Others Close to Them, etc?
Member of the public
[August 14, 2023 9:01 PM]
I am a strong supporter of PAs becoming a regulated healthcare profession in Ontario; I have been seen by PAs on multiple occasions, consistently receiving excellent care.

Overall, I believe that there needs to be broad education about what a PA is and how they fit into the medical system in Ontario. Regarding the proposed regulations, I am concerned that a lack of understanding of the PA role may result in the institution of overly burdensome medical directives. We should move away from this and instead focus on clear and concise guidelines that will allow PAs to exercise their professional judgment effectively. This will foster a more dynamic and agile healthcare system that can adapt to changing patient needs while maintaining the highest standards of care.
Other health care professional (including retired)
[August 14, 2023 8:04 PM]
As a practicing Physician Assistant, I welcome the move towards regulation on many fronts, including to support ongoing recognition, acceptance and legitimacy amongst other health professionals. This includes title protection, which this proposal supports, and which I am grateful for. If anything, reviewing comments on this forum have shown me that many still do not understand nor appreciate the unique training, experiences and roles PAs can play in the healthcare system, given the number of comments from other commenters suggesting that "[X] role does this in my practice and I call them a PA - I should still allow them to be called a PA" (when in fact, they are not a Canadian Certified PA).

While I support regulation, I have 4 major concerns related to the proposed document:

1) Wording around "Sub-Delegation": The wording in these documents around "sub-delegation" is unclear and ambiguous. I fear that it will lead to limitations in our ability to function amongst the healthcare team because other team members will see the stipulation preventing "sub-delegation of a delegated act" as a means to reject an order/direction/etc written by a PA. We need this to be clarified with clear outlines of the scope of orders and responsibilities assigned to PAs. Otherwise, I fear we will create delays in care and confusion amongst healthcare team members.

2)Creating the Structures to Support PAs to Train PA Students: Related to the above, I fear that the current wording limits the ability for PAs to train PA students. PA students' education and training are fundamental to their future success as healthcare practitioners. It is essential that they receive guidance from experienced Physician Assistant clinical educators who can impart real-world knowledge and skills. By encouraging PA students to learn from PA educators, we can ensure a well-prepared and competent PA workforce to meet the evolving needs of our healthcare system. In addition, experienced PA clinical educators also support medical students and residents in attaining their required professional competencies.

3) Reliance on Burdensome Medical Directives: Medical directives are burdensome and hinder the efficiency and effectiveness of PA practice. As a result, they are often not kept up to date to reflect current practice; or, when attempts to update them are made, it can be such a drawn out, administratively burdensome process that it takes precious time away from MDs/PAs to deliver care. For example, it took almost 1 year of emails, word document revisions, meetings and reviews to make small changes to our Medical Directive. Medical directives were introduced to enable PA practice because PAs were not regulated. With pending regulation, we should move away from overly restrictive directives and instead focus on clear and concise guidelines to allow PAs to exercise their professional judgment effectively. This will foster a more dynamic and agile healthcare system that can adapt to changing patient needs while maintaining the highest standards of care. It will also bring us in line with other jurisdictions.

4) No Guaranteed Role for PAs within CPSO Governance/Disciplinary Structures: There does not appear to be any work to propose amendments to other Acts that outline the composition of the CPSO council (as an example) nor any mention of the ways in which PAs will have representation within the various governance structures within the CPSO once regulated. If we are to become members of the CPSO (and I assume pay the necessary fees), I would expect the PA voice to be at these tables in some way. This should be considered in some way right from the start of this process.
Physician (including retired)
[August 14, 2023 6:47 PM]
I am currently working as a Family Physician with certifications in Occupational Medicine, Travel Medicine and Circumcisions. I currently employ a Physician Assistant in my practice and have been so impressed that I have hired another to assist with patient care! PAs have allowed faster access to safe health care and have allowed me to roster more patients that would have otherwise not been feasible. Like many other areas in Ontario, Kingston is currently in a crisis of healthcare with unprecedented amounts of orphaned patients with no family physician which has a direct impact on burden to walk in clinics, urgent care and the Emergency Department. Furthermore, it is contributing to worsening medical ailments that could have been minigated with timely assessment to primary care. Thus far we have relied exclusively on medical directives in order for my PA to practice. There have been instances where the PA has run into barriers as an unregulated healthcare progressional which include the following; filling out ministry forms, requesting homecare, ordering diagnostics at certain imaging centers, questioning by pharmacists about if PAs can prescribe. I support the movement towards regulation, but also agree that there needs to be a baseline template for scope of practice that defines what delegated acts PAs are allowed to perform. Minimizing medical directives would help the PA to practice to full scope and also eliminate undue confusion of the role. I have been very impressed by the education, knowledge and skill set of the PAs thus far and feel that we should help promote their ability to practice fully and safely.

I have worked with many nurse practitioners, and have found the scope of knowledge, practice ethics and dedication to patient care is far superior with physician assistants

they work at the level comparable to a Senior medical resident.

As such, they should be given the same professional autonomy as a senior medical resident, or a nurse practitioner

if it wasn’t for a Physician Assistant, I’ve had to close my office

Respectfully submitted,

 
Other health care professional (including retired)
[August 14, 2023 6:26 PM]
I am a current PA who has been practicing for 10 years, I have some concerns and comments about the current CPSO proposal for regulation.
As a profession, we have been waiting for the dream of regulation in order to practice at full scope and minimize the administrative barriers and overall confusion regarding the role, which has been a deterrent for employers and peers. The vague undertones of this current proposal threaten the opposite
Firstly, there is no mention of a template outlining prescriptive rights, ability to order diagnostics, perform procedures or complete ministry forms that would allow PAs to practice medicine with indirect supervision. Going forward, use of medical directives should be reserved for more advanced or sophisticated tests, medications and procedures.
This has been arguably the biggest barrier to practice and a huge source of frustration for PAs and employers alike. The constant questions of “can you do this?” and statements of “you cannot do this” - remains the largest battle.
At present - committees are required for approval of medical directives for hospital based PAs, which can at times take over one year to implement. This method also invites opposition by persons or administrators that do not work with PAs or know about our scope and training. This has created inconsistency for PAs across the province, which could be corrected with a standardized baseline of delegated acts.
Regulation was supposed to assist in clarifying what PAs can do and allow a governing body to oversee safe practice and address unsafe practices. There is nothing in the current proposal that states what exactly such practices entail.
It is important to minimize the amount of medical directives required for PAs to practice safely and effectively. With the current proposal, there have been no obvious gains (ie. reducing the need to exclusively rely on medical directives, fill out government forms, order medications and diagnostics).
PAs are still being prohibited from ordering pharmaceuticals or tests at certain imaging departments (regardless of medical directives) which is a barrier to care.
We have been denied completing ministry forms that are common in the workplace (ie. ministry of transport forms, WSIB, LHIN services, home care, death certificates, LTC application forms). Will we now be able to do this?
At a time where the scope of practice for pharmacists and nurses are increasing, the PA continues to be restricted despite that we went through rigorous medical training to become advanced healthcare providers whose job is to be the extension of physicians. Since the inaugural class of 2010, and military PAs prior, we have proven ourselves to be safe, effective and reliable. We have accredited post-secondary schooling that models medical school and rotates with medical students. We have an accredited certification process. We have the same annual CPD requirements as physicians. Experienced PAs are often in a teaching role to medical students and residents. We deserve more respect for the skillset offered. The Manitoba model for regulation should be the gold standard for regulation framework, as they have full scope and are a well oiled machine who have made a huge impact in Manitoba healthcare. We need to do better, or there is concern that the experienced PAs will seek employment outside the province and worsen the current crisis.
Ontario is in a healthcare crisis with unacceptable wait times to specialist consultation, lack of family physicians and increasing burden in the ED and longterm care facilities. This is why we were created in the first place. Help us help you. Help us help our patients.

After being regulated in every other province with success, this proposal feels disappointing and frustrating. We are concerned as a whole that this may actually be a step backwards. To date, this profession has been a constant uphill battle when discussing scope, administrative issues, salary and integration to healthcare settings. Regulation was our hope to make a meaningful and positive change. Unfortunately, I fail to see the gains with the proposed model other than that regulation fees that will cost us a substantial amount to the individual PA - and I’m not sure how this will help PAs become better recognized, protected or established.
Physician (including retired)
[August 14, 2023 4:52 PM]
As a Physician who spent 14 years working with PA's in the US I see the tremendous possibility for improving primary care in Ontario.

With the millions of Ontario residents without a family doctor the possibility of incorporating IMGs as Physican Assistants is an opportunity not to be missed.

We need to use this opportunity to innovate before other jurisdictions due the same. See example below in Tennesse.
https://www.medscape.com/viewarticle/993693
There is a finite workforce and we need to use the IMGs residing in Canada to their full potential.

Any IMG who has completed schooling in an accredited Medical School and has completed a residency should be considered a PA equivalent and be granted a temporary license immediately. A pathway to full licensure needs to be ironed out. Those without a residency need to also be given a pathway, rather than driving Ubers or working below their potential.
Medical graduates who have not matched should also be given a direct pathway to a temporary license.

Please put forward a pathway for our fellow citizens and permanent residents to utilize their talents to help provide medical care.
If Team Canada was second to last consecutively like we are in the Commonwealth Fund's report there would be a lot of questions to be answered. Why should we continue to be handicapped with a workforce shortage? We can work together.
https://www.commonwealthfund.org/publications/fund-reports/2021/aug/mirror-mirror-2021-reflecting-poorly
Physician (including retired)
[August 14, 2023 3:39 PM]
I welcome the move to regulate PAs in Ontario - they are valuable members of our health profession and this is an important step in acknowledging their role in our health care system. However, I am very concerned about the sub-delegation restrictions.

As I understand it, as written, this proposed regulation will limit PAs from performing many of the roles and tasks that they currently do, and will be a significant step backward, for PAs, patients and physicians. The demand for PAs in Ontario and Canada is rapidly increasing, as they help significantly with physician workload, enable faster and greater access to quality health care for patients, and they contribute to the overall functioning of health care teams. They also contribute to the health education of medical students and residents, and PA students. With the limitations of the sub-delegation section of this policy, they will not be able to order fully assess, work up, diagnose and treat patients to the full extent that they do now. They will not be able to teach procedures of which they are often more expert than their medical colleagues, because they perform these procedures on a daily basis.

It is critical that this issue is addressed and corrected. If not, instead of ensuring the quality and sustainability of a growing and contributing profession of PAs in Ontario, their effectiveness will be significantly reduced and will result in the exact opposite of the original intention - to promote invaluable support to our existing human health resource crisis.
Other health care professional (including retired)
[August 14, 2023 3:13 PM]
I have been working in a family health team with a PA for over a decade now and find the PA to be a valuable part of the team. I am fully in agreement of the regulation of this profession. I noted the clarifications I wanted to suggest have already been made in the comments, so I will not duplicate again here. But wanted to comment with my support of this process. It's a long time coming! Thank you.
Physician (including retired)
[August 14, 2023 3:04 PM]
It is timely that Physician Assistants are being brought into the Regulated Health Professionals fold, as part of the College of Physicians and Surgeons of Ontario, and treated as the healthcare professionals that they are. I view this as a very positive step and one that is in fact overdue.

It appears that there are some legitimate concerns from other regulated health professional groups and these deserve to be addressed. Unfortunately, some of the responses take the form of objections that appear to be knee jerk reactions and reactionary in nature, and suggest territorial and anti-competitive motivations, rather than constructive or helpful criticisms.

Healthcare is an evolving field and needs to serve the needs of the public effectively by adopting progressive and inclusive policies and frameworks. This includes allowing Physician Assistants to work without unnecessary fetters and obstacles, by welcoming them to work within their scope of practice, as per their training and expertise, working closely with physicians and other members of the healthcare team.

I am a hospital-based psychiatrist working at a university affiliated teaching hospital, and have through my work experiences developed the utmost respect for the outstanding contributions that Physician Assistants make on a daily basis. They are well trained, knowledgeable, skilled, extremely professional, dedicated, diligent, and are very effective members of the treatment team, and add tremendous value to the healthcare team and the care that is provided to patients and families.

In hospital settings individual Physician Assistants often work with multiple physicians and provide care to patients in several different units/wards in inpatient care, and/or may be assigned to multiple programs in outpatient care. As the experiences during the Covid-19 pandemic has made abundantly clear, there is a need for flexible approaches to healthcare that include virtual, remote, and tele-health services, along with service collaboration between healthcare team members operating at different sites, and/or some team members providing care in person and others providing care or supervision virtually. There is an imperative to have health systems that are flexible, responsive, agile, and efficient, permitting greater access to care, reducing costs, and producing efficiencies. Allowing Physician Assistants to communicate with the supervising physicians they work with, using all modes of communication, would enable effective supervision and guidance, rapid communication and execution of orders, referrals, and other interventions, and lead to a more efficient and effective healthcare delivery system. This could include collaboration and communication not only with other team members but other physicians. The policy should not be overly restrictive and needs to be flexible and responsive, and this is achievable, whilst also ensuring the necessary safeguards are in place.

While Physician Assistants are not aiming to act as completely independent healthcare practitioners, as part of their role and the services they provide while operating with and under physician supervision, there is a need to permit physicians and healthcare teams to able to bill for the services provided by Physician Assistants while providing such care. New billing codes or other mechanisms need to be put into place to facilitate this.

There needs to be clarity that Physician Assistants function as an extension of the supervising physicians, and that the supervising physicians are taking responsibility for the decisions made, the orders, tests and referrals initiated; and while they may be communicated or entered into the medical record by the Physician Assistant, they are originating from the supervising physician and need to be treated as such. There appears to be some concerns about this being sub-delegation, or an illegal chain of delegation, and the College needs to make it clear that these views are invalid. It is important that any such misinterpretations or misunderstandings be dispelled with respect to this issue.

With regard to the delivery of certain services, such as psychotherapy, while there is a need for training and expertise so that adequate and competent care is provided, these services are provided by multiple healthcare team members, such as physicians, psychologists, social workers, nurses, occupational therapists, behavior therapists, and so on, and this should include Physician Assistants as well. The rules should clarify that appropriately trained Physician Assistants can be delegated to provide psychotherapy in an approved manner.

These clarifications and changes in the regulations governing Physician Assistants will be positive steps, and will enhance the effectiveness of the healthcare service, promoting better public health, and strengthening our communities. Let us be more forward thinking and progressive, and permit Physician Assistants to function in an optimal way, and join us in the efforts to make healthcare better for all.
Other health care professional (including retired)
[August 14, 2023 2:44 PM]
Section 52.2
Feedback: I have concerns with this. Other regulated health care professionals such as OT/RN/SW are able to provide structured/manualized psychotherapy in a variety of settings. I recognize that individuals who are not appropriately trained or competent in this should not provide psychotherapy but this should not exclude those who are trained and competent. With an already overburdened mental health care system, it is integral that all those who are capable and qualified to psychotherapy, are able to provide it. Perhaps the wording can be changed to reflect that those who are appropriately trained can be delegated psychotherapy.

Section 52.3
Feedback: I foresee challenges arising with this and in fact, issues are already arising (ie referrals for imaging/outpatient prescriptions not being accepted). With the current wording, it will result in other healthcare professionals believing that they are not able to enact orders made by the PA. Since PAs act as an extension of the supervising physician(s) (SP), if an order/referral is made by a PA (ie, to change a wound dressing, to complete vital signs etc), it should be treated as though the order also came from the SP. I also hope that the exception for students in the RHPA extends to PAs.

In addition to the above noted concerns, I hope that the CPSO will also ensure that there is some flexibility in terms of the level of supervision required for the PA. For example, in the inpatient setting, the PA should be able to round on patients and order tests which are within their competency/scope of practice while the SP is offsite but available for telephone or virtual consultation as needed. If an emergency situation arises that requires an onsite MD, there can be an onsite covering MD for emergencies. In my setting, the MD may also work in an outpatient clinic or be offsite for a day. I am able to reach them via phone or email to confirm treatment plans and will implement them accordingly. We also have an on-site physician for crises/emergencies who I will go to if there are acute issues that require an MD’s presence.
There also needs to be a way address billing for services provided by PAs. I recognize the concern about allowing PA’s to bill independently for fear of PAs trying to become/act like independent practitioners. However, physicians need to be remunerated for services provided by the PA, so perhaps a new billing code could be made that physicians can use to bill for the services provided by the PA.

I hope that the CPSO will appoint a PA onto their council so as to provide appropriate feedback and education on the role of PAs and how best to go about their regulation.
Physician (including retired)
[August 14, 2023 2:43 PM]
Regarding 52(2): Numerous HCPs that are non-physicians can be trained to provide psychotherapy and do provide psychotherapy. PAs should be no different. As such, I would recommend adjusting this to the following:

(2) A member who is a physician CAN delegate to a member who is a physician assistant the authorized act of treating, by means of psychotherapy technique delivered through a therapeutic relationship, an individual’s serious disorder of thought, cognition, mood, emotional regulation, perception or memory that may seriously impair the individual’s judgment, insight, behaviour, communication or social functioning, PROVIDED THAT THE PHYSICIAN ASSISTANT IS APPROPRIATELY TRAINED TO PROVIDE PSYCHOTHERAPY.
Physician (including retired)
[August 14, 2023 2:26 PM]
52 (3) A member who is a physician assistant shall not delegate the performance of an act
that has been delegated to them.
This could cause logistic issues. To cite an example, consider the case of a procedures clinic that routinely performs bedside invasive medical procedures like thoracenteses, paracenteses and lumbar punctures and a physician assistant that has been performing these procedures to perfection for several years. Also consider the setting to be in an academic institution with resident trainees who are being mentored by the highly experienced and trusted physician assistant. The proposed amendment will create new hurdles for the PA to mentor trainees if they are prohibited from teaching trainees how to do the procedure that has been delegated to him/her. In the setting that I am referring to, not just residents, but colleague physicians out of touch with the mentioned procedures have sought and continue to seek the referenced PA's guidance to re-train themselves in the said procedures. Thus, having witnessed the institutional and university-wise value addition the referenced PA brings to the table over the last several years, I believe this amendment namely 52 (3) will be counter productive.
Other health care professional (including retired)
[August 13, 2023 8:56 PM]
52(1) A member who is a physician assistant shall only perform an act under the authority of section 4 if the performance of the act has been delegated to the member who is a physician assistant by a member who is a physician.

Feedback: This statement is vague. The wording implies that a PA may only preform something if it has been asked (delegated) explicitly by their supervising physician. This would be very limiting and cumbersome for a PA to have to review everything with their supervising physician in order to diagnose or manage a patient. PA’s are highly knowledgeable and skilled through their training in diagnosing and management. Currently, PA’s are practicing under detailed medical directives that allow them to assess and treat patients underneath their supervising physician. A PA should be able to assess a patient and order labs/start an appropriate treatment if needed without requiring to get explicit delegation from their supervising physician first (depending on the case/PA skill level and knowledge). A PA’s scope of practice is that of which the supervising physician has delegated and taught them, as well as what the supervising physician feels comfortable of the PA completing based on going performance and skill growth and evaluation.


52(2) Despite subsection (1), a member who is a physician shall not delegate to a member who is a physician assistant the authorized act of treating, by means of psychotherapy technique delivered through a therapeutic relationship, an individual’s serious disorder of thought, cognition, mood, emotional regulation, perception or memory that may seriously impair the individual’s judgment, insight, behaviour, communication or social functioning.

Feedback: The restriction of preventing PAs from psychotherapy would have a large negative impact, especially on our PAs working on mental health and addictions, psychiatry, and primary care. Part of the PA role is increasing access to care and this would add another barrier to patients accessing mental health care. PA’s that are properly training in psychotherapy should be able to provide psychotherapy.

52(3) A member who is a physician assistant shall not delegate the performance of an act that has been delegated to them.

Feedback:
This is not clear and quite concerning as it could be interpreted in several different ways that can negatively impact the PA Role. The inability to sub-delegate would restrict and limit the role of the PA, prevent ability to work effectively and efficiently, and negatively impact collaborative team work.

The inability to sub-delegate a controlled act is limiting and challenging. For example, placing a finger or instrument beyond the verge of urethra or anus is a controlled act. Does this mean that a PA would not be able to order a Foley to be inserted or a suppository to be given to a patient.

The dispensing of medications is also considered to be a controlled act. How would this impact the prescribing action of PAs and the acceptance of PA written scripts at pharmacies.

There are already several struggles and challenges with PAs signatures being accepted on imaging requisitions, prescriptions, etc, and this proposed amendment will further worsen this.

I am a PA who works in both the inpatient and outpatient health care setting. The ability to sub-delegate is crucial to my role in giving both written and verbal orders to nursing for patients, ordering testing and imaging, requesting consults and referrals, and writing prescriptions.


9.2 (1) Where section 22.18 of the Health Professions Procedural Code applies to an applicant for a certificate of registration authorizing practice as a physician assistant, the applicant is deemed to have met the requirements of subsection 9.1.

Feedback: This is not clear. There is no reference to section 22.18 of the Health Professions Procedural Code. Can we please clarify?


Title Protection
Physician Assistants need Title Protection. Several jobs on Indeed are listed as “Physician Assistant” but are actually the role of a Medical Office Assistant. This is inappropriate to have these two roles confused. Patients often thinks of PAs as an assistant in the physicians office instead of a clinician.

In addition, IMGs and PAs are not interchangeable terms nor roles.
IMGs should be separate from PAs and have to undergo training to become a PA or conduct a residency to practice as a physician. The PA title should be protected similar to Manitoba and the US and the use of "Physician Assistant" by IMGs should be discontinued.

Physician Assistants have to undergo training through an accredited PA school and completes the PACCC Certification exam. Only individuals who have completed this should be known as a Physician Assistant.

PAs on CPSO Council
It is also important that there are PAs present on the CPSO Council. This would be extremely beneficial as the PA on the council could properly educate on what the PA role is and what PAs do and better advocate for us PAs.
Prefer not to say
[August 14, 2023 2:09 PM]
52(1) A member who is a physician assistant shall only perform an act under the authority of section 4 if the performance of the act has been delegated to the member who is a physician assistant by a member who is a physician.

This sounds like it is the Supervising Physician who is regulating PAs, not CPSO. The draft does not define the PA profession what PA can do and canont do, which is standard of any regulated profression. Instead, the draft has passed that to individual Supervising physician. The odd thing is the skill set you are assessed as competent by one physician can not be transferred to working with any other physician, even within the same area of practice, for example, from one family physician to another.

CPSO should either allow transferrable skills to be transfferred or find ways to establish profile of indicidual PA, in graduated manner.

"an act" is very broad, broader than "Controlled Acts" .
Physician (including retired)
[August 13, 2023 8:28 PM]
I am a family physician who has worked with a PA in an inter-professional practice for 15 years. The proposed regulations state: “A member who is a physician assistant shall not delegate the performance of an act that has been delegated to them.”
Our PA "co-implements" the performance of an act with other members of the inter-professional team. We do not consider this sub-delegating because the medical directive covers the entire process of care. it is unclear to me whether this subtlety is appreciated in these proposed regulations.
Other health care professional (including retired)
[August 13, 2023 8:28 PM]
As a former RN and a current PA, I have been both in a position of being a regulated and an unregulated health care provider. I can see the standardization and benefits that a regulatory college brings to both the public and health care providers. It also brings clarity of the role and title to the public. Thank you for taking this step forward with physician assistants in Ontario.

Some suggestions with regulation:
1) Make it very clear in the regulation (and have the CNO provide education) to nursing colleagues about new changes with regulation and carrying out orders from MD/NP/PA in Ontario. Physician-nurse conflict has been historically a source of tension and stress, which have been contributing factors in job dissatisfaction and burnout for nursing staff.
2) Include controlled substances in prescribing rights. Practically speaking, this can limit significant delays, especially in specialties such as oncology, surgery, etc. This can help our nursing colleagues carry out orders efficiently and provide higher quality care.
3) Remove medical directives. They create additional work and stress on physicians, administration teams and nursing. Both the development and the implementation of them take away take away patient care. PAs are regulated by the College of Physicians and Surgeons of Manitoba (CPSM) in Manitoba, without medical directives, and have their own distinct category of registration. Physician assistants that are trained in Canada are taught practice with integrity and within the limits of their scope, acknowledge when they do not know something and seek assistance from their supervisor (similar to residents, nurse practitioners, etc).
Other health care professional (including retired)
[August 13, 2023 8:18 PM]
I am a PA practicing in mental health. With the addition of PAs to the practice I work, wait times have been significantly reduced in a patient population that desperately needs access to care.

I'd like to first address the impact on the restriction to psychotherapy. There is a significant lack of adequate mental health care in this province (and country). Utilizing PAs in the field of mental health is occurring currently, however, limiting the ability to practice psychotherapy will reduce the impact PAs can have in the mental health system. Similarly to how the college states that a physician should ensure the PA they are delegating too is adequately trained before delegating any act, this should apply to psychotherapy as well. A PA who receives proper training to perform psychotherapy, and it is within the scope of their supervising physician, should be permitted to perform psychotherapy. PAs are not independent practitioners and are always working as physician extenders. Adding psychotherapy to this extension in a mental health setting would be beneficial for patient care.

Regarding the prohibition on the sub-delegation of controlled acts - this should be reconsidered as it impacts limiting the ability to practice psychotherapy will reduce the impact PAs can have in the mental health system. Similarly to how the college states that a physician should ensure the PA they are delegating too is adequately trained before delegating any act, this should apply to psychotherapy as well. A PA who receives proper training to perform psychotherapy, and it is within the scope of their supervising physician, should be permitted to perform psychotherapy. PAs are not independent practitioners and are always working as physician extenders. Adding psychotherapy to this extension in a mental health setting would be beneficial for patient care.What designates a sub-delegation? If a PA is entering an order for an injectable medication to be given to a patient by a nurse, is that no longer permitted by these rules? This would significantly hinder collaborative care especially in hospital settings and negatively impact patient care creating unnecessary hurdles where PAs are currently practicing.
Other health care professional (including retired)
[August 13, 2023 8:17 PM]
As a practicing PA, I have been eagerly awaiting regulation for years. Thank you CPSO and committee members who have made this possible. I believe that PAs are valuable addition to the health care team and regulation is key to ensuring standards of care. With this being said, I have some concerns about the proposed draft of regulation.

1. The draft states that PAs will not be able to perform psychotherapy. PAs working in psychiatry across the province are already providing psychotherapy so I have significant concern about this restriction. PAs scope reflects their supervising physician, therefore through training & delegation a PA should be able to provide psychotherapy as appropriate.

2. I have concerns about not being able to sub-delegate. I am afraid that the language will be interpreted in a way that other professions (e.g. nurses, pharmacists, xray techs) will refuse to accept orders, prescriptions & reqs from PAs which creates barriers to care. Although the CPSO clearly states that subdelegation does not apply in situations where professions are performing something within their own scope, I don't believe that people understand that nuance and it will be used against PAs.

3. Need for PA representation on CPSO council. As it stands, CPSO will regulate PAs but there is no PA representation on the CPSO council. I am concerned that PAs will not have a voice since CPSO's main role is to serve physicians.

4. Title protection. Currently there are jobs being posted as "physician assistant' which are basically medical assistants that require no medical background and are minimum wage jobs. Because there is no title protection in Ontario, this is permitted but it contributes to the public's misunderstanding of what a PA is.

5. The draft document focuses on delegation and it seems that everything a PA does must be delegated. By CPSO definition, delegation is when a regulated professional grants authority to another professional "who is not legally authorized to perform the act independently". Since PAs cannot work independently and require the legal supervision of a physician this makes sense, however PAs have an outlined scope of practice and once regulated PAs should be presumed to be able to practice to their full scope in the keeping with the area of their supervising physician. This would mean that delegation is implied by hiring a PA and therefore direct order or medical directive should not be necessary. This is not reflected in the document at all.
Other health care professional (including retired)
[August 13, 2023 7:50 PM]
I am in support of regulation of PAs, however there is confusing language around sub-delegation. More clarity needs to be written in regarding working with other health professionals and more clear medical directives. Limiting the ability to sub-delegate decreases the efficiency and proficiency of PAs. There needs to be re-evaluation of this point to ensure PAs can practice to the best of their abilities and help with the health care crisis.

As well, given the immense need for mental health practitioners, PAs with the training to perform psychotherapy should be able to do so. The current language in the proposal does not allow for this, which greatly impact the ability for patients to seek help. PAs develop strong relationships with their patients, and are in a capable position to provide psychotherapy.

Please consider reviewing the language in the proposed regulatory document to allow PAs to practice more efficiently and practically.
Other health care professional (including retired)
[August 13, 2023 7:39 PM]
Having been a PA for 7 years and working in challenging environments with very strong nursing unions, I have concerns related to some of the proposed regulatory amendments to regulate Physician Assistants. There are significant restrictions on a PAs scope of practice in some unionized settings due to differing interpretations of the Regulated Health Professions Act as it relates to the Delegation of Controlled Acts. Because PAs are not included in the Regulated Health Professions Act, unions have expressed the incorrect notion that a PA's orders are not in fact an extension of the supervising physician but rather directly from the PA. This places an unnecessary restriction on the ability to practice and leads to significant redundancy, delay in patient care, and frustration from supervising physicians. To illustrate why I feel it is important that there is a clarity for PAs in the CPSO Policy for the Delegation of Controlled Acts, as well as the inclusion of PAs in an amendment to the Regulated Health Professions Act, here are some examples:

In reference to the CPSO Delegation of Controlled Acts, the union members were directed not to carry out orders for any of the controlled acts outlined below, when written by a PA, without speaking to the supervising physician over the phone to confirm them:

5) Administering a substance by injection or inhalation. Staff would not would not process any orders, including dose adjustments for: inhalation therapies (MDI, diskus or nebules), supplemental oxygen, vitamin B12 injections, vaccinations, insulin or ozempic.
6) Putting an instrument, hand or finger,
1. beyond the external ear canal, *Staff would not process any orders without confirmation from a supervising physician for: ear drops to treat cerumen impaction, otitis media, otitis externa.
2. beyond the point in the nasal passages where they normally narrow *Staff would not process any orders without confirmation from a supervising physician for: nasal sprays including fluticasone, normal saline.
3. beyond the larynx,
4. beyond the opening of the urethra *Nurses Staff would not process any orders without confirmation from a supervising physician for in and out catheterization to obtain urine samples, place catheters or remove catheters.
5. beyond the labia majora, *Staff would not process any orders without confirmation from a supervising physician for the insertion of vaginal ovules including estrogen, flagylstatin, clotrimazole creams.
6. beyond the anal verge, *Staff would not process any orders without confirmation from a supervising physician for rectal suppositories or enemas.
7. into an artificial opening in the body.

Further to my concerns above, after reviewing the proposed regulations as well as the Canadian Association of Physician Assistants (CAPA) submission, I fully support the concerns and recommendations submitted by CAPA.

I appreciate that regulation will come from the CPSO and look forward to being one of your members. I thank you for the opportunity to provide feedback.
Member of the public
[August 13, 2023 7:21 PM]
I am confident in the intense training that physician assistants receive in Canada. Their clinical hours greatly exceed that of Ontario nurse practitioner programs. I am happy to be treated by physician assistants, as it reduces my wait time to access specialist medical care. I am greatly in favour of regulation of physician assistants trained in Canada as this will help them to be better recognized and utilized in Ontario.

Also, I live in a border city. In the States, it seems that they have figured out how helpful physician assistants can be to the public and I hope that Ontario can take their lead.
Other health care professional (including retired)
[August 13, 2023 10:38 AM]
As a rural ER PA with over a decade of experience and after reviewing the proposed regulations as well as the Canadian Association of Physician Assistants (CAPA) submission, I fully support the concerns and recommendations submitted by CAPA:

Impact of the prohibition on the sub-delegation of controlled acts and restrictions on PA’s ability to practice efficiently and effectively.

Impacts on collaborating with other health professionals and being able to work most efficiently and effectively.
* Problems with reliance on medical directives.

Impacts on training students (“learners”).
* Ensuring that the exception for students in the RHPA extends to Pas.

Recommendation 1: The CPSO should work with CAPA on an amended Delegation of Controlled Acts policy that incorporates PAs, provides clarity, and ensures our members are able to work in a sufficiently flexible environment.

More clarity on collaborating with other health professionals.
Clearer and simpler medical directives.

Recommendation 2: The CPSO should clarify that the exception under the RHPA for students/trainees to perform controlled acts, extends to acts delegated by PAs.

Impact of restrictions on psychotherapy.
* Ensuring that PAs, who are properly trained/qualified, can still practice psychotherapy.

PAs are physician extenders that practice with negotiated autonomy. Enacting these proposed regulations would be limiting to PAs and they would not be allowed to practice to their full scope, hindering their practice and the patients served.
Other health care professional (including retired)
[August 12, 2023 7:32 PM]
This regulation amendments refers to delegation as the mechanism in which PAs become authorized to perform controlled acts. Since there is no further details I assume the mechanism of delegation will remain the CPSO policy on “Delegation of Controlled Acts.” If this is the case I find this mechanism problematic because of the ambiguity of the policy, various institutions interpret requirements differently. Additionally when the CPSO policy on Delegation of Controlled Acts is scaled to a PAs scope of practice the requirements of such a delegation document are prohibitively massive. Please see my full research on this issue here: https://ojs.lib.umanitoba.ca/index.php/jcpa/article/view/612/pdf . If this regulation amendment fails to address the problematic mechanism of delegation to a PA there will be a wasted opportunity to remove administrative barriers to enhancing the healthcare workforce. I suggest a new policy to address how physicians delegate to PAs.

The phrase “the physician assistant shall not delegate the performance of an act that has been delegated to them” needs grater clarification. Even the Consultation Backgrounder paragraph on Clarifying No Sub-delegation fails to put to rest controversy regarding weather a nurse can implement an order generated when a PA invokes a medical directive. A few health facilities interpret that a nurse cannot act on PA medical directives due to the sub delegation principle. The College of Nurses of Ontario’s website currently has an article that says a nurse cannot accept an order or delegation to perform a controlled act from a PA and cites the inability to sub-delegate as the rationale. (reference: https://www.cno.org/en/learn-about-standards-guidelines/educational-tools/ask-practice/working-with-physician-assistants/ ). If this language is not clarified and the interpretation that nurses cannot execute PAs medical directive gains momentum in more institutions it completely threatens any benefit of implementation of PAs in Ontario.

I appreciate that there will be no specifying a supervisory relationship between a physician and a PA (i.e., through a supervisory contract). This will allow much greater flexibility. However, I don’t understand how a mechanism of delegation can be established without a supervisory relationship (i.e., who signs the medical directive document). This is either a flaw in logic, or like many other aspects of this process needs greater clarification.

While I can only speculate on how this regulation amendment will influence how PAs are able to contribute to healthcare for Ontarians, the simple act of being a regulated healthcare profession carries a considerable legal and political weight in Ontario. Professional oversight, and educational considerations offered by the CPSO will be very high value for the PA profession. I commend all the work that has been done thus far by the CPSO.
Physician (including retired)
[August 12, 2023 2:31 PM]
I have been working with PA for the last 15 years and greatly appreciate PAs contribution to Primary Care in Ontario. I am concerned with wording and interpretation of section 52 (3):
proposed wording will significantly limit current work flow, interdisciplinary interactions, will add administrative burden and thus limit access to care as a result. Example from our clinic would be PA no longer be able to order vaccination at well baby and well children appointments without explicit MD order to RN.
Other health care professional (including retired)
[August 12, 2023 2:01 PM]
I am a physician assistant now working eight years in critical care in the province of Ontario and I am writing to advocate for clear guidance and recommendations from the CPSO regarding the regulation of Physician Assistants.

Regulation must incorporate specific language that will:
o Facilitate an optimized scope of practice for PAs under their supervising physicians
o Enable PAs to continue to work efficiently with other healthcare providers
 For example writing orders/treatment plans that are enacted by nurses or other allied health care providers
 Our scope of practice will still be defined by the scope of practice of our supervising physicians and medical directives. Therefore consistent language in medical directives is essential as well for safety and consistency.
o Ensure optimal training opportunities or PA students, medical students, and residents.

Optimizing the scope of practice for PAs, while maintaining appropriate supervision, will have significant benefits for both patients and the healthcare system. By supporting existing PA practice and optimizing PA scope, we can contribute to reducing wait times and improving overall healthcare delivery.
Clear and unambiguous wording around sub-delegation is vital to avoid misunderstandings and misinterpretations among healthcare providers. PAs are trained in a medical model and proposal wording should ensure PAs can continue to function like medical residents (i.e., with a graduated level of responsibility under staff physician supervision) under medical directives that outline their scope of practice. Nursing and other allied health must be able to execute the orders of PAs within their own scopes of practices laid out by their colleges. The new proposed regulation must clearly outline how PAs are expected to collaborate and maintain our current scope of practice with other health professionals.
This language around the scope of practice of PAs and sub-delegation will be essential to ensure that PAs can continue to work efficiently and within our full scope.
I am disappointed at lack of advocacy for PAs to have access to the restricted/controlled acts that we are specifically trained to do in our respective training programs (i.e., prescribing, ordering investigations, writing orders for other regulated health professions around controlled acts, etc.). I hope this can be reconciled in updated regulation language.
I also wanted to comment on how burdensome medical directives can hinder the efficiency and effectiveness of PA practice. Medical directives were introduced to enable PA practice because PAs were not regulated. With pending regulation, I would encourage the CPSO to move away from overly restrictive directives and instead focus on clear and concise guidelines will allow PAs to exercise their professional judgment effectively. This will foster a more dynamic and agile healthcare system that can adapt to changing patient needs while maintaining the highest standards of care.
Thank you very much for reading. All the effort and time placed in this process does not go unnoticed and is greatly appreciated. Thank you!
Organization
[August 11, 2023 9:10 AM]
Canadian Association of Physician Assistants (CAPA)
Note: Some content has been edited in accordance with our posting guidelines.
Response in PDF format:
PA Regulation_CAPA Response_20230811.pdf
Organization
[August 11, 2023 8:45 AM]
Ontario Trial Lawyers Association (OTLA)
Response in PDF format:
PA Regulation_OTLA Response_20230811.pdf
Member of the public
[August 11, 2023 7:27 AM]
Good Morning,
During the early drafts of the documents that resulted in MAID, during 2014-2015, I was invited to share my comments with the CPSO.

Since that time, as I receive email messages about other draft policy documents or policy documents pending edit, I have occasional read carefully and only replied closer to deadline when I might have relevant comments to contribute.

My comments today include and are limited to my thoughts beyond or to add to the documents I have read including the extensive discussion comments and replies.

First, definitely retain Physician Assistant (PA).
For several reasons including consistency with degree, rest of Canada.
And, refer to the rest of the provinces and their positions - for example the July 22 comments from Manitoba.
I agree with “grand parenting” from the backgrounder.
The nursing organization - CNO -  had an opportunity to contribute to the draft policy - good that they were considered.

Under membership in the CPSO, a directory and affiliation with MD, named perhaps.
Liability insurance mandatory.
Continuing education.
Rare professional misconduct included.
CPSO ID number

Obviously, various areas of practice, paediatric ward, orthopaedic, cardiac, surgery, obstetrics, cancer clinic, dermatology, community clinic, other - all with relevant specialized competencies.

Always delegation by designated MD.  Introduction to a conscious patient, family member, hospital staff, others as …….  “I am (name).  A PA and I work with Dr. (name)”  or similar.  Is there a name tag or not - in hospital setting for example?

Salary and benefits, hours of work, shifts, as needed - I have no comment with respect to range and the person or institution that bills and pays.

I do not agree with PA named on LifeLab or imaging reports.
The link to MD should provide for early access.

Definitely keep professional titles, roles as they are.
MD, PA, IMG, NP, RN, others …

Much has been contributed in the discussion, for your consideration.  I will limit my comments to the above.
Other health care professional (including retired)
[August 10, 2023 8:02 PM]
Enabling Mechanism (Delegation) – General Regulation Amendments
52. (1) A member who is a physician assistant shall only perform an act under the authority of section 4 if the performance of the act has been delegated to the member who is a physician assistant by a member who is a physician.

Feedback:
Does each individual act need to be directly delegated by a physician? This wording makes it seem like PAs would not be able to use clinical judgement to order diagnostic tests, do procedures, etc. without express orders from physician. This limits our practice.

52. (2) Despite subsection (1), a member who is a physician shall not delegate to a member who is a physician assistant the authorized act of treating, by means of psychotherapy technique delivered through a therapeutic relationship, an individual’s serious disorder of thought, cognition, mood, emotional regulation, perception or memory that may seriously impair the individual’s judgment, insight, behaviour, communication or social functioning.

Feedback:
This makes PAs not functional in any sort of mental health/psychiatric setting. Completely limiting when it comes to any sort of counselling. If PAs are trained in counselling, and if counselling is part of their medical directives, PAs should be able to counsel patients as long as the supervising physician and the PA are comfortable with the PAs knowledge/skill set/etc.

52. (3) A member who is a physician assistant shall not delegate the performance of an act that has been delegated to them.

Feedback:
This will significantly limit PA practice and PA teaching/preceptorship. This would make verbal orders impossible which would severely limit patient care.

Registration Regulation Amendments
9.2 (1) Where section 22.18 of the Health Professions Procedural Code applies to an applicant for a certificate of registration authorizing practice as a physician assistant, the applicant is deemed to have met the requirements of subsection 9.1.

Feedback:
This is not clear. I am not sure what this sentence means.

(2) Where an applicant to whom subsection (1) applies is unable to satisfy the Registrar or a panel of the Registration Committee that the applicant practiced the profession of medicine to the extent that would be permitted by a certificate of registration authorizing practice as a physician assistant at any time in the three years immediately preceding the date of that applicant’s application, the applicant must meet any further requirement to undertake, obtain or undergo material additional training, experience, examinations or assessments that may be specified by a panel of the Registration Committee. Proposed Regulatory Amendments to Regulate Physician Assistants Draft Regulation Amendments 3
(3) Despite subsection (1), an applicant is not deemed to have met a requirement if that requirement is described in subsection 22.18 (3) of the Health Professions Procedural Code.

Feedback:
Does this mean that an international medical graduate or an equivalent is able to practice within the scope of a PA and have the title of PA without having gone through an accredited PA program in Canada?

9.3 (b) the applicant is able to satisfy the Registrar or a panel of the Registration Committee that the applicant engaged in practice in Canada within the scope of a physician assistant during the two-year period that immediately preceded the date that the applicant submitted their application.

Feedback:
Does this mean that an international medical graduate or an equivalent is able to practice within the scope of a PA and give themselves the title of PA without having gone through an accredited PA program in Canada? The wording is confusing. IMG and PAs should not be able to be interchangeable titles.
Physician (including retired)
[August 10, 2023 11:08 AM]
PA students train alongside medical students and residents. This interprofessional approach to learning is an important reflection of what collaborative and effective interprofessional practice should look like. We do not have adequate volume of PAs to provide direct teaching but would strongly encourage the increase in PA complement that would allow PA students to learn from PA educators within a community setting. PA students' education and training are fundamental to their future success as healthcare practitioners. It is essential that they receive guidance from experienced Physician Assistant clinical educators who can impart real-world knowledge and skills. By encouraging PA students to learn from PA educators, we can ensure a well-prepared and competent PA workforce to meet the evolving needs of our healthcare system. In addition, experienced PA clinical educators also support medical students and residents in attaining their required professional competencies.

Given their extensive training in the medical model and clinical experience, PAs function similarly to senior medical residents under a supervisory structure. This enhanced level of autonomy, combined with PA-physician collaboration, can lead to better patient care, and contribute to optimizing healthcare resources. By working collaboratively, PAs can enhance patient care, strengthen the healthcare workforce, and foster public trust in the capabilities of PAs.
Organization
[August 09, 2023 2:57 PM]
Canadian Medical Protective Association (CMPA)
Note: Some content has been edited in accordance with our posting guidelines. 
Response in PDF format:
PA Regulation_CMPA Response_20230809.pdf
Organization
[August 09, 2023 12:21 PM]
Family Health Team
Response in PDF format:
PA Regulation_Attachment_20230809.pdf
Other health care professional (including retired)
[August 09, 2023 8:22 AM]
My concern is regarding proposed amendments:
1) Part XII 52 (2) is that it needs clarification. As a Physician Assistant working on Psychiatry I provide supportive psychotherapy during visits with the patients. This does not mean that I am providing official psychotherapy sessions but as part of assessments and treatment in all patient interactions supportive psychotherapy is a big component.
2) Part XII 5 (3) also needs clarity. Working in a hospital environment, in urgent situations orders are not written down but conveyed verbally which are then followed up by written orders. This amendment that may cause confusion for the nursing staff and allied health care staff and lead to disruption in care. Another aspect for the same amendment is student supervision both for Physician Assistant and Medical students. How can they learn if the supervising Physician Assistant is not allowed to delegate ?
3) The role of Physician Assistant is to be physician extenders and provide smooth and seamless care to patients not create barriers. Physicians do not have to be physically there in each encounter as that is another roadblock.
4) Physician Assistants should have representation in CPSO.
5) CPSO should take guidance from Physician Assistant regulations from different regulatory bodies like in New York State where the profession has been regulated since 1970s
Physician (including retired)
[August 08, 2023 4:06 PM]
I have been working with PAs for many years now and can attest to their invaluable contributions to the healthcare system. I’m confused as to why psychotherapy has been removed from their scope of practice. Mental health plays a big role in the types of visits with healthcare practitioners, and to not have PAs able to provide support in this area, seems like a step backwards.

In addition, PAs should be awarded the same ability to delegate tasks to appropriate members of the healthcare system/healthcare allies. Otherwise this creates a layer of complexity that will ultimately form barriers to seamless patient care.

Lastly, physician assistants should be able to hold an official title, similar to nurse practitioners and other healthcare practitioners, then be included at tables involving healthcare reform. Their identity as an important member of the healthcare community cannot be ignored, and should most certainly be acknowledged.
Member of the public
[August 07, 2023 6:34 PM]
There are a few concerns regarding the current proposed document.

52 (3): Requires clarification of the role of PAs hold in regard to sub-delegation. In order for PAs to do their job effectively and efficiently, they require to delegate to other members of the healthcare team (nurses, technicians, etc.). The current proposed legislation poses many barriers to PAs practicing and helping the already over-burdened healthcare system. PAs are trained under the medical model, and thus are qualified to delegate these orders. Using the current language is not appropriate or clear regarding PAs being able to sub-delegate.

52 (2): Requires clarification on the role of performing CBT to patients. In order for PAs to effectively and efficiently treat patients in mental health, they will require the ability to perform CBT (under the direction of a supervising physician). Without this, PAs will not be as useful as they can be, and thus further burden the healthcare system.

Additionally, I am concerned that the current draft does not highlight important topics such as title protection or prescribing rights - which need to be addressed in order for PAs to practice safely and effectively. Currently, IMGs are working in similar positions as PAs and we need title protection in order to uphold the safety of our patients and profession moving forward.

Regarding some of the previous comments in this thread. PAs are taught to introduce themselves as PAs - never a physician or doctor, and I personally have never seen this done amongst my colleagues. They are taught to be cognizant of ones limitations, and to communicate this clearly to their supervising physician in order to uphold safe patient care. They are not able to replace physicians, as they need this supervisory relationship in order to practice medicine. PAs are simply a tool to improve healthcare efficiency, without taking roles away from other providers. In the current state of our healthcare system, I personally believe we should welcome the use of PAs to improve efficiency of care.
Other health care professional (including retired)
[August 06, 2023 6:16 PM]
For one, I’d like to say that I’m happy to finally see that regulation of the PA profession is underway. As a working PA, regulation has been regarded as a positive, but it does not come without its concerns as well.

Regulation should offer the opportunity for title protection, recognition of the role and profession as well the potential for more job opportunities. With the proposed draft, I have concerns that these will not be a possibility.

The draft is far too vague, and in fact sounds more limiting with respect to the scope of practice. There needs to be more clarification about the delegation of acts, as well as commentary regarding the ability and breadth in which a PA can prescribe medications, for example. As many have already mentioned, regulation of PAs in Ontario should mimic that of the PAs in Manitoba, where implementation of the role has not only been successful but advantageous for the healthcare system.

PAs are not doctors, but we are trained under the physician model, and as generalists and physician extenders, we have the pot Eula to bridge the gap in our current healthcare crisis and extend care to many more patients. It would be quite unfortunate if Ontario regulation as I understand it now, limited this possibility in any way.
Other health care professional (including retired)
[August 06, 2023 7:54 AM]
1. CPSO Presentation: PAs must be present at the CPSO council. Who can represent us better than our own profession. We hope this would not be dismissed, or postponed.
2. Delegation: As many have said, we should be able to delegate what has been delegated to us. This hinders expediting medical managements and hence accessibility to care.
3. Universal guideline: PAs working with MDs who have roster patients have more independence compared to "fee for service" MDs. Either ministry has to accept PAs can work independently with delegation, or not. Why for example for a simple medical case, the doctor has to make a meaningful interaction? If patient has a viral infection, it is a simple conservative management, why do doctors have to waste their time. Or, even working for a specialist, you have regular and simple follow ups. If doctor tells you patient doing well, why does a doctor has to see them as well. The aim should be accessibility to care which our country is having issue with - having many months of waitlists to see specialists or having to wait hours in emergency rooms and walking clinics. Anything we can do to enhance accessibility, should be promoted. So hoping PAs would have more independence as it is the case for roster patients and as it is implemented in US.
4. Strict guidelines around using our title: PAs and IMGs should NOT be interchangeable. Medical facilities should not hire IMGs as PAs.
5. Legal review: We hope the guidelines would be reviewed by one or two lawyers who have experience in regulations. This may cost but gives PAs and the public good protection and perhaps different point of views that could not be seen by those of us who do not have legal background.
Many thanks for all parties who are involved in the regulation compilation and review.
Physician (including retired)
[August 05, 2023 8:24 PM]
52 (3), which prohibits further delegation of an act delegated to a PA, is a bit ambiguous, as it could be interpreted that PAs cannot write patient care orders in inpatient or outpatient settings to be carried out by other regulated health professionals ie. vital signs q8h to be done by nurse, or administer oral (or intravenous) medication. Can the wording of 52 (3) be reconciled with the ability of PAs to write patient care orders (under the supervision of a physician)?
Other health care professional (including retired)
[August 05, 2023 10:13 AM]
- 52.(2) psychotherapy - needs to be addressed, should be apart of the scope for PAs, especially as PAs have adequate training to do so.
- 52. (3) “A member who is a physician assistant shall not delegate the performance of an act that has been delegated to them.”
o The wording indicates that a PA would need to carry out all orders independently, without any aide from nursing or other colleagues
o For example, we see people in clinic and may require injections to be done. Typically, the nurses preform the injections, which PAs sub-delegate that task or request to the nursing staff. The wording in this proposal suggests that PAs cannot request such a simple act. This impedes the efficiency they currently have.

Please consider that with the current state of the health care system, PAs are a solution to be used adequately. PAs do NOT replace physicians, they extend the practice and can fill the gaps in health care. They practice a medical model that mirrors the supervising physician staff. PAs allow for more patients to be seen. They reduce patient wait-times. They increase productivity. They allow for more provider-patient care time and encounters, that build strong rapports.
Prefer not to say
[August 04, 2023 1:53 PM]
1. I noticed the debate about title "Physician Assistant" versus "Physician Associate". I completely agree with the notion that it can confuse the public one way or the other. To make the matter even worse, there is also a title called "Physician's Assistant" . This really undermines the true value of PAs.

2. my understanting of "regulation" is that it controls WHO can DO WHAT, in this case, PAs can perform the delegated tasks from a physician. This is exactly the same as the existing CPSO policy, under which many members of regulated or non-regulated professions have been functioning. As long as the current CPSO exists, PAs do not need the draft regulation to work. PAs now have to pay extra dues to do exactly the same. This leads to my next question.

3. Is the registration mandatory given the above reason? Can they opt to not register with CPSO? How would this impact their practice? Can they still call themselves Physician Assistants?
Physician (including retired)
[August 04, 2023 12:04 PM]
I work at an academic institute and have had the privilege of working with two amazing PA's for the last 7 years. Our clinic could not function without them. Together they have done over 10,000 pain assessments over that time period. They are extremely competent and work very well with the interdisciplinary team. Their assessments skills are comparable to a senior resident. They have developed comprehensive Medical Directives that have been signed off by all the 18 physicians working in the clinic. These directives are over 60 pages in length and have been approved by the MAC. They are updated periodically to ensure relevance.
The human resource challenges facing the Canadian Health care system requires innovation and having health care professionals that can work collaboratively. Our clinic uses a variety of health professionals including OT's. PT's Social workers, dietitians, psychologists and psychiatrist. The PA works extremely well with all these disciplines. We also have an NP who practices independently of the physicians.
I am glad the CPSO is addressing the issue of scope of practice of PA's. They are an invaluable addition to providing health care to the public. This is the correct approach in ensuring sustainability and appropriate regulation.
Physician (including retired)
[August 02, 2023 5:59 PM]
Note: Some content has been edited in accordance with our posting guidelines 
As a very busy and aging physician in General Practice, the extension of PA licensing, is the only way that I can foresee continuing to maintain my practice and my own health. It is also the fastest and most efficient way to ease the burden generally on the Health Care System. I have been a mentor/supervisor for the [redacted] PA programme for the last several ears, and the students i have had have been extraordinary. Unlike other groups that have been felt to be a possible solution, that have actually been trained to "think like Doctors" which is a completely different and incredibly helpful approach. My practice includes up to 50% Psychiatric work by time, and I have no need to delegate that, but being able to delegate while I'm doing that will allow me to provide care for more patients. It would also potentially allow me to take some time off without spending 1-2 hrs getting caught up for every day missed. I hope this will become a reality soon, as I would have hired at least 2 of my former students on the spot if they fell under the proposed changes as I understand them. I would be happy to discuss this with anyone who might find my perspective useful, thank you
Physician (including retired)
[August 01, 2023 11:01 PM]
To what extent are PAs allowed to work in a diagnostic radiology setting? Would it be appropriate for PAs to provide the consulting radiologist preliminary reports for the consulting radiologist to review and sign off?
Member of the public
[August 01, 2023 6:55 AM]
My impression is that there are doctors who are medically trained to practice on their own. Then there are PAs who are there to help “extend” care they’re supervising doctors provide to more patients. And the college now wants to regulate PAs so they can be like the doctors without needing doctors? So why not also regulate the nurses that are working as doctors? I know you’re going to say “because they’re trained in the nursing model” but in reality they’re practicing medicine - we have all know NPs who are working independently as doctors so why aren’t they regulated under cpso? And there are naturopathic doctors - they’re actual doctors because it’s in the name and apparently they can “prescribe” oil of ginseng and order tests but they’re also “trained” differently so CPSO doesn’t want to touch that? There’s so much mixed messaging here and I don’t understand what the term doctor even means or does anymore. There are too many different training models (nursing, medicine, physician assistant, naturopathy) putting out ”professionals” who in the end are all practicing the same way and it makes no sense. I’m not sure anymore who to ask for when I go looking for medical care or if I get a NP or PA if they’re the same or different or what an “osteopathic trained urologist” can do differently. I’m so confused. It used to be easy, go to the clinic/hospital, the doctor will diagnose and treat me. The nurse will help the doctor. The surgeon will cut into me. Why has it gotten so confusing?
Other health care professional (including retired)
[July 31, 2023 1:31 PM]
I am very supportive of the regulation of Physician Assistants by the CPSO.

Will there be any section on the prescribing and ordering rights of Physician Assistants, or this suppose to be assumed in section 52(1)?

I think that outlining a sub section on medical prescribing and ordering would be supportive of the seamless incorporation and standardization of Physician Assistants into healthcare settings. Useful example of this is the New York State Regulatory Document on the Supervision and Scope of Duties of Physician Assistants (https://regs.health.ny.gov/content/section-942-supervision-and-scope-duties) as well as the Regulation Document for PAs in Manitoba by CPSM (attached below). It clearly outlines that prescriptions and medical orders may be issued by licensed physician assistant when assigned by the supervising physician(s). It also outlines how the prescription should be written and signed.

The CPSO should modify the proposed document to include these details under the appropriate section of the medical act to ensure PAs are practicing to their full potential in Ontario. It would be very disappointing if the lack of inclusion of such details set the PA profession back!

Thank you for the consideration
PA Regulation_Attachment_20230731.pdf
Other health care professional (including retired)
[July 31, 2023 12:51 PM]
52 (3) requires significant clarification of the role PAs hold in regards to “sub delegation” of tasks, especially for the hospital setting. As physician “extenders”, PAs must be able to order order investigations (labs, imaging, etc.), medications, etc. that nurses, technicians, and other team members will then carry out. The CPSO needs to clarify and establish this flow of care in writing so that there are not barriers created by other organizations afterwards (i.e., other HCPs/institutions refusing to carry out orders by PAs). Perhaps it would be useful for the CPSO to delineate the difference between “delegation”, which they define as “a mechanism that allows a regulated health professional who is authorized to perform a controlled act to temporarily grant that authori­ty to another person who is not legally authorized to perform the act independently” versus the act of ordering the initiation of controlled acts that are within the scope of practice of other health professionals (i.e., a PA orders a nurse to administer an injected substance). The CPSO already differentiates these two terms in their document on delegation of controlled acts (https://www.cpso.on.ca/en/Physicians/Policies-Guidance/Policies/Delegation-of-Controlled-Acts) and I believe further explanation in the PA regulation document could be easily incorporated. Overall it is crucial to health system efficiency, team based care, and patient outcomes that PAs are able to fulfill their roles as physician “extenders” without significant barriers.
Other health care professional (including retired)
[July 30, 2023 11:38 AM]
It is quite saddening to read some of the comments below, who do not seem to understand the physician assistant (PA) role. In my time researching the profession, being a student and working as a PA, I have never met a PA colleague who called themselves a physician, who pushed for independent practice, or who portrayed themselves in a confusing way to patients. I chose to become a physician assistant to work in a collaborative environment, care for patients and build a trusting relationship with my supervising physicians. I am PROUD to be a PA. I ALWAYS introduce myself as such, and explain how I will care for them, sharing that I always present cases to my supervising physician (SP). I am aware of my own limitations and will not act in a way that puts a patient or their family at risk for harm. Any instance where I feel I am in a situation above my knowledge, I will right away ask for help and see my SP. I can confidently say that I do not see myself as a physician nor do I want to replace one. I want to provide team-based care to patients and support physicians while we all navigate through the current Canadian Healthcare crisis.

It is also important to remember that PAs in Canada are trained in recognized, well-known universities (University of Toronto, McMaster University and University of Manitoba). At U of T, the program is greatly mirrored off the MD program, taught by many physicians, and supported by clinical preceptors who are physicians. We go through an intensive, 24-month program with multiple tests, exams, as well as a final certification exam by the Canadian Association of Physician Assistants. Once graduated, we have to obtain hours of yearly CME.

In regards to the draft, I have a few questions:
1) Will there be any clarification around PAs being unable to delegate tasks that were delegated to them by physicians? Using broad verbiage may lead to confusion and different practices across various environments.
2) Could there be a clause protecting the title of Physician Assistant to those graduating from accredited programs?
3) Given I have seen comments regarding the concerns of PAs presenting themselves as physicians, would a clause that does not allow PAs to portray themselves as "MD", "Physician" or "Doctor" be helpful?
4) Will there be a clause regarding prescribing rights?

Below, I attached the pdf for PA regulation by CPSM, as it may be encourage conversation or bring further suggestions regarding PA regulation in Ontario.

Thank you CPSO for allowing your members, as well as future PA members to participate in the discussion regarding our regulation. It is very much appreciated.
PA Regulation_Attachment_20230730.pdf
Physician (including retired)
[July 28, 2023 12:08 AM]
52 (2) - PAs can be trained in mental health

Will there be any training pathways that will allow INTERNATIONALLY TRAINED DOCTORS (outside US) to go into PA program without significant barriers?

PAs would be a huge asset to having in our very broken healthcare system especially with personnel crisis.
Physician (including retired)
[July 27, 2023 11:45 AM]
I have been working with physician assistants for 3-4 years now. Thy are very professional and well trained. I also worked with PA students and to me, I did not find lots of difference between their training and the training of medical students including those trained in Canada.
I am a physician who has been seeing large volume of patients in inpatient, outpatient and emergency settings. I think without having a PA working with me, I would not be able to see these volumes.
I also worked with PA in Manitoba few years ago and I think PA in Ontario are not any different from those in Manitoba where the role of PA is more obvious in the system.
I believe we need to support PA and we need to have more PA's in different specialties in the system. given the knowledge and training the PA in Ontario already have, I feel it is not difficult with some training and supervision for them to work in any medical specialty.
Regarding psychotherapy, I think with some training PA will be fully capable to administer that. I don't see a difference between RN, SW, OT getting training and doing psychotherapy and PA's in this regard.
Physician (including retired)
[July 25, 2023 1:07 PM]
I have had a PA in my family medicine office for 1.5 years, nothing but good things to say! Excellent knowledge, bedside manner. As other commenters have mentioned some of my patients prefer him since we purposely allow him more time to see patients. I often act as a 'second opinion' on complex cases which is very efficient.

Physicians' should push for more PA's, especially when speaking of more 'team based care.' They work with us and can be trained by us. We should be careful with nurse practitioners since they have their own guidelines, rules etc. and government feels they could replace family MD's... A physician with physician assistants could see a huge number of patients successfully for far less than total cost of NP.

The CPSO and OMA need to make sure physicians can bill for PA services as delegated acts...Right now the billing system will kill any future PA possibilities. I have increased my roster but cannot technically bill FFS for patients seen... this is a huge limitation. This has to be fixed!!
Other health care professional (including retired)
[July 25, 2023 1:04 PM]
The delegation model does not look like it will bring the flexibility as intended. I feel like there can be a lot of push back from other health professions with the Physician Assistant role due to the ambiguity of it.

It is better to follow Manitoba which showcases how effective Physician Assistants without removing their skill sets and setting up barriers to their practice.

Why move away from the model that Manitoba has setup and is being used across other jurisdictions already?

If you use what has worked across the country then there wouldn’t be so much confusion amongst physicians, physician assistants, allied health and community members.
Other health care professional (including retired)
[July 24, 2023 10:03 PM]
PAs have been functioning in the province of Ontario for over a decade yet they continue to have to jump through numerous hurdles to provide patient care. Although the existing model allows PAs to practice via delegation, it is far from ideal.

1. Medical directives are extremely complex, variable from PA to PA (even amongst PAs within the same specialty) and in practice, do very little to protect patients. They serve as an administrative hurdle to hiring/integrating PAs into practice, are seldom reviewed / updated (as they are extremely lengthy) and are often misinterpreted.

2. Rules around sub-delegation are often misinterpreted by other healthcare professionals who will refuse to take orders from PAs. This may also lead to confusion amongst PA trainees and other medical trainees (medical students, residents etc) who can also be trained by PA preceptors in certain circumstances.

3. The delegatory framework makes tracking PAs work/productivity in the province challenging as PAs do not have any unique identifiers (i.e. billing numbers) that help distinguish them from their supervising physician. This also leads to challenges in ordering tests at outside institutions (i.e. labs/MRIs/imaging requisitions) that are at times declined, regardless of medical directives and physicians info being documented. The current model also makes it difficult to track PA productivity/practice patterns within the system (as we cannot easily track what they are ordering/prescribing, given that their work is tracked under the identifier of the physicians with whom they work).

PAs are an incredibly under-utilized and un-tapped resource within our healthcare system. Over the last decade, we have tried to force PAs to function via a set of rules that were created prior to the existence of the PA profession and do not account for the unique PA-physician relationship. The CPSO has an opportunity to clarify the multiple grey areas surrounding delegation/PA practice in Ontario. This can be easily achieved by looking at what is done in other provinces (such as Manitoba) who have incorporated PAs, while maintaining a supervisory relationship, with far less administrative burden/bureaucracy. The current proposal does not clarify or address the many grey areas that currently limit PA practice in the province and will continue to lead to confusion and various interpretations of the rules. There is also no evidence that suggests these rules do anything to protect the public in their current form.

The CPSO has a unique opportunity to help effectively and safely integrate PAs in Ontario, at a time where health human resources are scarce and Ontarian's struggle to access care. It would be in the best interest of the public, physicians and PAs to create a clear, standardized and simplified process for PA regulation that recognizes the unique education, training and skillset of PAs. This can reduce the numerous administrative hurdles that currently exist, avoid misinterpretation by other professional groups and also allow us to measure PA productivity and impact to our healthcare system.
Other health care professional (including retired)
[July 24, 2023 4:23 PM]
CPSO needs to create PA-specific leadership roles within its Council and include PA education program reps, similar to current med school reps and physician electoral reps. When making decisions about PA regulation & practice, PAs need to guide those discussions. PAs will be paying registration fees to the CPSO and should be well-represented.
Member of the public
[July 24, 2023 2:23 PM]
I think there needs to be widespread education on what a Physician Assistant is. Reading the comments on this thread, it is worrisome that many commenters who identify as Physicians seem to be missing the point about what a PA is, what their scope of practice/potential can be, and what their education is. I have received care from PAs both in hospital and at my family doctor's office. I have nothing but amazing things to say about PAs - everything from their knowledge of my condition to their bedside manner has been extraordinary. I have run into issues with my PA providing care though (Xray and MRI requisitions not being accepted because it was signed by a PA; pharmacy giving trouble because my script was signed by a PA, even though it mentioned "on behalf of Dr. ___ CPSO#). This can all be simply fixed with this regulation initiative.

CPSO and Ontario have a huge opportunity in their goal to regulate PAs. That opportunity is to implement a new profession in our healthcare system that has the ability to make the system more efficient! We need to get with the times in 2023, follow provinces like Manitoba, countries like the USA, UK. Allow PAs to prescribe and order tests if their supervisor deems it appropriate; allow them to sub delegate as well. They will cut down the wait times we are seeing and make many services more accessible to patients in Ontario! I have seen first hand how amazing PAs can be, and how much they can contribute to a health care team. Please use this opportunity to ensure they may function as full members of such teams. Our healthcare system needs it.

Thank you,
Physician (including retired)
[July 24, 2023 11:07 AM]
I'm a semi-rural family physician who has been working with a PA for two years.

The addition of a PA into my practice has allowed me to significantly increase the size of the roster, better serve the needs of our community, and decrease my own burnout. There are portions of our patient population who prefer to see our PA secondary to her particular skill set and bedside manner.

In my experience, PAs are highly skilled healthcare practitioners who should be regulated by the CPSO and supported by GPs as valued colleagues. They are not a threat to our ability to practice, but rather partners who are able to expand our reach and serve more of a public in dire need of primary care.

I also strongly believe that GPs should be able to bill for services performed by trained/skilled PAs and reviewed by their supervising physician, without the requirement of being in the same room. A qualified PA is able to seek clarification and aid from a physician as needed, and the responsibility of adequately training and supervising a PA - knowing how far and when to trust their skills and abilities - is on us.
Other health care professional (including retired)
[July 24, 2023 11:00 AM]
The regulation of PAs in Ontario has been a long time coming and glad to see that it is finally moving forward. It is a bit disappointing that CPSO has opted not to follow in line with how other provinces, like Manitoba have elected to regulate PAs.

I do worry that the current regulation guidelines are quite restricting and could prove challenging to PAs having increased efficiency. As it stands, 52(3) can be easily interpreted to mean that PAs cannot provide orders to other care providers, including nurses. This will hinder PA practice and limit their ability to better assist Physicians with the heavy demands of patient care. If you reflect on the CNO response in this comment thread, it is clear that support will not be provided for what some may interpret as sub-delegation. The perspective should be that nurses are co-implementers of orders, the verbiage used in the delegation has to be quite clear to ensure PA practice is not further hindered.
Physician (including retired)
[July 24, 2023 12:49 AM]
The Canadian Armed Forces has been training and incorporating physician assistants (PAs) into their healthcare system for decades, and for a long time the military was the only Canadian PA program in existence. As a military physician I find PAs are invaluable. I have had PAs working under me remotely and occasionally even in different provinces or different countries. We also send PAs on military ships as the senior clinicians with the only reach back being by phone. Yes, they need oversite in some capacity, but honestly after a few years of practice I would consider an experienced PA to be a colleague. Incidentally the military also uses primary care paramedics in our clinics. Every clinician works to their scope of practice. In my current clinical environment (walk-in/urgent care) I only see 10-15% of the patients that come in (the most complex), as the bulk of the patients with simple primary care concerns are seen by the paramedics and PAs with minimal to no consultation with myself. The Canadian healthcare system desperately needs more clinicians, and if we aren't open to alternative types of clinicians having independent (or partially independent) scopes of practice, the system will not be sustainable.

I would suggest consultation with the subject matter experts that work in credentialing in the Canadian Armed Forces, as well as the military PA national practice leaders, to guide development of this policy.
Physician (including retired)
[July 23, 2023 10:10 PM]
Hello,
As an ER physician who works with PAs on a daily basis, I can attest to their skills, insight and knowledge and ability to improve patient care and the quality of care provided in a hospital system. PAs should be brought under the CPSO to provide both protection of the title from those who do not meet the necessary qualifications of a PA, and to provide regulatory oversight for all PAs working within the province.

My concerns with the current draft amendments revolve around several points in particular:

52(2) - this significantly impacts the role of PAs in mental health and psychotherapy, as many of the approaches utilized to care for patients with mental health and/or addictions concerns utilizes elements of CBT, DBT, IPT etc. in each patient interaction. Where does the CPSO place the line for PAs being involved in the care of patients with comorbid mental health concerns or concurrent presentations?

52(3) - this requires significant clarification of the roles PAs have in delegation of tasks, particular in hospitals. In the current writing, it is unclear if a PA who orders labs, or x-rays on a patient within a hospital setting will be able to "delegate" these tasks to the nurse or imaging techs appropriately without significant barriers and roadblocks. This needs to be clarified!

52(5,6) - this document has no mention around the interaction of PAs with medical learners, particularly residents and fellows. This is key given the currently written subsections could be interpreted to either extreme when a resident or fellow provides a PA with delegated tasks.

Thanks again
Physician (including retired)
[July 23, 2023 5:18 PM]
PAs should be required to have their own liability insurance and participate in ongoing CME.
Other health care professional (including retired)
[July 25, 2023 7:27 AM]
P.As in ontario have the ability to get there own liabiltiy insurance, and are required to complete 400 hours of CME
Other health care professional (including retired)
[July 24, 2023 9:28 PM]
The requirement of a PA to hold the CCPA national certification requires that PA undergo the same CME requirements as physicians, a min of 40 hours per year and 400 hours (80 hr/ yr) in every 5 year cycle submitted and tracked by the Royal College of Physicians and Surgeons, the same requirements as any physician in Canada.

The Liability insurance is optional at this point. Many PAs choose to seek their own insurance. Currently most are agents of the employer therefore the employer is liable. Mandatory insurance is a condition of regulation so also would be the case. I wonder if CMPA is willing to also insure PAs or will they need for profit insurance companies?
Physician (including retired)
[July 23, 2023 4:34 PM]
I support the implementation of PAs at the hospitals in specific roles that needed, I believe PA shouldnt be allowed to work independently and i dont support the role of PA in community based clinics.
Physician (including retired)
[July 23, 2023 3:59 PM]
Having PA's in clinic can help us with the overload of work - as a dermatologist, we are a rare resource that patients more access to. By delegating to a PA some of the easier duties we could be freed to see more consultations.

PA's cost money and it takes us time to train them. We need to be able to bill for their visits even if we are not there.

I agree with first visits need to be reviewed in person, but subsequent follow ups do not, we can review them at a later date, when reviewing the charts in EMR. We can also review them in person intermittently or if they have concerns.

right now we are billing for delegated procedures but ont visits. ie not billing a codes.

many PCP are billing for their Pa and others are not - It is very unclear.
I know the dermatologists through our last DAO meeting are not wanting to hire a
pa for these reasons. If can't bill for their time it is not worth it.

This is a barrier to hiring them.
Physician (including retired)
[July 23, 2023 6:56 AM]
PA should work as there name indicates ; as a Physician assistant .
They should not be independent in prescription and managements or procedures ,

It is unfair to a patient to have a much lesser trained person treating them and making decisions without consulting a doctor
Member of the public
[July 30, 2023 7:16 PM]
I would urge you to research and experience the benefits of what a PA can do. I have had a PA for several years as my primary caregiver and would choose them every time if given a choice. Perhaps they were not as experienced when they initially started to practice, but with many years of practice working with my Family doc, I don't see much difference. If something is more complex, he definitely checks with the doc - but I've had sutures done and vaccines given and my prescriptions filled...all independently with no direct supervision required. This speeds up my visit and I can actually get in to see someone now without waiting weeks.
Physician (including retired)
[July 22, 2023 8:10 PM]
PA should be a supervised role under a physician. I agree with others that they should be employees of a physician and the physician can bill some additional codes to provide them adequate income. They are not trained as physicians and therefore should not be seeing patients without direct supervision.
Bringing them under CPSO makes sense. Their rates should be the same as physicians are paying.
Other health care professional (including retired)
[July 22, 2023 8:07 PM]
Further clarification is needed regarding Section 52 (3) - sub delegation. As it is written currently, and interpreted (evident by the CNO statement posted on July 21/2023), a PA cannot sub delegate an act delegated to them by a physician. As the CNO has pointed out in their statement, subsection 41(1) in regulation 275/94 of the Nursing Act, 1991 prohibits a nurse from accepting the delegation of a controlled act, unless the person delegating the controlled act was, at the time of the delegation, a member of the College or a member of another College authorized to perform that controlled act by a health profession Act governing his or her profession. Many PAs in Ontario currently practice in settings that require placing orders typically fulfilled by nursing staff and other allied health care professionals to facilitate patient care in a timely and effective way. This is crucial to the function of PAs in our system (a system where many hospital services and departments depend on PAs). If one of these orders contain a controlled act (i.e. Administering a substance by injection or inhalation - Section 27 (2), 5; Regulated Health Professions Act, 1991), nursing or other allied health professionals will not carry out the order, thus, making the role of a PA in this setting counterproductive. From experience, PAs are highly educated, knowledgeable, and competent medical providers that increase access to care, decrease burden on the system and their supervising physicians. PAs have proven themselves to be safe, effective, and integral health care providers on many wards, hospital services, surgical teams, FHTs, etc. It is unreasonable to have this sub delegation regulation included in this legislation in such vague terms. At a time when our system is stretched thin, and stressed, PAs can be part of the solution to our health care Human Resources crisis. However, they need appropriate and logical regulation to be able to continue their contribution to patient care in Ontario. The regulation is set up to ensure that PAs will be held accountable for their actions, that they will participate in continuing education, and hold liability insurance. There is no need to create a barrier to the continuum of care by having sub-delegation removed from the PAs' regulation. Further specific explanation regarding sub-delegation are needed to circumvent any obstacles PAs may face when practicing after regulation. More importantly, adjustments are needed to this section of the draft proposal to provide further direction in the context of submitting orders that may contain a delegated control act given the Nursing Act, 1991 section on this (as this would be interpreted as sub delegation). The PA regulation needs to stipulate that PAs can perform controlled acts (through delegation) and sub delegate so they may function to the full ability of their knowledge and scope.
Physician (including retired)
[July 22, 2023 3:12 PM]
Regarding registration requirements, what is the policy about IMGs. If they are accepted as physicians , do they still need training? Also many of them write medical council of Canada exams and will their work as PA will be accepted towards their clinical experience?
What will be the payment options for PA's?
Thanks
Other health care professional (including retired)
[July 26, 2023 10:45 AM]
IMGs should be separate from PAs and have to undergo training to become a PA or conduct a residency to practice as a physician. The public should not confuse IMGs with PAs, they are two completely different roles. The PA title should be protected similar to Manitoba and the US and the use of "Physician Assistant" by IMGs should be discontinued.
Other health care professional (including retired)
[July 25, 2023 9:41 AM]
IMGs and PAs are not interchangeable terms nor roles. PA education in Canada is standardized and adapted from the Canadian medical school curriculum. IMG education is not the same, they should be looking to work as physicians.
Physician (including retired)
[July 22, 2023 2:48 PM]
It’s a horrible decision. Family physicians are going to face again the worst outcomes of this decision .
Other health care professional (including retired)
[July 22, 2023 10:28 AM]
For the subdelegation: does this mean as a PA I would have to physically administer medication that I am delegated to order? Or will Nurses be able to carry out these orders? I believe a more clear language would help clarify that. Thank you for your time!!
Other health care professional (including retired)
[July 22, 2023 10:14 AM]
It is great that the CPSO is putting forward regulation for PAs. PAs have been providing great service for over a decade there. After reading the drafts, reflecting, and reading through these comments it seems clear that there is a lot of misunderstandings on the education, training, and role of PAs in Ontario and the rest of Canada. I’m from Manitoba. PAs are legislated and regulated under the RHPA and the CPSM. We practice medicine under our certificate of practice or “license”, are authorized prescribers, and do all this under a contract of supervision with a Physician Registrant of CPSM. We don’t have medical directives and we don’t operate under a delegation model. We have functioned well for over 20 years, we are thriving, growing, and have amazing relationships with MDs, NPs and the the entire multidisciplinary team in Primary Care and specialty services including northern and remote communities. All other provinces have or are looking to the same model which, is similar to what is seen in most US States. Ontario seems to be developing a completely different model. We encourage Ontario to reconsider this model as it will create access barriers for patients and limit the effectiveness of PAs to help communities and Physicians. The solution is already out there and is proven. Follow the Pack on this one.
Member of the public
[July 24, 2023 4:54 PM]
I am in agreement with the Manitoba model. Although Ontario tried to make the delegation model a new concept with the best intentions in mind, there ultimately seems to be more problems in a realistic and practical standpoint amongst stakeholders.

CPSO, it might be in the best interest to consider the Manitoba model as it’s been proven to be effective and the model that is becoming the primer for the other provinces in Canada.
Physician (including retired)
[July 22, 2023 9:00 AM]
The overall framework and details of regulated acts in the General and QA/CPD sections make sense.

I have issues with the current registration requirements listed in the Draft policy. 9.1 (2) "a Canadian Certified Physician Assistant (CCPA) certification by the Physician Assistant Certification Council of Canada (PACCC)"

The issue is to get certification one must complete an MCQ test. This test is geared at a first year PA student with questions on mostly pathophysiology but not at the level expected of a student at the end of a professional program. This exam is also mapped to EPA (entrustable professional activities) but it is impossible to map an MCQ test to the framework of EPAs.

I would request CAPA change their exam to be geared to an entry to practice level.

In addition, I would advocate for a practical exam for certification. Someone who is booksmart does not mean they will be professional and communicate well with patients which are just as vital as medical knowledge, so I would ask CAPA in the next year to work on this or get external support to get to this level.

I am happy to provide more info if required if not coming across well in writing

Thanks
Other health care professional (including retired)
[July 26, 2023 7:47 PM]
I agree with this comment completely. From what I have seen, the exam is not a reflection of PA practice at all! The content on the exam is completely ridiculous and does not focus on diagnosis/treatment but rather asks questions on irrelevant details that no physician/PA uses in medical practice. CAPA needs to re-evaluate this exam and make it similar to the US PANCE exam or make it more medical practice focused, so we can have confidence in certified PAs ability to diagnose/treat etc. Otherwise, this exam is not a good way to judge if a PA has the knowledge to practice or not.
Physician (including retired)
[July 22, 2023 8:37 AM]
There is no mention of training for the PAs. As physicians whether independently licensed or with a supervisor successful completon of residency is necessary as is board certification.
This is setting dangerous precedent and harm to patients. It should be mandatory for physician assistants and other mid levels to identify themselves as such. The college should also ensure that there is reasonable competency and years of training (not just schooling and rotations). It seems as though delegation is to the physicians discretion however should the PA make a mistake or misdiagnosis or be inappropriate with a patient is the physician liable? Are they subject to a college complaint?
The objectives are not clear in the document, please spell out what training a PA will have, what is/is not appropriate for them to see. Further, billing has not been clarified- does the physician get to bill a supervisory code? Does the PA bill under the MDs billing number?
Physician (including retired)
[July 22, 2023 7:21 AM]
I agree that the PA program should be under CPSO and require CMPA insurance. Roles should be clear, and agree hiring should be physician driven not administrative. I work in a rural outpatient clinic and a nurse is assigned to work directly with me with no physician involvement which has led to more work depending on nurses skill. (Thank fully now my nurse is excellent). Even clarity on reviewing labs for MD might be useful.
Other health care professional (including retired)
[July 22, 2023 5:13 AM]
The proposed restriction of not allowing PAs to subdelegate acts would ignificantly hinder the role, and in some settings, effectively make the position defunct. If I understand this correctly, for example, in an Emergency Department setting, this would mean a PA would have to physically administer each medication, place every IV, accompany patients to imaging etc, thereby greatly reducing their ability to provide swift and effective care. PAs have time and again prove their effectiveness in extending physician care, in places it's needed most, what sense would it make to move the role backwards and reduce the ability of PAs to fill these healthcare gaps. If this part of the proposal must go forward, consider a compromise, and detail specific acts that can be delegated (such as acts that are, in the absence of a PA, preformed by nursing and other Healthcare roles), and those which cannot (acts, that in the absence of a PA, are preformed by MDs, and which fall under the designation of delegatable duties).
Physician (including retired)
[July 22, 2023 4:09 AM]
For Section 9.1, please clarify whether physicians who graduated from medical school and residency outside of Canada, such as in countries India, Mexico, China, would qualify in 9.1 (1) as "another program as approved by council" and 9.1(2) as "another certification as approved by council." There are over 2.2 million patients without a family doctor in Ontario - the ability for family physicians from foreign countries to be able to start practicing quickly without waiting or while waiting for lengthy licensures and re-education would greatly help with the burden of orphaned patients.

Please also clarify somewhere whether PAs that are currently employed prior to these new regulations will now have to register with CPSO when the regulations come into effect, or whether those who graduated prior to 2023 and were practicing prior to the new regulations will automatically be registered with the CPSO. Ie: Are these new regulations only for new graduates of the CCPA program/equivalent and those looking to practice as a registered PA from different stream?

I am uncertain if this will already be the case, but it would be nice if graduates of Canadian certified PA programs are automatically registered with CPSO and assigned a unique PA type CPSO number, instead of having to do any individual manual registration process themselves. That way results from Lifelabs, imaging centres, etc. can be sent directly to the PA for review and copied to delegating physician.

Thank you.
Physician (including retired)
[July 22, 2023 12:21 AM]
Physician assistants should be funded by the government. They are helpful, legitamate and educated. Canada needs to get with the times. What the The CPSO should do is to have more regulations to safeguard PAs from physicians and uneducated members of the public who in 2023 still don’t realize that PAs are different from unlicensed unmatched international graduates and seem to through the Physicians assistant term haphazardly.
Physician (including retired)
[August 01, 2023 6:32 AM]
I agree!! I have been surprised by the amount of work IMGs have been allowed to do in clinics. They’re marketed as physician assistants to patients who don’t know any better. At least PAs have training. I’ve heard of IMGs even doing pain injections for a doctor and then just reviewing it later with that “supervising” doc.
Physician (including retired)
[July 21, 2023 11:31 PM]
Physician assistants can be helpful if we actually use them. In primary care, funding for PAs can ensure a regulated trained person who finished a program in canada deserves to assess, diagnose and formulate management. Trained PAs can suture, administer injections, splint.

Primary care is at a crisis and CPSO needs to help support regulation of PAs. These should be trained delegated individuals

What the CPSO shouldn’t do is allow unregulated unmatched IMG’s to touch, assess and diagnose patients. I heard the CPSO said it was okay for a doctor to ‘employ’ unmatched IMGs to treat patients remotely. That in my opinion seems very, dangerous and sketchy.
Physician (including retired)
[July 21, 2023 10:22 PM]
I believe that we should include all IMGs to be PAs since they are often if not more qualified to be PAs and hence should qualify to be PAs immediately upon verification of their credentials.
Other health care professional (including retired)
[July 26, 2023 10:52 AM]
Strongly disagree. PAs and IMGs are not the same and should not be used interchangeably. The PA model in Manitoba has functioned successfully and IMGs are not integrated under PAs. This is also true for the US, PAs are successfully functioning with standardized training and IMGs are focusing on obtaining a residency if they can match. There is no need to have IMGs who had no PA training effectively transitioned into the PA title and role.
Other health care professional (including retired)
[July 25, 2023 9:38 AM]
I respectfully disagree. IMGs and PAs are not interchangeable terms nor roles. If an IMG passes the Canadian examinations, they should be looking to work as a physician. You should also refrain from generalizing a PA's knowledge as subpar and IMGs are superior. PA education in Canada is standardized and adapted from the Canadian medical school curriculum - more often than not, a SEASONED PA has been trained to function like the attending's personal resident within 5 years training under them. Not all IMG education is the same, and at times, is lacking the transferability of their knowledge into the Canadian system. If it does transfer over, you should be pushing for IMGs to become physician in Ontario, not a PA.
Physician (including retired)
[July 25, 2023 8:41 PM]
I strongly disagree. PAs cannot and should be considered at the same level as a 'personal resident' (assuming by that you mean medical/surgical residents....) because residents are MDs that can sign their own orders and often run entire services on their own with varying levels of oversight by attendings. PAs do not have this ability. The same way you note that IMGs and PAs are not interchangeable, neither are PAs and residents. In 2019, the University of Mexico lost accreditation for their neurosurgery residency program and it took twenty-three (23) NPs/PAs to replace the work of 8 residents at 5x the cost to the institution. Residents are overworked and underpaid and in many cases are the glue keeping academic hospitals together. Residency is beyond just the years after medical school, there are rigorous objectives to meet, testing (i.e. the Royal College exam for board certification), plus significant more clinical exposure than PAs get.

IMGs are very hardworking folks & I am constantly baffled by folks like you saying "they should focus on being a physician" when you know good and well that they are barred at several steps of the process. According to you, an IMG that passes qualifying exams to be a resident physician, is less qualified than a PA school graduate? That doesn't make much sense to me.
Physician (including retired)
[July 21, 2023 9:15 PM]
They should be required to work directly under a physicians supervision
Physician (including retired)
[July 21, 2023 7:32 PM]
with the shortage of Physicians i think its better to get Pa's support.
Thay should work with physician.
Physician (including retired)
[July 21, 2023 7:19 PM]
I am a FP working in Emergency Medicine in remote/rural hospitals, usually single doctor coverage. There is therefore considerable wait time to see the ERP and hence, the hospital has hired NPs and thinking about PAs.

Several questions arise about CPSOs decision regarding PAs:

1. Liability: Who is liable if the PA misses and misdiagnoses a critical ailment??

Examples:
Missed Dx of AAA in an elderly patient with chronic constipation and abdo pain - misdiagnosed as ongoing constipation..
Missed Dx of an ectopic pregnancy in a young female with urinary symptoms and clueless that she might be pregnant and gives a wrong date for her LMP, missed diagnosed as UTI.
Missed Dx of an ACS in a pregnant female who has been suffering indigestion and hence misdiagnosed as GERD.
Missed Dx of SCIWORA in a young child who fell while jumping on a trampoline; misdiagnosed as MSK sprain in the neck based on a negative C-Spine X-Ray.
etc., etc., etc....
What happens when these patients eventually end up in the ED a few days later with life or limb catastrophe that end tragically (simply because it is now too late and the pathology has advanced too far to be treated adequately, ESPECIALLY IN RURAL COOMUNITY EDs WITH LIMITED RESOURCES. Who is responsible when the family files a CPSO complaint and takes legal action against the ERP (simply because there is a MD after his/her name). The PA visit a few days ago and the ORIGINAL missed diagnosis will have been long forgotten by the patient and his/her family.

2. Billing:

As a norm, the hospital that has hired the NPs and PAs only permit them to see Cat 4 and Cat 5 patients (sore throats/ear aches/UTIs etc). The ERP is left to deal with the high risk and high stress patients (Cat1/2/3).

The problem is, the OHIP shadow billings generated by the "quickies, ie the Cat4/5 patients" is NOT paid to the ERP since these patients were not seen by him/her, COMPLETELY ROBBING THEM OF INCOME that they should legitimately be entitled to. The hospital refuses such payments to the ERP since the patients were NOT seen by the ERP in the ED/hospital!!
Is it the CPSO's intention to deprive the FPs of legitimate income in an already challenging financial environment????

3. Education:

A typical FP goes through several years of College/University Education followed by 4 years in Medicine and another two (soon to be three) years of FP training. The Residency training is grueling not to mention at minimum wage and long hours with NO overtime!! A PA/NP spends a fraction of the time in their training (and there are some nurses who have started doing on line correspondence courses to become NPs - Nurse Practitioner Program - No Bachelor Degree Needed, offered by one of the Universities that shall stay nameless!!); these individuals are now being permitted to work in the same position as a MD in the hospital/ED. The question is, what differentiates the MD from the PA in the minds of the patient if the PA is able to Dx a UTI or Tonsillitis or Otitis Media??
What kind of RESPECT does the MD get from the patient?? Is the MD equal to the PA/NP?? There is a major crisis of respect among Physicians trained as FPs. Fewer and fewer medical students want to become FPs simply because of the lack of respect for the FM profession - the general perception is, because FPs are NOT categorized as SPECIALISTS, they are therefore just flunkies relegated to perform scut monkey work, in the eyes of the patients and the "Specialists" as well!!
Even in Australia where FPs are categorized (legally) as SPECIALISTS, the public perception is that the GP is a scut monkey! Check out the latest publications reflecting these sentiments from the RACGP (Royal Australian College of General Practitioners)!! Lack of respect for the FP/GP is NOT just restricted to Canada!!!

Question to the CPSO: If FPs have NO respect within the health care system (since they are now no better than NPs and PAs), will the patients trust the FP and rely on their clinical acumen? Will the patient INSIST that they be referred to a "Super Sub-Specialist" for any ailment for which the patient is not getting their wishes and demands met by the FP and hence the patient is unhappy?? Is the CPSO ready for a deluge of complaints to the CPSO from the patients because their FP is unwilling to refer them to the specialist (while the patient's friend got referred to the Specialist by their PA/NP for a similar issue) and hence complain to the CPSO that their FP is rude/uncaring/judgmental/biased etc. etc. Is the CPSO unwittingly (perhaps not unwittingly!) forcing the profession of FP out of business completely?? If so, why not just STOP the FP stream completely and permit ONLY the Specialists to practice in Ontario!!!!!
Physician (including retired)
[July 25, 2023 8:47 PM]
Excellent questions. I am in surgical residency and find it abhorrent how much we are essentially destroying the family medicine specialty before our very eyes, and it will take years before we even know the damage we are causing. 'Specialists' may look down on family doctors, but even as a resident every single day I see patients with getting PREVENTABLE procedures that would've been caught by a good system of family doctors. We are essentially rotting the specialty from the inside out and are surprised by the reluctance of medical students to pursue it, and now scores of patients go unmanaged and unmonitored.

Surgeons and other 'specialists' are deluding ourselves if we think that we can practice without the support and backbone of family medicine intact. We NEED to protect family doctors!!!! And looking at our neighbours down south, we NEED to do our best to avoid harming patients by allowing diploma mills for poorly trained NPs and PAs to contribute to this problem!!

I support FPs in the push against their disrespect by everybody!
Prefer not to say
[August 03, 2023 11:49 PM]
I share your concerns about the situation of FPs. However, you may have misdirected the cause of that. It is not because of existance of PAs or NPs or IMGs. FPs who hire PAs or NPs do the hiring willingly knowing they would help with their practice, and hence, their patients. PAs are not forced on them.
Other health care professional (including retired)
[July 27, 2023 2:17 PM]
This is ill informed misinformation at best. Please do your research on the curriculums of the PA programs in Canada. These highly regarded Universities are some of the top in the world. Each PA program is modelled and adapted from their respective medical school curriculums and combine 12 straight months of didactic learning with ~2500 hours of clinical experience. The graduates that these programs produce are not replacing primary care physicians, they are helping them through the crisis we find ourselves in.
Physician (including retired)
[July 21, 2023 4:53 PM]
I support the use of PAs.

One of the challenges has been that NPs can work independently, whereas PAs have to be always under direct supervision.

I do NOT support PAs working fully independently, but would support language that allowed for arms - length supervision. For example, can see non - emergent patients independently as long as MD available within 15 minutes and reviews the chart..

However, there is a huge MISSED OPPORTUNITY here, alluded to by others in this consultation. That is the IMG MD grads.

We have all this language, regulation and credentialing around PAs - who have a bachelor's degree... while we do NOT have a process to allow IMG candidates who have passed the medical doctor Canadian Board examinations! They are far better trained, and in some cases already were practicing elsewhere.

I would MUCH rather have a trained MD who has passed the LMCC part I and the NAC work in this role..

I have worked with NP, PA and with IMG grads. The IMG grads are eager, AND they represent an opportunity to train potential future independently licensed physicians!

Please, Please, Please provide a framework - whether called PA or "clinical assistant" or "MD assistant," whatever.. there are more candidates and they are hungry to work and can help us with real downstream resource challenges.
Other health care professional (including retired)
[July 25, 2023 9:43 AM]
IMGs and PAs are not interchangeable terms nor roles. PA education in Canada is standardized and adapted from the Canadian medical school curriculum. IMG education is not the same, they should be looking to work as physicians.
Organization
[July 21, 2023 3:18 PM]
College of Nurses of Ontario (CNO)
Note: Some content has been edited in accordance with our posting guidelines.
Response in PDF format:
PA Regulation_CNO Response_20230721.pdf
Other health care professional (including retired)
[July 22, 2023 10:35 PM]
In my opinion after reading the feedback letter, I am interpreting a hidden agenda within the CNO's recommendation. I write my thoughts below, however, if my interpretation is slightly off, then I apologize.

1. Delegation: Physicians should be the only ones able to direct PAs. There is no unintended consequence of a physician delegating to a PA. Why? It's because Physicians and PAs are trained under the same medical model and the physician has extensive medical knowledge to be able to mitigate concern and supplement a PA's initial plan when required for patient care. The indication of "unintended consequences by limiting PA delegation to only physician" raises a red flag for me. I suspect it is a push to maintain status quo and push for NPs to allow to delegate to PAs. If this is the case, I respectfully disagree with this push. NPs do not have enough clinical and diagnostic training to be able to safely delegate to a PA. Upon review of the primary care NP curriculum, 500 hours of clinical placement is what I found in terms of clinical training for an NP. PAs under their education alone acquire nearly 4-5x as much medical clinical training and MDs alone acquire nearly 10x as much just after medical school compared to the 500 hours. Therefore, to summarize, the safest route for delegation, especially from a medical care and patient safety perspective, is to limit delegation to a PA to only the lead physician.

2. Sub-delegation: In my opinion, I feel sub-delegation is needed, and should only be limited to the ability of the PA (as their role is defined to delegation from physician). Refusal of sub-delegation puts a slippery slope, especially with nursing and allied health professionals. Without subdelegation, a nurse is not legally required to perform an order from a PA, who is acting as an extension of the physician. This creates more risk than benefit if anything. What happens if the nurse refuses an order from a PA that might be life saving for a patient simply because she's worried about losing her license based on CNO's policies? What happens if a nurse refuses a treatment plan made collaboratively by the MD-PA simply because the PA delivers it and it changes the prognosis of a disease course? These are real concerns that need to be considered. If anything, I think that on top of the PA regulation by CPSO, the regulated health professional act, Nursing act, and any allied healthcare act, should be required have an exemption for PAs to subdelegate.
- To physicians who are reading this, would you want a PA to keep coming back to you saying that a nurse or any other allied health keeps rejecting the PAs orders simply because they don't have to legally follow it? Wouldn't it be more work for you to reorder things every time causing an increased workload?

In summary, if we want to regulate PAs, regulate them with their maximum scope of practice that we have seen work in other jurisdictions. By limiting areas or putting up barriers to many aspects of the PA's scope of practice, you are limiting a great resource that is suppose to benefit the overall healthcare system.
Other health care professional (including retired)
[July 21, 2023 11:56 PM]
Thank you for your response CNO. In response to the delegation portion, I believe its 100% better for PAs should only be delegated by a supervising MD.

PAs are trained to be an extension of their supervising physician. They are trained the same medical model and undergo a modified curriculum adapted from the medical school curriculum. Therefore, PAs take the same thinking and approach to that physicians would take with treating their patients.

PAs do not serve as an extension of any other currently regulated healthcare providers. They are not taught a nursing model of care like NPs and RNs nor any other allied healthcare model for that matter. The thinking and approach is entirely different.

In conclusion, delegation to PA should only be done by their supervising MD(s), not anyone else.
Physician (including retired)
[July 21, 2023 3:15 PM]
I am in agreement with the proposed changes to bring PA's into the CPSO.
Physician (including retired)
[July 21, 2023 3:07 PM]
I believe PA shouldn’t be allowed to work independently. They encroach upon the role of Nurses and doctors and create delays and cause additional burden to the system. What I have observed is that when nurses have to report to a doctor they have to go through the PA’s and often PA’s think themselves to be doctors and order unnecessary investigations and it delays the whole process of urgent and effective care for the patient. I understand physicians need some assistants too for their work in any setting. If PA’s could be answerable to a particular physician who they are working with and likely if could be hired by the same physician will work better but allowing them to work independently is a havoc.
Physician (including retired)
[July 21, 2023 1:32 PM]
I think certified PA’s would help alleviate the current crisis facing family practice and the health care system.
Physician (including retired)
[July 21, 2023 1:09 PM]
I feel PAs should only perform care where there is an existing (or imminent) physician-patient relationship. They should not be seeing patients independently that the physician has never seen or will not be seeing.

It is my understanding that to bill OHIP fee for service, physicians need to be directly involved in the encounter. This needs to be considered in drafting the Policy.
Other health care professional (including retired)
[July 22, 2023 1:15 PM]
I think it's important to emphasize that PAs are never consider independent and the role itself never meant to be build that way. PAs work in collaboration with their supervising MDs under an agreeable set of directives. Even if a PA had to initiate the patient encounter (e.g., ER), it is usually under an agreement or direction with the supervising MD they work with. The patient is often concisely presented to the supervising MD after pt encounter + management plan before proceeding with an initial care.
Physician (including retired)
[July 21, 2023 12:48 PM]
PA should have liabilty covered by cpso and required to get cmpa on top of continued education
Physician (including retired)
[July 21, 2023 11:53 AM]
what about IMG,s who have dome MCQEE1 and 2 or cleared NAQOSCE will they be able to take part in this program.
Other health care professional (including retired)
[July 22, 2023 1:26 PM]
IMGs and PAs are not interchangeable terms nor roles. If an IMG who has passed MCCQE 1 & 2 and cleared NAC, they should be looking to work as a physician.
Physician (including retired)
[July 21, 2023 11:33 AM]
While the addition of PAs and NPs to our practices is inevitable, I think the CPSO needs to be quite careful in how it proceeds with regulating PAs. PAs and NPs cannot be advertised as equivalent to family physicians. I am not a family physician, but see many of my family physician colleagues moving away from the practice (i.e. to emerg, hospitalist etc), or leaving the country. Patients see GPs and PAs and NPs as equivalent, and they are not. The amount of training and hours of experience are not comparable (even less so with family medicine moving to a 3 year program).

I think the fact the CPSO has agreed to regulate PAs will further confuse the public. As such, very clear guidelines need to be made about their scope of practice and delegated tasks... and who is liable etc., which at this point I cannot say it is.
Other health care professional (including retired)
[July 22, 2023 7:51 PM]
Completely agree that independent practice is not the goal. But autonomy based on training and experience can help so many people who require care in this country. For example, I work with two physicians, one with 25+ years experience and one with 10. I learn what they do and work to apply it to my patient population, adding my own knowledge, training and experience to the process. As such, our patients get three providets instead of one. It's not about becoming independent, but working as a team to provide faster, better, and more knowledgeable care.

I am a PA and work with two phenomenal physicians, and I'm able to take their knowledge and experience, apply it, build my own knowledge and help Canadians manage their complex medical conditions. I see my role as helping physicians manage increasingly complex patient populations, improve wait times for care, and disseminate knowlege from my supervising physicians. I am so fortunate to work with two amazing physicians and I hope I make their day easier, keep them practicing medicine in an increasingly demanding system and improve care for Canadians in my care. My hope for regulation is to allow me to apply what I have learned in my 13 years of practice and 9 years of postsecondary education to care for canadians.
Physician (including retired)
[July 21, 2023 11:08 AM]
As a practicing family physician I do not support the role of physician assistance, encroaching upon primary care.

It is hard enough for us to maintain our role and carry a profession forward, without being undercut by the government proposals of inadequately trained assistance, who take on the role of the family physician in provinces is such as British Columbia.

They ought to have a defined and confined mandate from which they can operate and cannot take the place of a full-fledged family physician who has invested years of their life training arduously, and has a depth of knowledge that a physician assistant simply cannot match. I certainly know which of the two groups I would have my family members see.
Other health care professional (including retired)
[July 24, 2023 2:12 PM]
Please educate yourself on the role of a Physician Assistant. The profession was built on the relationship between the Physician and the PA. Without a Physician, there is no PA. PA's are not trying to be physicians, if they wanted to be one they probably would have attended med school. PA's are an extension of a Physician, they work in collaboration with the physician and most importantly their work is DELEGATED by the Physician. With the amount of patients in Ontario without a Family Physician, we should all be so lucky to have access to more health care providers who are capable, educated, and eager to practice as a Physician Assistant.
Other health care professional (including retired)
[July 22, 2023 7:57 PM]
I truly hope that no one really believes PAs want to take over primary care or replace physicians. There is not replacement for physicians due to their training and experience. PAs can help primary care physivians manage increasingly complex patients, but never replace them. As a PA I would never once considered replacing a physician. I want to be on their team, and can do so much as their teammate. PAs are there to keep physicians in medicine, not replace them. We NEED physicians. There is no replacement
Their are extremely well trained in Canada.
This is not action for independent practice, but instead a request that we can, through our training, provide care in a regulated fashion to improve care for Canadians. Unregulation is a barrier to working. And Canadians need more healthcare providers. Let us help you. Let us work in a safe and regulated fashion.
Other health care professional (including retired)
[July 22, 2023 12:15 PM]
Some of the negative comments by other primary care providers, who have probably never worked with PA’s or fully understand the role of a PA or how they fit into the continuity of care for patients in clinical practice or urgent care is disappointing. Your negative perspective is based on your own salary and egotistical ideology and not for those in need of our care.
Physician (including retired)
[July 21, 2023 10:48 AM]
Physician assistants should be allowed to practice alongside MDs in primary care and specialty medicine. They should not be confined by regulations that require the MD to be present on-site and have direct patient contact with every single patient they see. We have a robust model of physician assistant education in Canada and we are not utilizing our trusted PAs to their highest potential if our regulations continue to require unnecessary direct oversight.
Physician (including retired)
[July 22, 2023 4:29 AM]
Agree! I am a family doctor with a full practice. I have found the PAs we have worked with to be extremely helpful, diligent and knowledgeable after adequate clinical experience. If used at their highest potential they are extremely important in helping to provide care to patients in need of medical access and can free up time for us to see other more complex patients. The policies/regulations are written in a way where Physicians can delegate only when PA has competence and skill in the area of delegation. And about increasing time and burden to the doctors... or being concerned with the way PAs practice - every practice and every physician has a choice whether or not to employ a PA. You may choose not to work with PAs if it will be a burden to you! I don't believe this is relevant to the topic of CPSO regulating PAs which is important to hold them to a standard of care that physicians have with patients (a very good thing!)
Physician (including retired)
[July 21, 2023 10:30 AM]
Physician Assistants have been invaluable in extending the work of Hospitalists. There should be a an expedited route to certification for those trained in vetted non-Canadian programs e.g. one year of supervised work in the setting they intend to practice.

There should be flexible, but equivalent payment options e.g. hospital based, Family Health Team, or small group/solo community practitioners.
Other health care professional (including retired)
[July 21, 2023 9:58 AM]
I strongly support PA’s coming under CPSO, however have one concern regarding PA’s unable to sub-delegate. Many PAs currently work in internal medicine and other hospital specialties where they help look after patients under MD supervision - this obviously includes placing nursing orders. The wording is unclear and I fear that PA orders would be rejected based on this wording. This clearly goes against what PAs are intended to do, which is to support the supervising physician in their clinical duties. This will only create further work for the MD who will need to go back and clarify or re-place the orders. This wording needs to be clarified.
Physician (including retired)
[July 10, 2023 1:17 PM]
I am a retired Orthopaedic Surgeon.
Twenty years ago I did a study for the Canadian Orthopaedic Association about 'physician extenders'. I was asked to address the problem of a shortage of Orthopaedic Surgeons and the ever-growing waiting lists for consultation and surgery.
I concluded that we needed to make better use of the physicians we had, and the best way to do that was to introduce Physician Assistants into Orthopaedic practices.
The ideal model is the US PA system, whereby the PA is employed by the surgeon. This ensures that there is a proper working relationship between the PA and the MD; it also ensures that the PA is actually helping the MD to provide more services.
(If the PA is employed by the hospital or the government, they actually add to the surgeon's workload, as he now has to supervise someone who doesn't work for him/her. And often they are working in competition with the MD.)
The payment mechanism would be straightforward. Whenever a PA provides a service (e.g. followup visit, assist at surgery) a bill is submitted to OHIP with a suffix indicating that the service was provided by a physician assistant. The fee would be prorated and paid to the surgeon, who would pay the PA a salary.
I see no problem with the regulations you have proposed, but I believe that Physician Assistant should not be employed by anyone other than a physician.
Physician (including retired)
[July 22, 2023 4:34 AM]
Completely agree! Very good insights! Thank you.

Currently we employ our PAs under ourselves (family doctors) and we work well with them. They have been extremely helpful to our practice. I agree OHIP should help pay for PAs at PA rates to help subsidize the cost of healthcare provided and paid out by the physicians. They are seeing patients and providing important medical services with physician delegation.
Physician (including retired)
[July 21, 2023 1:00 PM]
Agree 100%. The hiring entity is by the physician only
Physician (including retired)
[July 21, 2023 12:12 PM]
I am an Internal Medicine specialist in rural Ontario with significant physician service shortage. I have had to turn down patients multiple times despite a ability, training and a real desire to help the local community physicians and patients.
I strongly agree with the payment model to be fair and given to the physician under whom the PA is working so there is optimal supervision and close relationship for the benefit of all. PA need to work as physician extenders not as primary care givers due to the nature of training and medicine.
Physician (including retired)
[July 08, 2023 12:14 PM]
How do we ensure that PA's do not encroach on the role of family physicians? I strongly believe allowing PA's to work independently would essentially eliminate Family Practice / GPs as we see it.
Other health care professional (including retired)
[July 22, 2023 8:07 PM]
I don't think any PA wants to encroach upon primary care physicians and take over. There are about one thousand PAs practicing in Canada right now, and although it may change, we have been trained in a model of team based care. If you, as a primary care physician, could hire a PA and pay them via billing or whatnot, and they could help you manage your patients why would you say no? I work in specialty medicine, but do so alongside two phenomenal physicians and I go consult hem in more complex cases, and otherwise provide care to hundreds of Canadians who would otherwise not get seen. I would never want to replace them, and could never given that I don't have their training and experience given their residency and felloowships. But together we have reduce a wait time of 2 years to 6 weeks, I have 9 years of postsecondary education, and 12 years of subspecialty medicine experience. I can provide excellent care, but do so alongside my physicians.
Physician (including retired)
[July 06, 2023 11:58 AM]
I believe the background and updated policies to include Physician Assistants are well written. I have no comments/corrections to suggest.
I can say having worked with Physician Assistants as a family physician, I valued their work immensely and am pleased to see the CPSO support integration of PAs with physicians as one way to address the need for physician extenders to reduce physician burnout.
Member of the public
[June 30, 2023 6:38 PM]
As a family caregiver/translator who has been with family members who were admitted into hospitals, I would like to provide my input on PAs.

The implementation of PAs at my local hospital has showed me the efficiency, they bring to the healthcare team. Many of their coworkers as well as their supervising physicians have always praised them in front of my family members and I when we were at the hospital. Therefore, I welcome this addition to the Ontario Healthcare Teams from a patient perspective.

Some concerns that I have are:
1. How are PAs going to be funded? I have read an article that a delegated PA billing model at a reduced rate would be a possibility. This helps physicians, especially those in the community, to be able to financially sustain an addition of a PA. Moreover, the delegated PA billing model would likely put the salary of PAs on par with NPs.
2. Why are PAs being limited in psychotherapy? Wouldn't this limit their services in mental health field?
3. Is there a possibility to seek federal exemption for PAs to prescribe controlled substances? I would like to think it would quite difficult to hunt down a supervising physician every single time to get an order. I would like to say if NPs can prescribe controlled substances then there should be no reason why PAs cannot.
4. There needs to be clarity on the delegation part. PAs should be able to sub delegate to nurses and allied healthcare providers. If this wording is not clear, the PAs orders are at risk of being rejected every single time, and that would create a headache for the supervising physician as they would have to re-order it every single time.

From my perspective, the draft will need a bit of working on. It's better to iron out everything first before moving forward.
Physician (including retired)
[June 28, 2023 10:54 AM]
Note: Some content has been edited in accordance with our posting guidelines.

[Redacted]
 
Draft regulations OK.

Do you wish to be specific as to how often the competency of a PA to perform a delegated act needs be verified? Yearly, every two years, etc?

How is this to be documented?

Do we have a reciprocal agreement with the Yanks on recognition of PA training?
Member of the public
[June 26, 2023 7:42 AM]
I agree with the following mentioned by another member. Very clear restrictions need to be made so that we protect the public and also ensure some MDs are not abusing the system by hiring PAs to do their jobs for them.


1. PAs cannot work independently, cannot bill and must always be supervised with a physician being physically in the building
2. PAs cannot refer on their own, and must use the supervising MD's billing number
3. I strongly agree with the current wording that PAs cannot delegate acts delegated to them by MD to another health professional, including nurses.
Other health care professional (including retired)
[July 25, 2023 11:56 AM]
What is the rationale for not allowing PAs to refer out? If the patient has been seen/discussed with the Physician and part of the treatment plan the PA has been delegated to carry out involves referring, why should the PA not be able to do this if it has been delegated? And as the other reply mentioned, restricting the PA's ability to "sub-delegate" physician-delegated orders negates the role of a PA.....
Other health care professional (including retired)
[July 22, 2023 8:20 PM]
I would argue that not allowing PAs to delegate tasks delegated to them would only slow down and limit care. For example, if my physician delegates to me the ability to delegate to nurses to give certain meds e.g. Tylenol not yet ordered, or bladder scans, or ABIs, my role and signoff is allowing nurses to do their jobs in a timely fashion. In my experience, nurses want to provide care to their patients. Unfortunately, sometimes physician orders are required before being able to provide care. By being a PA on the ward and having their right to delegate this care I can speed up care to patients, help.nueses manage their workload, limiit adverse events by providing timely care, and support my colleagues in helping Canadians. By saying I can't delegate anything means I'm sitting there, not able to help a nurse. I want to help this nurse. She is amazing. This is standard care that needa to be done. I am knowledgeable in this area based on multiple years university education and subsequent years in mexic practice. But if the physician is busy managing a very complex situation, no one gets care until the complex situation is over. That's not fair to patients, nurses or allied health providers who just want to get the job done. Let's focus on what delegation can provide - timely, safe and appreciate care. And much less burden for physicians who are burning out at an alarming rate.
Physician (including retired)
[June 25, 2023 8:51 AM]
The role of the PA has to be a supervised one. Always. If not the any government will see this as an opportunity to cheapen the workforce, and who is going to be left to oversee and train?
The PA is not here to replace a physician, the role is there to support. That is the whole purpose of having different team members: we can't all be doing the same thing.

The better this is defined, the easier it is for everyone.

As a an IMG, with three Board exams (incl the Canadian) and a higher postgraduate degree working as staff in a tertiary centre, I have read the comments on the subject PA/IMG with interest.
To retrain as a PA, for an IMG, may be something that would be attractive for some, at least their working life would be secure and it would give them an opportunity to learn the Canadian system, before they then might or might not proceed to have their credentials fully approved. Exams would test their knowledge, so there seems to be little need for fear that the standard wouldn't be met, and their expertise would be of benefit to Canada. This seems an important discussion, but perhaps different to the consultation itself.
Physician (including retired)
[June 24, 2023 2:17 PM]
As a Family Physician working in remote First Nations communities in Northwestern Ontario, I sincerely hope this change allows for PAs to work under their own designation, but adjacent to physicians providing care in under resourced clinical environments where the administrative burdens have diminished our patient facing time to a sadly low level. PAs that are trained by physicians working in these communities should then be able to practice, without the MD on-site, to deliver primary care to community members and should be remunerated by Indigenous Services Canada (not from physician salaries). Remuneration is not a College issue, however independent practice is. There are some practice settings where it is vital that we find solutions for decades old under service issues.
Physician (including retired)
[June 23, 2023 6:11 AM]
Section 52.[2]
It seems prudential to include definition of terms. What is the precise definition of "psychotherapy technique"? What is meant by "serious disorder"? For example does it include general supportive / counselling for depression in a therapeutic relationship where thought is assessed to be intact, mood is significantly depressed, the individual is not suicidal and judgement is not impaired? This a common presentation in primary care family practice. The mental referral system is severely stained and under-resourced at the community level [frankly, an emergency situation]. Wait times for MH providers are very long. Many family doctors take on supportive counselling roles.

52. (1) A member who is a physician assistant shall only perform an act under the authority of section 4 if the performance of the act has been delegated to the member who is a physician assistant by a member who is a physician.
(2) Despite subsection (1), a member who is a physician shall not delegate to a member who is a physician assistant the authorized act of treating, by means of psychotherapy technique delivered through a therapeutic relationship, an individual’s serious disorder of thought, cognition, mood, emotional regulation, perception or memory that may seriously impair the individual’s judgment, insight, behaviour, communication or social functioning.
Physician (including retired)
[July 04, 2023 6:39 PM]
I concur with this statement.

Does this wording suggest that as soon as a mental illness is identified that the PA must immediately recuse themselves and hand over to the PA's supervisor? If not immediately then when? Is the intent to ensure that PAs do not engage in psychotherapy? Is the intent for PA's to not provide care to someone whose judgement is impaired? Perhaps it is me but these points weren't clear to me.
Physician (including retired)
[June 22, 2023 10:16 PM]
Am unclear of the relationship between physician and PA. If the PA makes a clinical error, where does the liability fall to?

I agree that there must explicit statements regarding PA's ability to work independently, and cannot bill.
Physician (including retired)
[June 21, 2023 12:19 PM]
Support Physician assistants becoming part of CPSO and support proposed policy

Currently, PA's are not allowed to bill for virtual consult care under OHIP. PA's should have scope of practice similar to Physician they are working with notwithstanding the identified/ proposed limitations already stated.
Physician (including retired)
[June 20, 2023 12:08 AM]
As mentioned by someone else, what exactly is the point of becoming a physician then if we're following the path of the United States and expanding midlevel roles? Every non-physician is getting massive role expansions.

I can speak on behalf of private family medicine groups (private online groups) that many are extremely discouraged by any midlevel expansion and plan to further leave primary care or just not start doing any primary care.

The physicians who encourage expansion of practice rights, as seen in these comments, plan to profit off physician assistants. And of course the comments from the PAs wanting to be called associates just highlights how far this goes.

Clearly this system is setup purely to discourage physicians and only encourage anyone who is not a physician.
Other health care professional (including retired)
[June 20, 2023 8:28 AM]
In response to your concern about expanded functions for PA's. I don't believe that PA's are removing the need for MD's/DO's. PA's were created to address the shortage of the MD/DO which is ongoing "Around 4.6 million Canadians are without a family doctor, according to a 2019 report by Statistics Canada. In Ontario, 15 per cent of the population is without a family doctor, 2022 research released by Inspire Primary Health Care showed."~https://globalnews.ca/news/9649124/family-doctor-resident-positions-vacant-canada/#:~:text=Around%204.6%20million%20Canadians%20are,Inspire%20Primary%20Health%20Care%20showed.
As for changing the title to Physician Associate, this was done to address the confusion of the general populous. Too many patients confuse a PA with a medical assistant or believe the PA is there to assist the doctor. The title "Physician Assistant" has been misleading and many believe switching "assistant" with "associate" can make a difference. MD/DO's are still in great demand.
Physician (including retired)
[June 23, 2023 2:03 PM]
I think we have seen in the United States that midlevels generally use the rationale of filling in shortages as a way to get independent rights. But then statistically, do not work in underserved areas.

That is besides the point. If you're able to practice medicine independently as a midlevel, then why even become an MD?

Primary care shortages exist because family doctors do not feel appreciated and supported doing actual family practice. More so, many PAs work in specialties.

As for the name change, I have strong faith that CPSO will never do that and there is zero evidence to indicate it will happen.
The correct term is Physician Assistant. The term "associate" simply creates extreme confusion and makes the patient believe PAs are equal to physicians, which they of course are not in any capacity.

Protecting the public is a primary objective of CPSO. And misleading patients severely undermines the public and their safety. I understand that a small number of patients may believe PAs are equal to a medical assistant, but that's just a matter of patient education and is not a patient safety issue. But patients believing PAs and doctors are equal in competency and training, is a major patient safety issue.
Physician (including retired)
[June 18, 2023 3:02 PM]
What is the point of gettting an MD now?

I have chiropractors ordering x-rays for fractures and arthroplasty follow-ups.

I have naturopaths asking for Vitamin D level tests and CRP tests.

I have Nurse Practitioners ordering rotator cuff ultrasounds on 90 year old patients.

I will not comment on foreign trained "MD"s.

Based on what I have seen over decades, I can only assume Physician Assistants will over order.

Why not just eliminate all of these positions and give the patients access to lab and imaging requisitions so they can fill them out themselves? It is happening essentially anyways.

The absolute waste in the public system is amazing. And each "medical" professional that orders a lot of tests is considered excellent by their patients.

But the CPSO and OMA know this.

Just make it a private system.
Physician (including retired)
[July 22, 2023 9:04 AM]
Totally agree! Naturopathic so called doctors do same when it comes to excessive amounts of testing and most of the time patients get the orders for free from the family doctor
Physician assistant should be hired by physicians, work under a physician and be paid by the physician
Physician (including retired)
[June 18, 2023 2:32 PM]
We have been utilizing the services of PAs in hemato-oncology for a number of years and their contribution is immense. These changes are welcome, but some aspects need clarification as there are many ingrained restrictions in practice.
Once a PA has been designated to perform a certain role, it should not be necessary for a supervising physician to be in the building. While this is not specified by the CPSO, some administrators consider this necessary. I see no need for this limitation. Some of the PAs perform procedures as well, if not better, than some physicians.
Is there still a restriction on prescribing opiods? In our field with cancer chemotherapy, opiods are prescribed for pain control and if the physician delegates this role to a PA, there should be no restriction.
Welcome the option of joint-supervision by a group of physicians, rather than having only one supervising physician. This is important in hospital and in-patient service, where the physicians rotate.
I do not agree abut the restriction on mental-health care, especially when PAs are working in a mental health setting or patients with cancer and end-stage disease are being assessed for mental health issues. The PA should be able to refer to a mental health specialist, if designated by the supervising physician. This may require some change in wording.
For PAs working in hospital settings, referral to other specialists is a routine requirement and should not be restricted. I suggest that the physicians can delegate this role to a PA, if they deem this task appropriate for a PA.
Physician (including retired)
[June 17, 2023 6:52 AM]
Thank you to the CPSO for doing this hard work, and a special thank you to Dr. Nancy Whitmore for her transformational leadership. It has been very palpable.

Two comments.

The first is about supply. We have countless IMG physicians in Ontario delivering pizza or driving taxies. We'd ideally want to create a path for them to practice medicine in their specialty and serve Ontarians. Short of that, we should seriously consider allowing IMG physicians, who do not qualify for CSPO registration as physicians at a particular time, to register as PA's with certain requirements like language test or passing the NAC exam (or the previous MCC Evaluating exam).

The second is about PA practice in institutional settings. The regulations as written envision the MD-PA relationship as mostly a one-to-one private relationship. In a large institution, PAs would be hospital employee, largely part of a pool, with delegated acts empowered by collective and institutional (rather than individual) medical directives. Much of the responsibility of managing PA's (including hiring, evaluating credentials, scheduling and monitoring etc.) would not fall to individual physicians in the organization but rather to an office like "interprofessional practice" in collaboration with the physician group/leadership. A structure like that needs to be addressed in the regulation. PA's in hospitals will become more and more a part of the way we deliver care. We need to be ahead of that.

Thank you.
Other health care professional (including retired)
[July 25, 2023 12:09 PM]
IMGs are not PAs and PAs are not IMGs. They do not have the same training and do not graduate with the same credentials or designation. IMGs should be their own separate designation.
Other health care professional (including retired)
[June 21, 2023 11:05 AM]
Hello,

PAs and IMGs are not interchangeable. PAs have specialized education that meets Canadian standards and accreditation. They also write a certification exam and have continuing education requirements. IMGs do not have the same professional/educational standards that PAs adhere to at present (even in the absence of regulation) and there is no way to know whether an IMG’s education would be appropriate for them to work as a regulated PA in Canada. Becoming a PA in Canada is also extremely competitive. Using IMGs and PAs interchangeably is a disservice to our PAs who worked hard to earn their degrees.
Physician (including retired)
[July 21, 2023 10:17 PM]
I agree, PA and IMG are not interchangeable. Simply because IMG are individuals who were trained elsewhere in the world to become physicians, while PA are trained here to become assistants to physicians. The years of education, knowledge and training of an IMG are way more than PA. Hope this clarifies some of the huge differences between PA and IMG.
Physician (including retired)
[July 25, 2023 9:03 PM]
Exactly. Thank you. The absolute insistence people have to denigrate IMGs...when many IMGs go to medical school for 6 years while PAs are trained for 2 years. Of course IMG training varies a lot around the world, but so does medical training in Canada if we want to be honest with ourselves. Being trained in Canada for 2-4 years doesn't magically make you know more than someone else properly trained for 6. I am in residency with IMGs whose level of clinical knowledge embarrassingly dwarfs mine. Immensely.
Member of the public
[July 31, 2023 8:09 PM]
So, why don’t we replace all our Canadian physicians with IMGs? Why are we wasting tax funding on more Canadian physicians when we can just let those from other countries come practice here? Since by your logic, 6 years of IMG education triumphs 4 years of Canadian medical education which equip IMGs better for residency than our Canadian grads.
Other health care professional (including retired)
[June 16, 2023 3:59 PM]
One area that is not addressed is PA billing.

I understand the concerns many would have with regards to PAs suddenly practicing independently if they are given billing codes, however that would easily be addressed if there is clear legislation prohibiting PAs from practicing without a supervising physician. Or if PAs could bill for their services only under their supervising physician, with the supervising physician ultimately being responsible for what is billed, then there is no risk of independent practice.

Certainly the rate a PA would bill for a service would be a fraction of what a physician would bill for the same service. However, allowing PAs to bill for similar services as physicians - but at a reduced rate - could surely save the healthcare system millions of dollars.

One clear example is surgical assisting. Currently, many physicians (particularly family physicians) will assist in the OR and bill OHIP for their time. They generally pick and choose when they are available, which means surgeons may not always have the same physician assisting them, and may run into problems of not having any appropriate surgical assists at any given time. There is no safety concerns with surgical assisting, particularly if you take into consideration the fact that even medical students can assist in the OR. If PAs are allowed to bill for surgical assisting time, they could bill the same time units as a physician would, but at 50% or 75% (for example) of the dollar amount paid to a physician, which would overall save the system money. I know many surgeons that would definitely prefer to have the same PA to assist them in all their cases for continuity, but are currently unable to do so, because they would have to pay the PA out of pocket for service that a physician can bill OHIP for at no cost to the surgeon.

I would think this is also a major barrier in physicians hiring PAs because so much of the PAs time would be unbillable time that the physician has to pay for out of pocket.

The second concern is the limitation and restriction on PAs delegating acts. It just makes no sense that for example, a PA working on a floor could be expected to complete an act themselves, but would not be allowed to ask a nurse to complete the same act. That should definitely be addressed.
Physician (including retired)
[June 16, 2023 8:13 AM]
pA’s cost to us are high and right now we can’t bill for their visits only procedures.

Not many dermatologist are adopting them in their practice as can’t bill for their time.

For example if I am out if office and they see someone I can’t bill,
Physician (including retired)
[June 15, 2023 12:04 PM]
The section 52 (2) about is unnecessarily limiting.

Physician assistants can easily have the skills, judgement and knowledge to safely and effectively perform psychotherapy. Mental health visits take up an inordinate amount of time for family doctors, and we already have a severe shortage of family doctors and psychiatrists.
Physician (including retired)
[June 15, 2023 10:37 AM]
In the sleep medicine field we have been using trained sleep techs as physician assistants for years. I wonder if the CPSO would consider adding the RPSGT certification to the list of qualifying designations to apply for registered physician assistant status, or at least the CCSH (certification in clinical sleep health)? A generally trained PA is of no use to me in specialist practice without alot of extra training, but the sleep techs have at least a clear grounding in the field.

I also wonder if there is room in the policy for physician assistants I have trained before the standards existed, and who are in a direct supervisory relationship with me, but who do not meet the CPSO requirements? I would hate to lose them after all the training I have put in with them, and for them to not be able to continue to do the work they have been doing all this time. I should also clarify that I have not been delegating controlled acts to them, only uncontrolled acts (e.g. background history taking, checking vitals, data entry, report preparation, patient education). Perhaps I would just need to find a different title for these individuals? But then I am concerned that the CPSO will no longer have a policy under which this working relationship is regulated. I wonder if there is a role for a class of PAs who are in a direct supervisory capacity with a physician in addition to the current framework being proposed by the draft policy?
Other health care professional (including retired)
[July 25, 2023 12:15 PM]
Physician Assistant is not just a "title," it's an actual degree and designation that is given after writing and passing a qualifying board exam and maintaining certification as a PA through continued education and memberships with the certifying bodies.. Those who have not graduated from PA school and passed their boards should not be just given this designation simply because they are "assisting" you at work.
Physician (including retired)
[June 15, 2023 10:12 AM]
I agree with the intent to incorporate Physician Assistants within the regulatory framework of the CPSO.

There are a few concerns regarding the draft proposal:
1) Section 52.4(b) is too vague, how might Physicians become "satisfied" and what are "reasonable steps" a physician might take to ensure a Physician Assistant "has the knowledge skill and judgment" to complete a task? Is it enough to assume the skill, knowledge and judgment due to the qualifications listed under section 9.1?

2) I agree with 52(1) and 52 (3)

3) 52(2) is quite worrisome - how might a PA or MD designate when psychotherapy starts within a clinical encounter? Does this preclude PAs working with / on Mental Health Units, or with any mental health presentations within a clinic? As others have mentioned mental health concerns can easily be 40-50% of any given Family Medicine clinic day. Additionally, if a PA has completed training (additional or otherwise) to be competent at psychotherapy, timely access to which is very much needed across Ontario, how does 52(2) not contradict the intent and content of item 52.4(b).

4) As others have stated how does the supervision of a "shared" PA take place within a group or clinic. Does their need to be a designated "lead" physician? Do all individual physicians within the "shared" service need to document the PA's competency under section 52.4?

5) Given the additional costs to the overall health care system from NP practices in terms of "rubric" work ups and referrals, PAs should only make referrals if their supervising MD agrees to the referral.

6) As some have commented, if a PA consults a specialist on a hospital admission, and that specialist makes recommendations, why can a PA in this specific context, delegate those recommendations to other Allied and Regulated Health Care professionals? By prohibiting such delegation of specialist's recommendations, does this not negatively impact patient care?

Thank you for the opportunity to participate in this consultation.
Prefer not to say
[June 15, 2023 8:12 AM]
Will PA dues but the same as physician dues? Reason for asking is PA dues should be the same as physician dues if receiving the same services from CPSO. Additionally, I do not want physician dues to be subsidizing PA dues. Thank you.
Other health care professional (including retired)
[July 24, 2023 11:37 PM]
The services offered are the exact same regardless of level. There is however a Residents or Post Graduate Education level fee. This recognizes the fact that Residents are supervised by physicians and are paid significantly less. Exactly the same as a PA. PAs additionally to meet the burdens of this regulation must be members of the Canadian Association of Physician Assistants which charges an annual fee of nearly $1000. Add on the requirement of a $ 1700 All Classes CPSO fee and several thousand dollars a year in liability insurance. Suddenly you will need to be paying your PA significantly more than 100K as they will be paying nearly 10% of their annual salary in licensing fees. The $345 Post Graduate Fee is more reasonable given the payment models as well as the restrictions to practice. PAs essentially work as life long residents, always supervised by and attending.

Canada Revenue Agency Prohibits PAs who are employed by a corporation (Medical Corp or Hospital) from writing off the cost of CME. It is the responsibility of the employer to ensure that their employee is funded for their required training. PAs currently complete the same Mainport RCPSC CME requirements as Physicians. CME is very expensive even with reduced rates for PAs.
Physician (including retired)
[July 21, 2023 10:22 PM]
I agree, it should be the same as long as they receive the same service from CPSO.
Other health care professional (including retired)
[July 21, 2023 10:44 AM]
PA dues should not be the same as physicians nor should physicians have to subsidize the dues of PAs. PAs already have an association for which they pay dues to. Additionally, physicians and PAs there is a huge salary discrepancy (and rightfully so) but the fees should be equitable rather than just one blanket fee.
Physician (including retired)
[June 15, 2023 7:52 AM]
As a Physician , it is not easy to ensure as to PA’s competence. I feel the PA ‘a should be better of having the same regulatory body as Nurse practitioners as their scopes of Practice match closely. How are PA ‘Z going to be paid if working in Private Clinics .
Physician (including retired)
[June 25, 2023 3:40 PM]
NPs and PAs are very different due to how they are regulated. PA are also educated in the physician model of care. NPs are independent practitioners with their own scope and separate regulatory body. So you can hire them but cannot change their scope of practice to meet the physician’s scope or style of practice. PA on the other hand can be employed to reflect the supervising physicians’s scope of practice using delegation and training and thus can be much more versatile and tailored to each physician or group of physicians.
Physician (including retired)
[June 15, 2023 6:45 AM]
The amendment may include addressing the expectation for availability of the supervising physician. (I view some delegated acts would carry necessary/urgent physician assessment -- for example in obstetrical scenarios). I view regulation may need to encompass potential scenarios where a supervising physician is overseeing a clinic staffed by physician-assistants only, where direct oversight (ie. onsite availability) may be expected.
Physician (including retired)
[June 15, 2023 6:18 AM]
What is the CMPA’s view?
Physician (including retired)
[June 14, 2023 9:52 PM]
It is very important to ensure the public's safety. This would be by explicitly stating:

1. PAs cannot work independently, cannot bill and must always be supervised with a physician being physically in the building
2. PAs cannot refer on their own, and must use the supervising MD's billing number
3. I strongly agree with the current wording that PAs cannot delegate acts delegated to them by MD to another health professional, including nurses.
Physician (including retired)
[June 14, 2023 8:45 PM]
The supervisory and delegator requirement for physicians to oversee care by PA's should be ironclad. PA's should not be able to bill independently, or practice independently, and the oversight provided should not just be a financial arrangement of collaboration in name only. The details of the required level of supervision should be clearly spelled out. In the US there is a movement toward "independent practice" for unqualified professionals that pursue it at the expense of patient care.
Physician (including retired)
[June 14, 2023 6:24 PM]
I am concerned that section 52(1b) is unclear:

52(1b) The member who is a physician is satisfied, after taking reasonable steps, that the member who is a physician assistant has the knowledge, skill and judgment to perform the act safely and competently.

Admittedly my experience with PAs was in the UK, but PAs were on a rota and it was not expected that you had direct knowledge of their skills/abilities prior to working with them. It was assumed that if a PA was working in a capacity, that the hospital/supervising physician had deemed them capable of that task/role after appropriate assessment.

I worry that the phrase "taking reasonable steps" suggests that each individual physician should evaluate each PA prior to a task or be responsible for any malpractice caused by it. I perceive a future in which hospitals hire PAs to perform roles beyond their scope and then place the blame on the nearest physician when harm occurs.

A more prescriptive approach to the role and limits of PAs would be more appropriate.
Physician (including retired)
[June 14, 2023 5:44 PM]
as a psychiatrist practising both inpatient and outpatient psychiatry in a variety of settings, I have been recent years provided a large consultation service to family doctors. Physician assistants are a great help on the inpatient setting for obvious reasons. I’m limited with respect to the number of consultations I can provide for the simple reason that I don’t have enough available “followup” appt times for adequate follow up and I’m not in favour of the “consultation model” without following up to see how my medical recommendations are working out. I feel that a Physician Assistant could greatly increase the number of patients I can consult on for my family medicine colleagues. While it isn’t strictly “psychotherapy” we do, it is certainly psychiatric care which is managing medication’s, managing side effects, giving support, creating a therapeutic alliance. This is all a part of psychotherapy is it not?
Physician (including retired)
[June 14, 2023 3:21 PM]
Yes I do think the regulations are clear enough to understand them. Yes, you will be how to access the position is it voluntarily or will an audit? I think for the first year there should be hotspots audits to see if they are compliant.
Physician (including retired)
[June 14, 2023 3:04 PM]
Note: Some content has been edited in accordance with our posting guidelines.
I was a Medical Officer posted to [redacted] in the late 1990s. The Medic and PA schools are based there. I strongly advocated for and approached the CCFP, CPSO at the time and my application for what is now being proposed fell on deaf ears. I am glad that their competency is finally being recognized.
Physician (including retired)
[June 14, 2023 2:46 PM]
Note: Some content has been edited in accordance with our posting guidelines.
Response in PDF format:
PA Regulation_Physician Response_20230614.pdf
Physician (including retired)
[June 14, 2023 2:02 PM]
I have two full time International Medical Graduates (MD's) working in my clinic under my delegation.

It is not clear how IMGs working as PAs will be regulated.

It would seem counterintuitive that and IMG would be required to quit working as a PA for the sole purpose of going back to University and attend a 2 year program to obtain a PA license from an accredited body.

Similarly, it is not clear what the Physical Assistant Integration Program with the Centre for the Evaluation of Health Professionals Educated Abroad constitutes, and whether this is the path for IMGs wishing to be licensed by the college as a PA.
Physician (including retired)
[June 14, 2023 10:04 PM]
I can see why you would believe it's counterintuitive for IMGs to go back to school, but in reality, many of them are not trained the same way we are. They are unfamiliar with our laws, ethical approach to patient care, and other non-medical (and sometimes medical) issues.
It's important for them to go thru that training.

By the way, a good example to see how IMGs are doing is to look at CPSO's disciplinary hearings and counting how many are IMGs (and mind you, those are the ones who made it thru our training programmes and practise as MDs).
Other health care professional (including retired)
[June 15, 2023 7:19 AM]
IMG’s can be trained to learn canadian system in 6 months and exposure to treatment of patients is very high in their back home, they have experience of 5-10 years in Govt hospitals in back home where patient attendance is 10 times higher than canada because of densed population, if IMG’s passed LMCC exams it means they learnt canadian health system, they are hired in family clinics by canadian licensed doctor in minimum salary when they are handling full fledge patient care only billing is done by MD. Its big exploitation, They studied 5-7 years same medicine in their medical schools which is almost same in whole world but they are forced to do it again here, that day is not so far when health system will crash in canada.
Prefer not to say
[June 16, 2023 5:04 PM]
It is not appropriate to refer to IMGs as PAs. They do not meet the same educational standards as PAs who attend accredited, highly competitive Physician Assistant education programs that meet Canadian standards.

IMGs and PAs are not synonymous and treating them as interchangeable is damaging to the PA profession and quite frankly a risk to the public. If you truly believe that IMGs can “learn the Canadian medical system in 6 months”, why do you feel that they should be called “PA rather than “MDs?” PA regulation needs to ensure that the PA title is protected and that PAs have a distinct role from IMGs to ensure quality care.
Member of the public
[June 14, 2023 1:47 PM]
I support this change.
Physician (including retired)
[June 14, 2023 1:22 PM]
the ban on psychotherapy is unjustified and at a practical level unpoliceable- when does good psychiatric management cross the line into psychotherapy when delivered as part of comprehensive mental health care.. is not a good Dr -patient relationship psychotherapeutic?
At our clinic 40% of primary care setting patients have mental health concerns and I understand that is a common finding in other practices. A good PA could do a good deal in supporting those patients mental health needs by offering supportive psychotherapy and where appropriate more specific modes of care like ACT, CBT DBT or psychodynamic with the same skill as social workers or registered psychotherapists with the added bonus of close medical supervision. The rationale for restricting access is not at all clear to me but the great unmet need for publicly accessible psychotherapy is clear.
Physician (including retired)
[June 14, 2023 1:14 PM]
I am a hospitalist in adult mental health units. I have concerns about PA's taking on the role in the mental health units. Some of my colleagues have opted to use PA's on the unit at times. It is common to have mental health patients have several admissions over the course of their life. It is reassuring to them to see familiar faces, rather than fill ins for other doctors. Furthermore, based on my review of their notes, their understanding of drug reactions and treatments is fairly basic.
Physician (including retired)
[June 14, 2023 1:04 PM]
The OMA and government also need to allow physicians' to bill for PA services, ASAP! How can we be expected to hire a PA if we are unable to bill for their services while paying their salary.
Physician (including retired)
[June 14, 2023 1:01 PM]
1- Are PA s will be able to work independently and open their medical practices and bill OHIP

2- Can they work in cohorts with a supervisor main physician and main physician can bill OHIP even not physically present in the office or physically present in the same location but not necessarily seeing patient unless any concerns from PA

3- Can PA refer to another physician

#2 question is important as everything goes through the context of funding and hiring PAs into the practices

I feel as long as there is a main supervisor physician for the PAs work then the main the physician can bill the OHIP as long as physically or virtually available for PAs and patient aware of that and main supervisor will be liable for the care. As the idea of PAs that we are not trying to create another nurse or NP but an integrated part of care and in the same time to look in all aspects from regulatory and financial views too.

For example about routine care pediatrics as the CPSO is aware of the sever shortage of pediatrics primary care and accepting newborns and pediatric patients into the communities as the sever shortage of Pediatricians or the overwhelming family practices so if a suitable PA who is comfortable in pediatrics can create routine care pediatrics practice under the main supervisor and this PA can follow these routine care pediatrics likes vaccines and check up and he/she backed and supervised by the main pediatrician in the same practice if any concerns or questions or next step to do for a medical concern, I think it will be a great care and helping parents and still under the main pediatrician but the only thing as mention that the main supervisor be able to bill for these patients who are seen by PAs even not physically seen by the main pediatrics as this is commonly done in the same idea in the teaching hospital. I feel PAs will be a great support for the community care as their work is monitored and meaningful as I gave one example of routine care pediatrics.
Physician (including retired)
[June 14, 2023 6:37 PM]
This is an excellent comment, completely agree that these 3 questions should be answered
Physician (including retired)
[June 14, 2023 12:37 PM]
I have now had a decade of training and working with physician assistants in the acute care setting, specifically the ICU. I am very pleased to see the CPSO finally place PAs under our college.

The one clarification I think is the co-opting of medical directives in the acute care setting. When a physician assistant writes an order under a medical directive, nursing and other health professionals should be aware that they are working under the direction of the attending or most responsible physician.

From experience at [redacted], this took some work with nursing and respiratory therapists to understand that they could follow orders given by a physician assistant.
Other health care professional (including retired)
[July 21, 2023 10:47 AM]
Completely agree! And as a PA working in a hospital currently, we receive substantial push back from nursing leadership with regards to our medical directives. Thank you for your support!
Other health care professional (including retired)
[June 12, 2023 9:25 PM]
As a PA who has worked in a family practice and hospital setting, I am excited to see that regulation is coming for PA’s and thankful to those who have worked hard to make this possible

However, I have concerns that the proposed changes do not provide PA’s with a unique scope of practice compared to other persons who could be delegated controlled acts. PA’s are professionals who are trained by accredited education programs to perform several controlled acts that could potentially be within their scope. These include communicating a diagnosis, inserting an instrument/hand/finger beyond the external ear canal/nasal passages/larynx/urethra/labia majora/anal verge/an artificial opening into the body, ordering the application of a form of energy, prescribing, and performing psychotherapy. PA’s should have a scope reflecting at least some controlled acts with the condition that PA’s perform these acts in connection/in consultation with their supervising physician. I am not advocating for PA’s to practice autonomously but I do feel that with our training and roles a defined scope of practice is reasonable.

Giving PA’s a scope of practice will set us apart from other delegates (eg IMGs) and ensure that organizations have incentive to use PA’s rather than other unregulated delegates (who are often easier to find/less expensive but less standardized in training than PA’s and potentially less safe for patients). The proposed regulation model protects the PA title, but by failing to give PA’s a scope it stops short of making the PA role unique. I worry that without a scope, the PA profession will disappear and ultimately be replaced by IMGs and other workers with non-accredited education and no professional standards/accountability.

Section 3 also needs clarifying to ensure that PA’s can continue to write orders and prescriptions, as others have mentioned. Within this section, as well, I feel it would be helpful for there to be wording that gives PA’s to have the ability to give verbal orders. Under present circumstances the inability to do this has limited my efficiency. For example, as a hospital PA if I consult a specialist and don’t hear back from them until after I leave the hospital, I cannot call the unit and give orders to implement the specialist’s recommendations. Nurses and pharmacists cannot take a verbal order from PA’s under current conditions. In this situation I would need to either go back to work outside of my hours or ask the on-call physician (who is usually different than my supervising physician) to write an order if I wanted the specialist’s recommendations to be implemented that day (in addition to discussing the recommendations with my supervising physician). The ability to give verbal orders would simplify this and ensure more efficient practice and care.

I hope that this feedback is helpful! Thank you again for working towards advancing our profession.
Other health care professional (including retired)
[June 12, 2023 12:41 PM]
I would like to further understand how this regulation would help develop autonomy of PAs across ON especially for virtual visits or telephone calls. We are in a situation where the integration through regulation of PAs can be vital and crucial to the current wait times in not only hospitals but also clinics. I understand the need to have a "meaningful contact" of a physician with a patient while they are in clinic. However simple calls should be something that can be delegated to PAs without direct involvement of PAs.

If telephone and virtual visits can be a part of delegation where a physician is not required to participate actively, this would help in getting to many patients.

Regulation should be similar to what it is in the US where the PAs are provided the autonomy at the comfort of the physician and PA. I hope this can be taken into consideration.
Other health care professional (including retired)
[June 10, 2023 8:11 AM]
I have concern with the section that states:
(3) A member who is a physician assistant shall not delegate the performance of an act
that has been delegated to them.
I understand the intent of the statement; if PA's are trained to do something and the physician approves their ability to do said task, then they should be the one to do it. However, the way this is written makes it sound like PA's cannot give any orders for patients (i.e. can an order be given to a RN to remove sutures or a surgical drain, which they are also trained to do safely and effectively)?. Physician Assistants work as extensions of the physicians. They help to regulate the flow of patient care and act as conduits of orders. By restricting delegation of orders, this limits the practice of the PA, and limits patient care flow.
Member of the public
[June 09, 2023 6:50 PM]
Will the title 'Physician Assistant' be changed to 'Physician Associate'?
The U.S. and the UK have all changed it to be 'Physician Associate', and given that this is the same profession, perhaps it would make more sense for the title of the profession to be consistent as well.
The word 'Assistant' while technically appropriate, is quite misleading to the general public and poses possible risks to patient care. For example, a layperson not familiar with the healthcare system may easily mistake a Physician 'Assistant' to be a generic 'helper' of the doctor, and this seems to sometimes lead to distrust in the professional medical advise given by the PA, which may lead to poor treatment compliance and worsen patient outcomes.
Regulation is the more pressing matter, of course, however seeing the U.S. PA regulatory body (AAPA) in their effort to change 'Assistant' to 'Associate' across the board costing them $21.6 million, it seems it would make the most sense for us Canadians to make this change as soon as possible. I think right now, with the 'Physician Assistant' name being written into official bills, it would be the most convenient to make this change now rather than postponing until later.
Physician (including retired)
[June 14, 2023 9:47 PM]
I would disagree. Physician assistant is understood enough and fairly and accurately conveys the role.

A physician associate is confusing as it can refer to physicians who are members of an association (say one of the various orthopaedic or oncology associations in Ontario).
Other health care professional (including retired)
[June 14, 2023 2:11 PM]
I find that it is far more likely that the term "physician associate" could mislead the public into believing that PAs are identical to physicians. It is critical to maintain protection of the term "physician" to maintain public trust in the healthcare system.

Hence the term "physician associate" is very likely not appropriate for use in Ontario. The term physician assistant is one the public already understands to a degree and we should absolutely continue with that.
Physician (including retired)
[June 14, 2023 2:10 PM]
Changing the title could create confusion among patients, employers, and healthcare professionals who are accustomed to the current title. Currently, the title of physician assistant helps differentiate the role from that of a physician. Changing the title to physician associate may blur the lines and cause confusion about the roles and responsibilities of each profession, especially for patients. As well, there could be legal implications to changing the title that would require legislation or regulatory changes.

What concerns do physician assistants have with their current title other than for uniformity with other countries?
Other health care professional (including retired)
[June 12, 2023 12:42 PM]
I completely agree with this comment. If we are at a point of creating such a large development for PAs it is important for us to follow suite with other PAs across the globe for uniformity.
Physician (including retired)
[June 14, 2023 6:25 PM]
I would disagree with the above. It is only but recently that physician assistants have renamed themselves as physician associates, and only their association. Meanwhile, legally speaking, their official title is physician assistant. Naming them physician associate would lead to confusion of their role and confusing with the title of physicians who supervise them.
Physician (including retired)
[June 14, 2023 1:13 PM]
A physician associate title is more appropriate. The physician extenders have played a tremendous role in patient care in the malignant hematology setting. They perform most of the bone marrow biopsies at our center.
Other health care professional (including retired)
[June 15, 2023 11:28 PM]
As a PA myself, the term Physician Assistant is absolutely most appropriate. "Associate" is entirely an attempt to blur the lines and mislead the public. It also represents some physicians who work as clinical associates.
Physician (including retired)
[June 14, 2023 8:41 PM]
Physician associate is necessarily confusing for patients. Can easily cause confusion regarding level of training and/or current enrollment in a training program. The name should not be changed.
Physician (including retired)
[June 25, 2023 3:22 PM]
A physician associate suggests a junior physician. An associate lawyer is a Lawyer but not a partner. A para legal is not an associate lawyer. A physician assistant is not a junior doctor, but an assistant, thus the correct term is Physician Assistant. Those who lobby for an associate term needs to get the chip off their shoulder. Be proud of being a Physician Assistant.
Other health care professional (including retired)
[June 09, 2023 6:38 PM]
I have concerns that we are refusing PAs the ability to perform psychotherapy when psychotherapy is needed so desperately by our population, the ability to access psychotherapy is so extremely limited, and physician assistants have similar education to SW, OT and even physicians when it comes to psychotherapy prior to residency. Should a PA be provided the training to do psychotherapy, or seek out the training or certification on their own, it does not make any sense to limit these highly trained medical professionals from providing psychotherapy to patients who desperately need the support. The risks of not allowing PAs to perform psychotherapy far outweighs the risks of allowing PAs to perform psychotherapy should a physician deem them competent and skilled to do so. Social workers and occupational therapist have very similar education and experience and are allowed this controlled act yet PAs are not even though they have additional oversight of a supervising physician. Recognizing that psychotherapy is not an act that can be delegated under the current laws a specific criteria should be set so that PAs with the training and expertise can provide this service to our community.
Other health care professional (including retired)
[July 22, 2023 6:10 PM]
I agree with your comments on the importance of PAs being able to provide psychotherapy. I am personally providing this service and it would be heartbreaking to have to abandon my patients if this comes into effect. It is an invaluable service that many don't have access to. I think limiting mental health resources 3 years after the start of a pandemic is the opposite direction we should be going in.
Physician (including retired)
[June 14, 2023 6:15 PM]
The restriction on psychotherapy is unreasonable. If a health professional is trained in behavioral, group, cognitive, psychotherapy, applied relaxation, etc, the health professional should be able to provide this service. Also, when providing advice when giving prescription or instructions, an element of psychotherapy is often warranted. PA staff should be able to provide services that are delegated to them, including behavioral and psychoeducation and instruction.
Physician (including retired)
[July 24, 2023 11:53 AM]
I agree with the comments about PAs and psychotherapy. I think this is a missed opportunity to provide a service that is so desperately needed. It must be under supervision and it must be regulated (at the responsibility of the physician who is delegating the service) but we must absolutely capitalize on this opportunity. The PA has to be trained and competent just like they have to for all other services. I don't see how psychotherapy is any different than any other responsibility that would be delegated to a PA. There should be no stigma that psychotherapy is different from any other medical service. Psychotherapy needs to be provided at a high quality and standard just like every other medical service. I do not understand the rationale behind this. I am a child and adolescent psychiatrist and I see so many young people and families whose trajectory could be shaped for the better if they had access to help (usually supportive and usually skills building). I have also worked with several physician assistant students that I have supervised who were talented and skillful and who could absolutely be trained to deliver certain kinds of psychotherapy (again, e.g., supportive, skills based). Psychodynamic psychotherapy requires skill and training so perhaps there should be a line drawn there but again, this is no different than any other limitation of a PA's skills in ANY specialty.

Thank you for the opportunity to provide feedback.
Physician (including retired)
[June 15, 2023 9:15 AM]
I think there is danger in assuming that it is safe to allow PAs to practice medical psychotherapy without major restrictions. Having familiarity with the functional 'tools' of psychotherapy does not qualify a person to safely apply them to treatment of mental health problems. It equates to assuming that being a parent qualifies one to be a school teacher or knowing how to cut and suture qualifies one to be a surgeon Mental Illness is not just a need for supportive care; it is always quality of life threatening and too frequently life threatening if not managed appropriately. Supportive care is often not enough. As with all other medical problems one must be trained to recognize, investigate symptoms, diagnose the disease(s), and then determine which treatment(s) are appropriate for the patient. Only then is it appropriate to start cautiously applying the "tools" (including appropriate counselling techniques, medications, support systems, referrals to other medical specialists, etc.). I sincerely hope that in medicine we are well past the stage of minimizing the importance of properly treating our patients presenting with mental health symptoms. Mental health problems require special care. Inappropriate care("bandaid care") can worsen the problems, cause the patient to give up trying to get help and result in disastrous outcomes.