Are Physician Assistants the Answer to Canada's Orthopaedic Surgeon Shortage?

Ted Rumble, M.D., FRCSC
Outgoing Chair, National Standards Committee
Toronto, ON

Eric Bohm, M.D., FRCSC
Co-Chair National Standards Committee
Winnipeg, MB

Michael Dunbar, M.D., FRCSC
Co-Chair National Standards Committee
Halifax, NS

Introduction
In 2002, the COA formed the National Standards Committee (NSC) and charged the committee with answering the basic question: "How can we better meet the orthopaedic needs of the Canadian population going forward?"

Under the guidance of Drs. Hans Kreder and Ted Rumble, the committee started to answer this question by releasing its 2004 National Workforce & Services Report. One of the main findings of this report is: Canada requires 4.5 properly resourced orthopaedic surgeons per 100,000 population to meet the needs of its people. Given that the number of orthopaedic surgeons currently practicing in Canada is 3.7 per 100,000 population, there is a significant shortfall of about 450 surgeons. This deficit contributes in an important way to excessive waiting times for orthopaedic services.

Workforce projections for the next 25 years have indicated that this situation will not improve, and in fact is likely to deteriorate even further. This stems from the simple fact that while the Canadian population continues to grow (over 300,000 people were added last year) the number of orthopaedic surgeons does not.

The ability to increase the pool of orthopaedic surgeons practicing in Canada is limited by many factors. We simply cannot train more surgeons because our capacity to add to existing training programmes is severely restricted. Even if this were possible, it would take at least ten years before this increased capacity had an impact. Foreign trained orthopaedic surgeons may be considered, but unfortunately this approach is not a panacea, due to provincial licensing requirements and ethical issues surrounding recruitment from countries with their own critical shortages.

If it is not possible to deliver adequate volumes of orthopaedic care using the existing number of orthopaedic surgeons, we must entertain either alternative orthopaedic care providers (nurse practitioners, etc) or increase surgeon productivity through the use of physician extenders. It is the National Standards Committee's opinion that Canada's increasing orthopaedic care requirements are best met through the use of physician extenders, such as physician assistants.

What is a Physician Assistant?
Physician assistants (PAs) are relatively unknown in Canada, yet are an integral part of orthopaedic care delivery in the United States. PAs are dependant medical practitioners who are university trained in faculties of medicine, and receive the equivalent of a Master's degree in medicine. They are then employed by their supervising orthopaedic surgeons. They may work on the wards, in the OR, in the clinic, in the office, and take call. They can write orders and prescribe medications, within defined limits. It has been estimated that a PA can provide about three quarters of the services provided by an orthopaedic surgeon. Their participation in an orthopaedic practice can dramatically increase service capacity.

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According to the American Academy of Physician Assistants, there are about 60,000 physician assistants practicing in the United States. Orthopaedics is one of the major areas in which they practice.

How Are PAs Educated?
A bachelor's degree with a 3.8 grade point average and clinical experience are the typical prerequisites for admission to physician assistant training programmes in US faculties of medicine. The curriculum is two years, and mirrors the medical curriculum, concentrating on the practical aspects of medical practice. Duke University has one of the best known training programmes, (see http://paprogram.mc.duke.edu/), and has been a model for the development of over 130 programmes in the US. PAs graduate as generalists; their first year or more in practice is an apprenticeship in their respective specialties.

How Are PAs Employed?
By law, physician assistants must be employed by a physician. This has benefited all stakeholders, as it provides the environment for a true collaborative practice. The practice of a physician assistant therefore mirrors that of his/her employer. Physician assistants may work in a variety of environments from academic medical centres to community hospitals to clinics.

What Orthopaedic Services Can PAs Provide?
The services provided by a PA mirrors those of his or her supervising physician, and extend from running intake and follow-up clinics to assisting in the operating room and caring for inpatients. More specifically, PAs are able to: prescribe medications within defined limits, order and interpret X-rays, function as first assist in the operating room, close surgical wounds, take call along with their supervising physician, apply casts, and perform many minor procedures.

Since the surgeon is ultimately responsible for all of the activities of the PA, he/she will determine the level of responsibility of the PA in his/her own practice. As a rule, the longer a PA works in an orthopaedic practice, the less direct supervision is required.

How Do PAs Differ From Residents?
Physician assistants are fully trained, and very experienced in their areas. They are very helpful to residents in training, because they shoulder part of the service component, allowing the residents to concentrate more on learning. PAs can also help educate residents in the practical aspects of medicine.

How Are PAs Paid?
Most American PAs are paid a salary by the physician/supervisor for whom they work. The surgical practice can bill Medicare or the insurance company (fees prorated to 80%) for services provided by a PA. This generates revenue for the physician's practice, which helps pay the physician assistant.

How Are PAs Insured?
Physician assistants carry their own malpractice insurance.

Are Physician Assistants Practicing in Canada?
There are many PAs practicing in the Canadian military where they work in primary care. The only province which has legislation to allow civilian PAs to practice is Manitoba (where they are known as Clinical Assistants).

The Winnipeg Regional Health Authority's surgical programme currently employs physician assistants in many different surgical subspecialties, including orthopaedics. The experience is that they have markedly increased service capacity, and have integrated well with the health care team. For example, the University of Manitoba Joint Replacement Group surgeons regularly perform 7 to 8 joint replacements per day by employing clinical assistants to run two operating rooms. These same assistants then help to provide postoperative care on the ward.

Conclusion
There is an orthopaedic workforce shortage in Canada that is going to continue to worsen with time. The incorporation of physician assistants into orthopaedic practice in Canada would better position us to meet current and future orthopaedic needs of the Canadian population. The National Standards Committee intends to document the Winnipeg experience with physician assistants, and then pursue the development and implementation of orthopaedic physician assistants across Canada.

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