Canadian physician assistants: A new profession with new educational insight

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Canada's educational training programs promote clinical knowledge, student centeredness, empathy, and teamwork.
Canada's educational training programs promote clinical knowledge, student centeredness, empathy, and teamwork.

Canadian physician assistants (PAs) have existed in the military since the 1960s. However, only in the last 10 years has the profession really taken off.  The PA profession started in the Canadian military as the Canadian Forces. The Canadian Forces developed into the Medical Assistants in the 1960s. It was not until 1984 that the name was changed to Physician Assistant.

These health professionals were trained in military hospitals and were used only by the military. They served in the Canadian Forces Station Alert, which is a northern outpost location, on military ships, and other locations in Canada and abroad. After the 1990s, military hospitals were closed, and these professionals needed to be absorbed into the greater Canadian health human resources system. Their scope of practice, liability, and competency were well understood and defined within the military, but transitioning into the greater Canadian system was challenging. In 2003, Canadian PAs were endorsed by the Canadian Medical Association (CMA), but these professionals are still working toward successful integration into the healthcare system. Canadian PAs do work throughout Canada and are making a huge contribution to primary healthcare needs, but issues surrounding reimbursement for PAs work are still being worked out within Canada's healthcare system. Although things are definitely getting better for PAs in Canada, they still face many struggles.

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Canada's educational training programs are some of the most innovative in the world and use techniques that promote and develop the skills that future clinicians need. Clinical knowledge, student centeredness, empathy, teamwork, patient communication, and skills in motivational interviewing are all important skills that our future clinicians need. The World Health Organization, THEnet (Training Health Equity Network), and CANMEDS are calling for these changes in medical education; however, transforming these objectives into our educational programs is challenging. The Canadian healthcare educational system has introduced some remarkable tools that we could learn from.

I learned about the Canadian PA program and its teaching techniques after interviewing a Canadian PA student I met during her international rotation in Ghana in 2014. She and 2 of her classmates had decided to join the University of Utah for their international rotation in Ghana. I observed her and her 2 colleagues in a clinic and in lecture, and I was very impressed with their questions, their ability to analyze a medical case, and how they interacted with their colleagues. I was indeed biased because I had just come back from a year working in South Africa where problem-based learning and other newer educational tools are used in their new clinical associate program. This interview focuses on teaching and learning techniques used in the Canadian PA educational system. I asked Alanna McMurray, one of the students from Canada, if she would let me interview her about her PA education. Below is a synopsis of our conversation.

Canada's PA schools

One of the first PA programs outside the military was started in 2005 at McMaster University in Ontario, Canada. As of February 2016, there are 4 PA programs in Canada at the University of Manitoba, McMaster University, the University of Toronto, and the Canadian Forces Health Service. There are about 500 PAs practicing in Canada, 300 of whom are working in Ontario.

First 12 months: Tutorial learning 

The overall program is 24 months long, and the first 12 months consist of academic type learning. The program includes tutorial-based groups that last for 4 hours, twice a week. In the first tutorial session of the week, they are given a case scenario that describes a patient's medical complaints.  As a group, they discuss what they think the differential diagnosis is, and the tutorial leader, either a clinician or a faculty worker, will lead them in their discussion of the case. The group then decides what the learning objectives are for the case. They meet again 48 hours later, after they have researched the learning objectives. For example, if the diagnosis was congestive heart failure, the students might study anatomy and physiology, if this was identified as a learning need. They have access to labs, textbooks, the internet, and lab assistants. At the follow-up meeting, they report the learning objectives to the group and work to establish a working diagnosis for the case. They also discuss the investigations they need to order for this patient, the management plan, and risk factors for this condition. It is a very student-driven endeavor. Alanna has found that she gets a deeper sense of understanding when the students work together to figure out the medical case. She thinks that this process is better for her education. The students' active participation will have a bigger impact on the student vs a lecture-based, passive teaching method.

First 12 months: Clinical lab experiences

In addition to the tutorial sessions, students also have clinical experience labs, which are hands-on learning experiences. These occur once a week and are more didactic, with more active participation. This is physician-taught, but working PAs in the community or faculty will often come in and teach them physical examination skills. Students also partake in an ethics class, in which professional competencies are discussed as well as the different types of ethical issues that they may face in their lives as health professionals. This class also addresses what a PA is and what their role in the healthcare system is, especially in regards to the fact that they are non-regulated. This class also discusses the limitations and expectations PAs face while working in a doctor's office, racial and ethnic differences, informed consent, and suicide.

Students also spend a significant period of time learning about patient–provider communication. Students work with leaders, who are psychologists and social workers, in small groups to learn how to develop these skills. The leader's role is observational, to help students develop their skills in patient communication.

First 12 months: Longitudinal placements

In their first year, students also partake in longitudinal placements. They are half-day placements, where they shadow a physician, an allied health member, a laboratory technician, or other healthcare professionals. This process gives them a well-rounded experience of what the healthcare system is like, and how PAs work in health care. It also provides a more hands-on experience in regards to other healthcare professionals whom they will be working with in the future. During the longitudinal placement, students spend a large period of time in a family medicine placement, because this is a major area where Canadians PA will work. Students will also shadow in other areas, including pulmonology, cardiology, hematology, neurology, immunology, malignancies, OB/Gyn, and infectious diseases.

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