The second year of the PA program is all clinical practice. These 12 months are spent working clinically. Students rotate through emergency medicine, internal medicine, surgery, psychiatry, pediatrics, and family medicine.
Apart from the core rotations, students also get 3 months of elective time, where they can choose to go back to their core rotations or go into different areas of medicine. They can also choose to do an international elective, like Alanna chose to do in Ghana, but they are responsible for setting it up themselves.
Second year: Short-term rotations
The core rotation dictates what is expected of the students. The rotations for surgery and internal medicine both last for 6 weeks and emergency medicine lasts for 4 weeks. All students have their own patient load. When Alanna did her internal medicine rotation, she had 6 patients she went to see on her own. She is expected to order blood work and X-rays, but she does have to get her orders signed off by a resident or fellow attendant. In the internal medicine rotation, they were also responsible for seeing new consults in emergency, referring them, or deciding whether they should be admitted into the hospital or be discharged. They could make the decisions, but an attendant had to confirm whether it was appropriate.
In surgery, they worked alongside surgeons and residents in up to 15-hour shifts, as well as some on-call shifts. They were also involved in treatment and management plan of medical cases and decided whether the patient should be referred for a surgical evaluation. Students also see patients in the outpatient clinics, for both presurgical or postsurgical follow-ups. Although they see the patients alone, the doctor still signed off on the recommendations.
When Alanna did her ER rotation, she went to a trauma center at Sunnybrook Hospital, where she worked alongside the trauma team. Again, she was responsible for seeing her own patients, and the doctors pushed her to develop her own plan for the patient.
Second year: Family medicine
The longest core rotation she participated in was in psychiatry. It consisted of outpatient clinics and ward rounds. She worked with emergency psychiatric patients in the morning, and dealt with patients in crisis as the first responder. She told me that she began to pick up on concerning symptoms when she saw her psychiatric patients. She was the first point of contact and had a vital role in the course of action for the patient.
The last short-term rotation she did was in pediatrics. She spent 2 weeks in the NICU or a level 3 nursery, dealing with premature babies who were mostly incubated. McMaster University emphasizes that students should learn about neonatal resuscitation. The students worked at McMaster Children’s Hospital, and were exposed to some of the sickest babies in the hospital. She told me she learned a lot during this rotation and faced a lot of barriers. She also spent time in the pediatric emergency department where she worked alone, and was expected to come up with her own treatment and management plans for her patients. Students do not learn a lot of pediatric care in their first 12 months of the program, and there was a huge learning curve for her in this rotation.
The Canadian PA educational model is based on theories of self-directed learning. Alanna believes self-directed learning works well and that it manifests lifelong learning. She tells me that when she works on medical cases in her training, she is comfortable not necessarily knowing the answer to a question, because she knows where she can find the answer, which is more important. She has developed important researching skills and a strong list of preferred resources. Alanna told me that educators state that McMaster students “retain information better,” and it is most likely because of self-directed learning. The program, especially in the second year, is very student-centered and it is hard for the students to not take charge in their education. Although the students feel challenged, they feel they are still being well-supervised.
Future of PAs
The future of PAs in Canada is uncertain, because PAs are not regulated. The main advantage of being regulated is that a PA could bill for his or her own patients, instead of going through a physician first. PAs have fewer rights as health professionals than nurse practitioners, who can bill for their own patients. The association is still pushing to be regulated, and hopefully in the next 20 years PAs will be regulated in Canada. Although PAs are able to find jobs after graduation where they work in family health teams, internal medicine teams, physician’s offices, or hospital teams, they work under contract and there is often uncertainty as to whether the contract will be renewed after 2 years. The Ministry of Health and long-term care will pay for up to 70% of the contract for a new graduate, and if the PA is not a new graduate, then the ministry will pay about 50% of the contract in a lump sum. However, the ministry holds the right to not renew contracts, and this frequently causes a lot of stress for PAs.
Alanna told me that she wants to address the tension between nurse practitioners and PAs. “I would like to talk to them about our training and where we are coming from. There is always room for new ideas and together we could be a really powerful team,” she said.
After talking to Ms. McMurray, I learned that we as professionals can all learn from each other. We can learn from how Canadian PAs implement new and innovative tools into their training programs. Patient-centered care, which requires the “soft skills” of empathy and patient communication, learning to work in healthcare teams, developing lifelong learning skills, and addressing knowledge deficits, are all important tools that our healthcare professionals will need for the future. We can all learn from each other as professionals, and speaking with Ms. McMurray reiterated the importance of connecting with our international colleagues.
Marie Meckel, PA-C, MPH, is a physician assistant who works in western Massachusetts. She spent a year in South Africa at Walter Sisulu University, where she taught clinical associates. Marie has spent the last year interviewing PAs and NPs and their international equivalents and American PAs and NPs working abroad.
- Canadian Medical Association and the Canadian Association of Physician Assistants. Physician assistant toolkit: A resource for tool for Canadian physicians. Updated 2012. Accessed March 22, 2017.
- Davis MH. AMEE Medical Education Guide No. 15: Problem-based learning: a practical guide. Med Teach. 1999;21(2):130-140.
- Fulop T. Setting the stage: Problem-based learning in the mirror of the great social target — health for all. In: Schmidt HG, De Volder ML. Tutorials in problem-based learning: A new direction. Van Gorcum Ltd; December, 1984.
- Jung HW. The birth of physician assistants in Canada. Can Fam Physician. 2011;57(3):275-276.
- Karle H. International trends in medical education: diversification contra convergence. Med Teach 2004;26(3):205-206.
- Muller S. Physicians for the twenty-first century: report of the project panel on the general professional education of the physician and college preparation for medicine. J Med Educ. 1984;59(11):1-208.