Forty-six health care providers and administrators were interviewed across 19 different healthcare sites (hospitals = 13, community clinics = 6), including 24 physician assistants, 17 physicians, 2 medical residents, 2 registered nurses, and 1 family health team administrator.
Although there are some variations between practice settings, such as the time and nature of physician collaboration and number of supervising physicians, there were numerous similarities identified in the cross-case analysis. Four interconnected themes emerged from this multiple-case analysis: PA role contribution to Ontario healthcare settings; developing role awareness and role clarity; supervisory relationship dynamics; and variability in funding and remuneration (Table 2). In addition, a number of outliers are presented within the context of the cross-case analysis. These outliers represent experiences, outcomes or exceptions that deviated from the main emerging themes.
Role Contribution to Ontario Health Care Settings
The PA role provides a versatile, flexible, and accessible health care provider who models collaborative, interprofessional care in complex settings. Favorable contributions of the PA include increasing patient access to care, fostering person-centered care, improving continuity and filling gaps in the health care system.
In addition, PAs take on a large amount of administrative work, such as patient care documentation, discharge summaries, dictations, consult requests, and resident/learner orientation, which helps improve patient flow.
“The success has been that they’re part of…a team that has taken a program with 1,200 cases and gone to 1,800 cases, with the same number of beds, right. They’ve become a significant part of our improvement and operations… We had all kinds of budget problems with… physician coverage, so they were also an economic success…a tangible reduction in costs for human resources during the day.” [MD, IM]
One unique contribution of PAs is the flexibility and adaptability of their skill set. Across all settings, physicians and PAs provided examples of where being consistently present in their setting or working with particular patients allowed the PA to become a procedure or content expert due to frequency of exposure and clinical experience, or develop a skill set that extends physician services:
“I think because I’m there every day and the doctors rotate, I’ve actually probably performed more of those procedures than most of the docs I work with” [PA, EM]
This expertise is reflected in physician feedback that described how other consulting services (e.g. orthopedic surgeons) started to prefer getting consults from the PA because of the PA’s understanding of the precise information that the consulting service requires:
“They’re so specialized and they see all of those cases, so [they’ve learned] exactly what each specialist wanted, [they’ve learned] how they wanted them cast, they really paid attention to these details that 30 [emergency doctors], who don’t get the same volume and maybe aren’t interested in the same way… so [there’s] really a great deal of satisfaction among orthopedic specialists who take referrals from the PAs.”[MD, EM]
One identified case outlier involves the interplay between increased patient volume and other setting-specific considerations. In settings such as general surgery, increased patient volume in the emergency department (e.g. patients waiting for a surgical consult) or an overloaded ward (e.g., arising when surgical beds are filled to capacity) puts a strain on staff because of the number of consults to be seen, pending discharges, and additional families to update. Faster surgery turnarounds facilitated by PAs may mean a higher need for recovery and ward beds, which were not always available. In contrast, physicians at Family Medicine sites were enthusiastic about the ability to handle increased patient volume because this meant increased access to care for patients and increased remuneration for physicians.
Developing Role Awareness and Role Clarity
The importance of role awareness and establishment of role clarity was echoed by all participants across the four settings. PA participants described both benefits and challenges associated with being an unregulated health care provider:
“Being unregulated is also a big thing, because now… unions in the hospitals that have a strong union presence, being unregulated does raise a lot of questions, especially when there are budget cuts… and then they start bringing in different levels of providers that aren’t regulated. It creates a bit of tension” [PA, GS]
In addition to challenges around lack of regulation, participants also reflected on the complexity of navigating delegation, controlled acts and variable uptake of medical directives. As others in the network of PA care (e.g. patients, health care providers, and administrators) became more aware of the PA role, role clarity is gradually established. Participants acknowledged the importance of organizational support; both for when the PA role is first introduced, and as it pertains to successful integration and role evolution.
Ultimately each case setting is now heavily reliant on the PA to deliver services, including day-to-day patient care, quality assurance initiatives, other administrative roles (i.e., lead PA), and resident or learner orientation and teaching. Navigating role and work environments with medical learners and residents can be challenging as the potential exists for challenges around role clarity and overlap. However, these can be ameliorated by an appropriate orientation of learners to the team players and roles within a site that employs a PA. Physician perception is an important driver of this role clarity:
“A resident is there to learn; their primary responsibility is towards their education. PAs are also learning and everything we invest in them we get back. But at the same time, the PAs have a bigger responsibility to manage flow, so they are more efficient generally than residents are, and they are always there… they’re not having to relearn the process” [MD, EM]
Unfortunately organizational and physician support can be undermined by other healthcare professions who may not understand the role, not accept orders written by the PA, or actively demonstrate resistance to role integration: “I know other pharmacies have a hard time understanding the role of PA and reject some prescriptions” [PA, FM], thus decreasing service delivery and efficiencies. In all settings, the PA’s enthusiasm, self-organization and role awareness enables the PA to either change perceptions or find strategies to maximize efficiencies.
With respect to case outliers, it was clear that the PA role is most easily defined by all team members in Family Medicine settings. This is likely influenced by the longitudinal nature of the PA-MD-patient relationship, and the parallel practice of the PA and MD. In emergency settings, any impact of continuity of care is limited to the PA-MD shift schedule and role definition is less controversial due to the close proximity of the work environment. PAs and MDs are seeing patients, interacting with nursing staff, and updating families in close geographical proximity, and opportunities to discuss a patient are more available. In general surgery and other inpatient settings, role clarity is more complicated due to turnover of residents, patients, surgeons/staff physicians in the midst of new consults, discharges and larger interprofessional healthcare teams.
Supervisory Relationship Dynamics
A key characteristic of the PA-physician relationship is trust, and the development of trust is influenced by the physician’s understanding that the PA knows when to seek help. The physician must trust the PA to seek help, and the PA needs to feel confident that the supervising physician is readily available for consultation when required. Failure to seek help or support the PA negatively impacts the relationship dynamics.
“If it’s a new doc, or I’m unfamiliar. Or if they’re a new hire and haven’t worked with a PA, they’re going to want to review most patients with us. But again it depends. It’ll also depend on my comfort level with a patient. If [the patient] is presenting [with something] I’m really not familiar with, or I feel that the patient is a lot more sick than I’m comfortable dealing with, then absolutely I’ll bring in my doc much sooner than otherwise.” [PA, EM]
The nature of the supervisory relationship allows PAs to learn from a variety of practitioners. There is considerable setting-dependent variability in the number of supervising physicians that work with a PA (ranged from 1-18). PAs are therefore exposed to a variety of practice styles, personalities, bed-side manners, medical expertise and other consulting services. PAs can then adapt their own practice style by observing others and determining patterns that work best within their own setting and clinical environment: “I appreciate and enjoy [different practice styles] and I think it’s nice that it allows me to be able to see all kinds of styles and create my own” [PA, FM]
Working with multiple supervising physicians also requires the PA to constantly adapt their own practice as “everyone has a slightly different clinical approach” [PA, FM] that requires the PA to “deal with multiple personalities” [PA, GS]. Negative interactions occurred when the PA felt alone or felt as though they lacked supervisory oversight: “I was somewhat left to my own devices at times when I feel like help might be needed and help’s not always readily available when the rest of the team is in the operating room”[PA, GS]. In addition, variable physician knowledge regarding liability and supervision was identified across each case setting.
Family medicine sites had a significantly reduced number of supervising physicians, compared to the other cases/settings. The family medicine PA-MD team are more likely to work in parallel, with both seeing their own patients and reviewing patient information together only when necessary. In settings with multiple supervising physicians, the PA must also adapt to a variety of practice styles and preferences, which can be a benefit (i.e., can adapt their own practice style) or a hindrance (i.e., there can be varying levels of autonomy that require the PA to constantly adjust their approach to satisfy the supervising physician).
Impact of System Variability on Funding and Remuneration
Across all four settings, funding was consistently identified as a challenge. PAs stated, “I’m not satisfied [with remuneration] because we are still at the same rate as actually, a little less, than when I was hired over 5 years ago, so that’s very frustrating” [PA, EM], or that “There has been very little increase. I do have job security which is nice, but there are absolutely no benefits, no increase in vacation [time]… there’s been nothing, so that’s very frustrating” [PA, FM]. In addition to dissatisfaction with their salary, cross-case analysis revealed very little employer/organizational responsiveness to consideration of incremental cost of living increases. Most PAs reported that their salaries have remained unchanged since the PA role was introduced to Ontario in 2006.
Funding comes from multiple sources, including global hospital budgets, departments, pay-for-performance, other allocated funding sources (i.e. Family Health Team allied health funds) or directly from physicians. The challenge of these variable sources is the dependency on intermittent, short stream funding and its impact on role sustainability. One Emergency Physician described the precariousness of funding PAs based on their contribution to meeting a pay-for-performance incentive to reduce wait times:
“The danger is that if our [department] performance went down, then we would no longer be able to afford [our PAs] or if the province stopped the program, we would no longer be able to afford them. So our PAs live in fear every year, because they do not have stability in their jobs. They do not have contracts; they do not have job safety.” [MD, EM]
Physicians and PAs across all settings called for a re-examination of funding and regulatory status: “My wish would be that there’s some funding model that comes up through OHIP (Ontario Health Insurance Plan) that would pay for them; procedure codes or coverage codes or something so there’s some funding available for [PAs].” [MD, IM]
“…Hospitals are constantly having to cut the budget; and that’s kind of what we’ve been running into lately is, more and more were being kind of asked to prove, not so much prove, we’ve proven our work; but we’ve been essentially told that, we love you guys, but we can’t necessarily fund you forever”[PA, EM]
One noteworthy case outlier relates to evidence of inappropriate billing practices and perverse incentives in select Emergency Departments. The organization was covering the salaries for the PAs in the emergency department, while the physicians were personally billing for the services offered by the PAs: “they cost nothing for us to have them, they generate income for doctors” [MD, EM], or “gaming the system” through physician or departmental use of the PA to earn incentives. For example, in multiple cases the Emergency Department arranged PA workflow to assess patients quickly, thereby maximizing their chances of meeting a pay-for-performance target and receiving a financial bonus for reducing wait times. The downside is that patients often waited longer to then be cleared by the physician, demonstrating multiple inefficiencies and the opposite intent of the incentive:
“Basically the whole reason you were sitting there is so you could write up a note to put a time on it, and then the patient would come in and say, the patient came at 8 to triage, you wrote a note, showed the doc at 8:05, and in the records it was like, oh the patient was seen in 5 minutes. But they weren’t seen in 5 minutes…now they’d go to the other waiting room and wait 2 hours to see the doctor. So their real wait time was 2 hours, but on paper it was 5 minutes, and to the government looks really good, and so then they can give the hospital more money.” [PA, EM]
In general, billing and funding issues are more complex in hospital settings as there is often no clear funding source, like in family health team PAs; conversely, liability insurance is less of an issue in hospital settings if PA is a hospital employee and thus covered under organizational insurance.