Duties and responsibilities

Expectations of physicians in practice

Working with physician assistants: Collaborating while managing risks

Originally published April 2016

Today, about 500 physician assistants practise in Canada1 and that number is likely to climb. For physicians, this increase provides more opportunity to develop a collaborative working relationship with these health professionals. While the current work arrangement between physicians and physician assistants has the potential to expose doctors to certain risks, these risks can be managed.

A physician assistant primer

Physician assistants, or PAs, are health professionals who care for patients by carrying out medical acts that have been delegated by a supervising physician.2 Since the 1960s they have worked in the Canadian Armed Forces’ healthcare system3 and today practise primarily in Manitoba, New Brunswick, Alberta, and Ontario.4

The regulation of PAs varies from province to province and continues to evolve. For example, in Manitoba and New Brunswick, PAs are regulated by the provincial medical regulatory authorities (Colleges). In Alberta, the College has a voluntary register of non-regulated physician assistants. In Ontario, the Health Professions Regulatory Advisory Council has recommended that PAs should remain unregulated, but that a compulsory registry be established under the governance and oversight of the Ontario College.5

Unlike in other provinces, there are regulations in Manitoba and New Brunswick that set out minimum educational and training requirements for PAs.6 The Colleges in those provinces have also established specific requirements with respect to supervision and other conditions on the practice of PAs.

Know the risks

Regardless of what provincial structure or system they work under, PAs are not independent healthcare providers. The medical services provided by PAs must be delegated by a licensed physician who then supervises their work.7 It is this responsibility of delegation and supervision of PAs by supervising physicians that exposes doctors to the risk of liability if the PA provides negligent care.

From a legal perspective, the courts expect supervising physicians to appropriately delegate and supervise a PA. In the event of litigation, supervising physicians will be evaluated on whether they met the standard of care when delegating and supervising tasks. The courts usually consider the degree of care and skill that might reasonably have been applied by a supervising physician in similar circumstances. Doctors who delegate tasks that are beyond an individual PA’s training and experience or do not properly supervise the PA may be criticized.

In addition, physicians who are employers of a PA should also be alert to the potential risk of vicarious liability. The principle of vicarious liability holds that as employers, physicians may be liable for the negligence of their employees when they are acting within the scope of their employment. Employees in these circumstances should also carry their own liability protection.

Managing the risks

None of these risks, however, should stop physicians from working collaboratively with PAs. Delegating certain medical acts to PAs allows physicians to tend to other duties and extend their services to patients. Their collaborative working relationship is most effective when supervising physicians take steps to manage the risks that can accompany the delegation of work and supervision of another health provider.

When deciding which medical acts to delegate and how much supervision is appropriate, supervising physicians should first assess a PA’s competencies, skills, and experience in the targeted practice setting (e.g. emergency department, anaesthesia, family medicine, etc.). It is important to recognize that PAs cannot perform tasks that are outside the scope of practice of their supervising physician.8

Assessing a PA’s capabilities can be difficult for supervising physicians, particularly when there is no regulatory authority that can be consulted. The physician must ultimately exercise good clinical judgment when determining if the PA is clinically competent to perform a particular task.

Physicians should also check with their College and their hospital or health authority, if appropriate, to see if these organizations have policies and guidelines on the degree to which PAs can perform certain tasks.9 This is particularly important in those provinces in which PAs are regulated.

Once supervising physicians determine what medical acts can be delegated, they must ensure that the PA performs the acts properly and safely. Physicians are responsible, for example, for giving direction, appropriately reviewing the assistant’s work and records, and ensuring the PA only performs the delegated activities. The supervising physician should also be available to the PA to give direction. The specific requirements for a supervising physician’s availability vary from jurisdiction to jurisdiction. Physicians should consult with their College for the requirements in their area.

While PAs are not independent practitioners, they can work with a “…degree of autonomy,"10 depending on the clinical task and their skills. The degree of autonomy should be agreed to by the supervising physician and the PA. 11,12 Many PAs may work under medical directives or standing orders issued by the supervising physician. Physicians must keep in mind, however, that the use of medical directives does not reduce their exposure to the risk of liability or discipline if there is any negligence on the part of the PA while carrying out the order.

CMPA protection

The CMPA supports collaborative healthcare, including between physicians and physician assistants, but it also recognizes that for collaborative care to be effective, all the health professionals practising within a healthcare team must have adequate liability protection.

The CMPA will generally assist physician members with medical-legal difficulties arising from their medical professional work, including from the supervision of other healthcare professionals such as PAs. The Association’s assistance, however, does not extend to non-physician healthcare providers, including physician assistants, who may see patients with a degree of autonomy.

In situations where PAs are employed by a hospital, region, or institution, physicians should inquire whether the PAs have liability protection through the employer’s insurance provider. When employed by individual physicians or private group practices, PAs generally must obtain their own liability protection from a commercial carrier. This protection, which can be obtained through the Canadian Association of Physician Assistants, should address all aspects of their employment and be adequate and appropriate for the work they do.

The last word

Physicians working with or employing PAs may be exposed to the risk of liability arising from the actions of the assistant. These risks do not need to be a barrier to collaborative care if physicians and physician assistants take appropriate steps to mitigate these risks, including using appropriate communication protocols.

Physicians wanting specific information on the medical-legal aspects of working with a physician assistant are encouraged to contact the CMPA.

  1. Canadian Association of Physician Assistants, PA Fact Sheet. Retrieved August 4, 2015 from: https://capa-acam.ca/about-pas/pa-fact-sheet/
  2. The College of Family Physicians of Canada, Position Statement: Physician Assistants, April 2011. Retrieved August 4, 2015 from: http://www.cfpc.ca/ProjectAssets/Templates/Resource.aspx?id=3309
  3. Canadian Medical Association and the Canadian Association of Physician Assistants, Physician Assistant Toolkit, A Resource Tool for Canadian Physicians, Revised Edition December 2012, Ottawa Ontario, page 6. Retrieved August 4, 2015 from: https://www.cma.ca/Assets/assets-library/document/en/advocacy/PA-Toolkit-e.pdf#search=PA%20Toolkit
  4. Ibid, p. 22
  5. Ontario Health Professions Regulatory Advisory Council, The Health Profession Assistant: Consideration of the Physician Assistant Application for Regulation, August 31, 2012.
  6. The Manitoba Regulations define both “clinical assistants” and “physician assistants” that are eligible for licensure as associate members of the College. Different qualifications and requirements exist for these two types of assistants.
  7. Canadian Medical Association and the Canadian Association of Physician Assistants, Physician Assistant Toolkit, A Resource Tool for Canadian Physicians, Revised Edition December 2012, Ottawa Ontario, page 6. Retrieved August 4, 2015 from: https://www.cma.ca/Assets/assets-library/document/en/advocacy/PA-Toolkit-e.pdf#search=PA%20Toolkit
  8. Ibid, p. 10
  9. Ibid, p. 13
  10. Ibid, p. 6
  11. Ibid, p. 6
  12. In Manitoba, approval by the College of the level of supervision in accordance with the requirements set out in the Regulations is also required.

DISCLAIMER: The information contained in this learning material is for general educational purposes only and is not intended to provide specific professional medical or legal advice, nor to constitute a "standard of care" for Canadian healthcare professionals. The use of CMPA learning resources is subject to the foregoing as well as the CMPA's Terms of Use.