Canada is a confederation comprising 10 provinces and 3 territories. Each jurisdiction has authority to establish parameters concerning the administration and regulation of its health professionals, including physician assistants (PAs). In addition, each province or territory has its own health system; separate systems also exist for federal employees such as Canadian Forces members and for statutorily mandated obligations such as with our First Nations Aboriginal people.
Four provinces have formal statutes that allow PAs to practice. PAs working in these provinces are granted permission to practice by way of their respective Medical Act, which stipulates that a physician can delegate to qualified individuals. Of the four jurisdictions, Manitoba and New Brunswick regulate practice and license for PAs through their Colleges of Physicians and Surgeons (medical boards). Alberta has a voluntary registry and is considering regulation. Ontario uses the delegated authority provision to authorize PAs to practice. Some PAs are working outside the public healthcare system in occupational settings in the Northwest Territories and in other provinces under similar clauses or allowances. Discussions regarding the introduction of PAs are occurring at many levels with stakeholders in British Columbia, Nova Scotia, Prince Edward Island, Newfoundland and Labrador, and Quebec. Physicians, governments, and medically affiliated organizations in these provinces have expressed interest in integrating PAs into their respective health systems but have not yet committed to the concept.
The history of Canada's PAs has origins with sick-berth attendants working in the Royal Canadian Navy in the 1900s and in other services throughout the 20th century. In 1984, the Canadian Armed Forces adopted this model and labeled these advanced trained medics as PAs. These senior-level medical personnel provided primary care to armed forces members and in some cases to civilians in remote operations and on military missions. The Canadian civilian world began to formally recognize the PA role first in Manitoba in 1999, with a formal homegrown education program that commenced in 2008.
The Canadian Association of Physician Assistants is a national organization that represents PAs across Canada (Table 1). The association advocates at the provincial, territorial, and federal levels for the advancement of the profession. It provides a unified voice, technical expertise, and a wide range of member services including professional development resources for the profession and practice insurance. The Physician Assistant Certification Council of Canada (PACCC) administers and oversees certification for PAs in Canada. The PACCC is a council of the association whose mandate is the delivery and administration of certification and quality assurance for the entry to practice certification examination. The Certified Canadian Physician Assistant (CCPA) designation is recognized as the national standard. Canadian certification is not a requirement for practice in all provinces; however, most employers deem it a requirement for employment.
Accreditation of the four PA education programs is provided through the Canadian Medical Association's Conjoint Accreditation Services. The three civilian university programs are two undergraduate programs in Ontario (McMaster University and the Consortium for PA Education) and a master's degree program at the University of Manitoba. The Canadian Forces PA program is restricted to serving members and grants a degree in collaboration with the University of Nebraska Medical Center. All programs are 24 to 25 months in duration and deliver curricula that support the Canadian PA association's scope of practice and national competency profile for PAs. The number of program seats is determined by the provincial government.
More than 400 PAs are practicing across Canada. Although this is a relatively small number in comparison to our respective US colleagues, the growth is remarkable considering that only one PA was working in Canada in a civilian setting in 2004 and the first non-military graduates were in 2010. Many have started to see the value that these health professionals bring to the healthcare system, thus helping to address health professional shortage challenges across the country and improving access to care for patients. With the profession only recently being introduced to the public system in Alberta and other provinces starting to express interest, one could believe that the profession is on the cusp of rapid growth in Canada.
Canada's PAs are seeing a slow but consistent increase in opportunities. The demand exceeds the supply of PAs, although it appears the question of fee-for-service economics in our single-bursar government-funded systems has restricted the expansion. Programs that receive block funding (for example, academic specialty groups in provinces such as Manitoba and Ontario) support PA recruitment as service demands increase or shift from postgraduate residents. Many innovators and early adopters of change support the concept; however, with minimal research on PAs and their economics in Canada, the arguments for the integration of these professionals is more based on common sense and intuition than empiric data. The restriction and slow expansion into fee-for-service primary care practices is limited. The question is who pays and who controls the expenditure.