Physician assistants in the Canadian Forces

Military Medicine, Nov 2003 by Hooker, Roderick S, MacDonald, Kent, Patterson, Rebecca

Canada is struggling with burgeoning health care access problems. At the same time, this nation may be overlooking an available resource to help address specific physician shortages. The services of more than 130 physician assistants in the Canadian Department of National Defense are used to offset and amplify physician services. Their extensive education and training, along with their international experience in wartorn areas, dealing with wounded and ill military personnel, refugees, civilians, epidemics, and other health care problems make them particularly valuable assets. Yet, upon discharge from military service and reentry into the civilian sector, they are left without the legislation and formal recognition as a health care provider that would enable them to use these skills to help improve medical care access. This study provides the first description of the training and activity of Canadian physician assistants.

Introduction

Universal health care access is an ideal that most countries strive for; Canada and its citizens are no exception.1 However, despite many attempts to improve access for all Canadians, barriers to physicians' services persist in select areas of the country.2 Various proposals have been offered to ensure that all citizens have equal access to necessary medical services.3-7 One means to improve physician access within this country has been at Canada's doorstep since 1992. This is the model of extending physician services that has been highly successful in the Canadian Forces-the nation's small but growing cadre of physician assistants (PAs).

PAs are highly skilled members of the health care team who provide a broad range of medical services, in both primary care and specialty areas, under the supervision of licensed physicians. They are trained to perform medical practice functions under a physician's direct or indirect supervision. Within the physician/PA relationship, PAs exercise autonomy in medical decision making and provide a broad range of diagnostic and therapeutic services. The clinical role of PAs includes primary and specialty care in medical and surgical practice settings. The PA's activity centers on patient care and may include educational, research, and administrative activities. As part of their scope of practice, PAs take comprehensive medical histories, conduct physical examinations, diagnose and treat illnesses, order and interpret tests, counsel on preventive health care, assist in surgery, and write prescriptions. What a PA does varies with training, experience, and clinical setting. In general, PAs see many of the same types of patients as physicians do. Cases handled by physicians are generally more complicated or those that require care that is not a routine part of the PA's scope of practice.

PAs in the Canadian Forces

Developed and extensively used by the Canadian Forces, military PAs have been an important component of extending scarce physician services. At the same time, they limit the labor cost of employing more doctors. Currently, the nation's 53,000 active duty military personnel rely on 80 physicians and twice that number of PAs (Table I). This creates a lean ratio of physician-to-patient population that would be unmanageable without highly trained and experienced medical personnel such as PAs, nurses, as well as various allied health members. Contract physicians are routinely employed to supplement military physician shortages at many bases, which may paradoxically cause an increased physician shortage in the community, as civilian patients are not entitled to receive care through military facilities.

Because so little has been promulgated about this national resource, we undertook a descriptive study on Canada's use of PAs. No health workforce research has examined this group of health professionals until now. If the nation is to address improvements to health care access for its residents, then all available and tested models at hand should be considered.

Canada, like many other nations, developed various attendants and assistants to care for sick and injured soldiers and sailors throughout the 20th century. Before World War II, they were called Sick Berth Attendants. After World War II, they became known as Medical Assistants, and the more advanced trained are Medical Technicians.8 Similar titles have been adopted in other countries. Prior to 1992, the role of the Canadian Medical Technician was expanded, which was modeled after a similar type of provider in the United States. In 1992, the PA title was authorized for its senior medical technician personnel.

Whether "in garrison" within army units or aboard naval vessels, PAs in the Canadian Forces are independent duty medical personnel. A PA in a typical garrison medical unit has many responsibilities and demands (Table II). The morning usually begins with screening and managing patients at "Sick Parade," a type of walk-in, urgent care clinic for uniformed personnel. Many of the patient problems consist of upper respiratory infections, muscle sprains, abdominal pains, and medication requests. The remainder of the morning may consist of return visits, undertaking procedures such as incision and drainage of abscesses, checking the status of injuries, and follow-up of referrals. Reservists and, especially in overseas or isolated posts, families of military personnel may be seen. In the afternoon, the PA has a number of responsibilities from performing physical examinations to overseeing the administration and human resource management of the medical unit personnel. This includes responsibility for the overall deportment and discipline of clinical noncommissioned staff and patients. Secondary duties include medical education for junior Medical Technicians and ensuring the readiness of all equipment and personnel in the unit. Throughout the day, the PA may encounter 20 to 30 patients.