What the Heck is a Physician Assistant? with Rachel Prato

About the Episode

Rachel Prato, a Canadian certified physician assistant (PA), discusses her role and the growing field of physician assistants in Canada. Trained under the medical model and working in collaboration with physicians, PA like Rachel perform various medical duties, including diagnosis and treatment, within a supervisory framework. The training for PA is intense and diverse, with a focus on primary care but opportunities in various medical fields. Rachel highlights the importance of PA in addressing healthcare provider shortages and advocates for collaborative work among different medical professionals.

Could PAs be the solution to improving access to care? Find out in this episode.

Objectives and Discussions
  • Role and Growth of Physician Assistant in Canada
  • Day-to-Day Activities in a Clinical Setting
  • Billing Models and Financial Considerations
  • Rachels' Personal Journey to Becoming a PA
  • Compensation, Scope, and Comparison with Nurse Practitioners

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Speaker Identification:

[Host]: Dr. Jordan Vollrath

[Speaker]: Rachel Prato

Jordan Vollrath (00:01.102)
All right, today we're talking to Rachel Prato. Rachel Prato is a Canadian certified physician assistant who practices primary care at the Moose and Squirrel Medical Clinic in Sundre, Alberta. Rachel graduated from the University of Toronto's Bachelor of Sciences in PA Studies in 2021, and shortly after moved to rural Alberta. So she's passionate about PA advocacy and was featured by the CPSA for a day in the life of a physician assistant in May, 2022.

She's currently involved in the curriculum development for the upcoming Physician Assistance Program at the University of Calgary. Rachel, thank you for joining us.

Rachel Prato (00:38.006)
Thank you so much for inviting me to be interviewed. I guess we should have gone over our names at the beginning, but it's actually pronounced "Prado". And if you're a good Italian, you would roll the R, but I'm not, so I can't do that.

Jordan Vollrath (00:45.262)
Prato, okay. Prato.

I apologize for bastardizing it already right up front. We're off to a good start here, 20 seconds in. So this has come up just recently on another episode of the podcast. I know here in Alberta, the premise of team-based care and trying to patch the cracks in our system, everything has fallen apart around us. And the premise of having physician assistants in clinics came up. And I was just like...

What the heck is a physician assistant? I've heard this term before. I thought this was something very exotic and foreign. They have them in the United States. I've seen posts on Facebook. I had zero idea we had any in Canada, but you said we're up to about 900 something now, almost a thousand in Canada, is that correct?

Rachel Prato (01:34.742)
something like that. I'm not sure the exact numbers, but it's definitely a growing profession.

Jordan Vollrath (01:39.162)
Yeah, so Dr. Myhr and Dr. Hilner from podcast last week or a couple weeks ago, they spoke very highly of physician assistants. And I think they knew you personally. That's how they actually made the connection. And so I'm super excited to learn what is the physician assistant. So why don't we start there? What is a PA? What do you guys actually do?

Rachel Prato (01:58.402)
So physician assistants are skilled medical professionals that are trained under the medical model. We work in collaboration with supervising physicians and practice medicine, essentially as an extension of their services and increasing accessibility to care. So that really kind of looks like we do histories and physical examination, we order investigations and interpret results. We're able to diagnose, formulate treatment plans.

do minor procedures or in some situations actually are in the OR and surgically assisting as a first assist. And we do all within the supervision of a physician. And so we are not an independent provider. We have a working relationship with a supervising physician either directly or indirectly. And direct supervision kind of looks like how you would review with a resident. And as you kind of progress in your career and you start to have that working relationship kind of shift.

you might be given more autonomy throughout. And that's maybe where the indirect supervision kind of comes into play, where your supervisor could be accessed only remotely. So in scenarios where PAs are working in kind of Northern communities, they're only accessing their supervisor through telephone.

Jordan Vollrath (03:15.278)
So what can't you do? It sounds very much like a physician then at that point. What's the actual difference then? Is it just that signing authority and the ability to write a prescription? Is there any other difference, I guess? I'm assuming there's some differences in just the training and the things that you actually do during your schooling. But when it comes to the actual patient visit, the patient encounter, what would the patient notice being different?

Rachel Prato (03:40.466)
Absolutely. So we're definitely we're not physicians. A patient might notice that we can take a little bit of extra time for their care. We work on an hourly kind of basis. And so we're able to maybe take a little bit more time in terms of patient education and having kind of that holistic or comprehensive care. We cannot prescribe controlled substances or narcotics.

and all of our prescriptions are written with kind of a co-signature from the physician or their information on the prescription pad, kind of depending on what system that you're using. We also can only work within the scope that our physician is comfortable with, and that's only what physicians are doing within their practice. So if you, for example, are skilled in doing IUD insertions, but the doctor you're working with doesn't do IUDs, you can't do that. And that is because there has to be a certain level of supervision there.

Jordan Vollrath (04:33.982)
It sounds similar to if I'm supervising a nurse at the clinic, right? They're only able to do the things that I'm qualified to supervise for, I guess, for the most part. So it sounds, again, very much like working with a resident, that same supervisory role, having that co-signing power on there. That's really cool. So what do you actually do in your day-to-day then at the sundry clinic?

Rachel Prato (04:53.346)

Rachel Prato (04:58.07)
Yeah, sometimes we're kind of referred to as like the residents never leave. So that's one kind of way to look at it. At Sundry, so I work Monday to Friday. I offer evening clinic hours and I also man our call phone one week out of the month. Within clinic, I have scheduled appointments, usually two back to back and then a free space where I either have time to review with my supervisor if necessary.

Jordan Vollrath (05:01.654)

Rachel Prato (05:25.718)
or for the most part is utilize a same day access. So we are getting patients that are able to come in for things that we're hopefully limiting them having to go to the emergency department for. And that's kind of how my schedule continues throughout the day. We've got a nice long lunch. So then we kind of continue on for the afternoon in that same sort of fashion.

Jordan Vollrath (05:45.222)
Okay, awesome. And so does the physician need to be like physically on site then? Or is it again, similar to how you'd operate with a resident in a rural area? Maybe the resident has taken the first call if you're in the ER or on the phone call. Does the doctor have to literally be there? Or can there be some separation physically?

Rachel Prato (06:05.13)
I think it really depends on what your supervisory agreement looks like with the physicians that you're working with. I think often when you are a new graduate and kind of new to practice, there's usually a present physician in some provinces depending on regulation. I know Manitoba typically wants six months of regular kind of reviewing and having more of that direct supervision. And then as you progress in your skill sets and near that working relationship changes and you guys have a better understanding of maybe what you're comfortable with, there's more of that.

and dependent supervision and autonomy.

Jordan Vollrath (06:38.122)
Very cool, okay. And then what does the training look like? How many years, what do you go through? I'm assuming it's very similar to going through medical school.

Rachel Prato (06:48.842)
So this is all kind of shifting as there's new programs that are being developed, but traditionally Ontario has two programs. There's the University of Toronto, which is kind of the consortium of PA education. It is paired with the Missioners Institute as well as the Northern Ontario School of Medicine that kind of collaborate to make this program. You can apply, given that it's a bachelor degree, with only two years of undergraduate experience. And then they have additional admission requirements such as

healthcare experience hours or recommended courses such as anatomy, physiology, and those types of things, but they're not mandatory, which is really nice because it allows for a very wide range of applicants. In my class, I had people that were previously like flight paramedics, engineers, social workers, right? And so not having that kind of strict science background really allows for, you know, a diverse pool of applicants. And then the University of

Natatoba, it is a master's degree. And so you would have to have an undergraduate in order to apply. The program itself is 24 months consecutively. So it's really kind of fast paced, accelerated learning. And we don't have summer holidays off you kind of get a little bit of a break at around Christmas time. And the first 14 months of that is didactic learning. That's where we're learning our clinical skills. We're having cadaver labs and doing anatomy.

physiology, pharmacology, medical foundations, those types of things. And then the next 10 months proceeding are our clinical rotations. And for every school, it's a little bit different, but they try to have a focus on primary care as PAs are supposed to graduate as more so generalists to practice. And so at the University of Toronto, I rotated through three rotations in family medicine. And then we have pediatrics, there's emergency medicine.

general surgery, psych and internal medicine, followed by two elective.

Jordan Vollrath (08:50.162)
And so it's very geared towards that primary care practice. Are there like specialties that you can go down? Is that something that might be coming in the future or is it pretty much like one track and you're on that sort of family medicine primary care road?

Rachel Prato (09:04.402)
Yeah, it's a really interesting actually in Alberta, the majority of physician assistants actually work within AHS facilities and there aren't very many of us in primary care. We are graduating as generalists and the idea is that when you start in any kind of specialty as long as there's a supervising physician, you're kind of getting a lot of on the job training. There aren't fellowships at this time and there isn't really a way to kind of sub specialized. It's more so what you're learning as

you kind of start into your practice. And so kind of the easy answer is wherever there's an MD, there can be a PA. And so I have colleagues working in urology in Calgary, people back in Ontario that are working in very kind of sub-specialty kind of medicine. So really there's a large scene and PAs can be really anywhere within the healthcare system.

Jordan Vollrath (09:54.266)
And so here in Alberta, you mentioned most of them are in the hospital setting. Is that the case across most provinces here in Canada, or are they a lot more in primary care like yourself in different locations?

Rachel Prato (10:05.33)
Yeah, I think that really kind of depends on the funding models that those provinces are using in order to be able to pay for PA services. So currently we're not able to bill Alberta Health, and so the PA's make a little bit more sense within an AHS facility, or if your clinic has kind of an alternative to a fee for service. So like, in my instance we do the blended capitation model, and my wages come out of the overhead that we get at the clinic.

So I think that's kind of a limiting factor.

Jordan Vollrath (10:36.822)
Would it work for a fee for service model? The reason I ask is here in Alberta, I think the vast majority of community clinic docs are on that fee for service model. If there's technically that direct supervision component, could the physician bill for it, or would that be against kind of that, the whites of the eyes rule where the doctor literally has to see the patient to bill for it?

Rachel Prato (10:56.178)
Yeah. So that's where things become a little bit tricky. In order to bill you have to be able to see the whites of the eyes and that sometimes that can limit the autonomy that the PA would then be having as you'd have to review or supervise and seeing every single patient that is seen during the day. So as far as I know, there aren't a lot of clinics that use PA's within the fee for service model, unless maybe in a walk in or an instance where if you had multiple PA's working for you, and as a supervisor, you're kind of just going in into rooms.

and laying eyes on the patient.

Jordan Vollrath (11:28.902)
Okay, so at this point, it's not really feasible to have like an entire army of PAs, like serving all of our like rural practices and our rural communities. Um, unless you're on that ARP model. Do you think that's changing anytime soon?

Rachel Prato (11:33.204)

Rachel Prato (11:40.437)

Rachel Prato (11:44.718)
Well, I know there's been some conversation around having non-physician billing services available, and I'd like to see something like that in the future, definitely. Or even just having some grant opportunities like other provinces have in order to kind of incentivize physicians to maybe want to have a PA to work in their practice. So, for example, in Ontario, new graduates, if you are hired, the government will pay 50% of your salary for the first year.

or if you are working really for two years. And that definitely kind of incentivizes MDs to look into the PA practice and hire new grads.

Jordan Vollrath (12:23.99)
So with the longitudinal family practice model coming out, you know, this new LFP billing model, then will that make it more amenable for more clinics to start hiring PAs? Would that cover the funding now if it's more of that capitation or blended capitation side of things, now there's financial incentive to have more patients rostered, more financial incentive to have more of that team based practice set up.

Rachel Prato (12:48.958)
Yeah, absolutely. So as healthcare kind of shifts towards more of that interdisciplinary care within the clinic that I'm working at, the affiliation allows for the clinic to be able to pay for my services, and also allows for us to have nursing staff that are able to kind of work at their full extent of their scope of practice, really kind of shifting that not all of our patients need to be seen by a physician every time.

Jordan Vollrath (13:11.138)
Very cool. And I don't know if you can speak to this cause I know you're here in Alberta, but how does it work in BC or Ontario for the PA's billing model and compensation? Is it pretty much the same? Like they have to be within that team-based sort of LFP capitation model, or are they able to actually build directly in any of these other places?

Rachel Prato (13:30.906)
As far as I know, PAs aren't able to bill in other provinces. I do know that in Ontario there's a lot more of the family health teams and kind of models that are that more interdisciplinary care. I can't speak to British Columbia.

Jordan Vollrath (13:45.382)
Okay, gotcha. And then what is the background, the actual history on the physician assistant side of things? I know to me, this seems very new and exotic, but you were mentioning just before we started recording, you guys have actually been around for many years now. How long does that history actually go back?

Rachel Prato (14:02.026)
Yeah, so physician assistants actually have a very rich history in the Canadian Armed Forces. In the late 1950s and early 1960s after the Vietnam War, there was kind of an entire collective group of medical medics or providers that were worked beyond their scope, kind of out in the field and they were returning to normal life. And so they were more so noted as senior medical technicians and not until 1984 where we

kind of collectively referred to as physician assistants and a more formalized training program was developed. The United States have been using PAs since around that same kind of timeline as well. And if you kind of fast forward a few years into 2008, 2010, that's where more of the civilian side we started opening up physician assistant programs. And that was the program that we talked about earlier with McMaster, U of T and Manitoba.

And actually within Alberta, there was a really successful pilot project that had happened in 2013, which allowed physician assistants to be practicing within HS facility. And actually retained a lot of non regulated PAs working within the province. And so in April of 2021 when we were regulated, there were already 40 providers within the province, which speaks to something and given that Alberta didn't have its own program. So where were they coming from? Right?

Jordan Vollrath (15:22.278)
How many schools are there right now in Canada training PAs?

Rachel Prato (15:25.81)
Yeah, so there are three currently, but there's promise for a lot more in the future. The University of Calgary, which I'm on the curriculum development committee for, is hopefully having a class with September of 2024. Nova Scotia has promised to open up a program as well as the University of Saskatchewan. So we're definitely seeing this huge shift and then the programs that already are existing. We're seeing the number of seats doubling in the next couple of years, which is very exciting.

Jordan Vollrath (15:39.938)
Wow, awesome.

Jordan Vollrath (15:54.774)
Well, that's incredible. And then what else is coming up then in the future for PAs? What's on the horizon for the next years and decades? Where do you see things going?

Rachel Prato (16:04.01)
Yeah, I'd like to see regulation be something that's happening. Right now, we only are regulated in Alberta, Manitoba, and New Brunswick. And so I think with regulation, it will become, you know, more widely known as a profession, as well as we get some credibility as we fall under the College of Physicians and Surgeons of Alberta in this province. And there are some, you know, necessary requirements in order to maintain our licensing and our title.

Jordan Vollrath (16:33.282)
Very hot and down.

Rachel Prato (16:33.31)
I'd like to see that to be kind of Canada-wide like we have in the United States.

Jordan Vollrath (16:38.598)
Yeah, well, it sounds like one more little, you know, hidden nugget or a little bit of gold coming to that LFP model is being able to expand the team and incorporate, you know, new team members. That's awesome. How'd you get into it yourself? What's the backstory there? What made you want to be a PA?

Rachel Prato (16:55.706)
Yeah, so I did an undergraduate degree at the University of Ottawa. I was doing honors in biomedical science and a minor in psychology. And I always knew that I wanted to work in a healthcare setting. I was just kind of figuring out where it was that I wanted to go. And it wasn't until my third year where I actually stumbled across the PA profession, just kind of looking things up online. And there's a lot of kind of advocacy groups for Canadian PA. And I realized that it was kind of checked all the boxes.

You know, I love medicine and I love to learn, but I also love life outside of medicine. And the PA program being short and condensed and very self-driven learning allowed me to really explore both and travel and kind of, you know, nurture all of my identities as well having, you know, the degree that I have, there's a lot of lateral mobility. So right now working in primary care, but if I wanted to, you know, go and work in dermatology or emergency medicine,

I would be able to make that shift without having to return to school, which is something that I quite enjoy about the profession.

Jordan Vollrath (17:57.998)
Yeah, right on. And then, so you went to the U of T. How did you wind up in sunny, beautiful Sundria, Alberta?

Rachel Prato (18:04.67)
Yeah, that's kind of a multi-step answer. So there was a huge housing crisis, you know, in Ontario. So Alberta was, if I wanted to ever be a homeowner, that was definitely something to consider. We've got the 5% sales tax, the beauty of the mountains, right? So there's a lot of things kind of driving me to Alberta. And then specifically sundry.

The Mooses Grove Medical Clinic is really an extraordinary clinic and kind of a model for primary care in the province and we've got some extraordinary physicians working there and they're very dedicated to allowing you know me to really fully appreciate my scope of practice and kind of are always behind me you know wanting me to advocate for the PA profession which I think is something really important.

Jordan Vollrath (18:51.734)
Which is wicked, yeah, so Dr. Rob and Dr. Michelle, they're pretty ahead of things, right? I think you guys were one of the first clinics actually to switch over to that blended cap model, so fertile grounds for having the PA. And then you mentioned you guys have hired a few new PAs recently as well. How's that been going?

Rachel Prato (19:08.502)
Yeah, so with this new graduating class, they've just have written their licensing exams and now are certified as physician assistants. We've got one student that had actually come from the University of Manitoba to finish his last rotation here with us and then moved as well as a new graduate from the University of Toronto as well. So now we are a team of three PAs.

Jordan Vollrath (19:31.062)
Awesome. How many physicians, how many nurses, how many PAs, what's the, what's a good ratio for clinics to have?

Rachel Prato (19:34.574)
I'm going to go to bed.

Yeah, it's hard to say. Right now we have three physicians and three PAs. We'd like to see kind of a dyad where potentially, you know, you would either see your physician or you would see the PA and they would work as a team, which is also nice for the MDs because we will be working through, you know, the same inbox, the same kind of panel of patients, really kind of getting to know our patients and have that continuity of care.

Given though that I've been here for a couple of years, there's been conversations around, I've been seeing everybody's patients for so long, there's definitely some people that will be upset if they're not able to continue to see me. And I think we're gonna have a little bit of that flexibility. But I think in the future, the idea would be that when you kind of sign on with our clinic, you would see one of the group of two.

Jordan Vollrath (20:24.178)
And then can I ask what's like the salary band for a PA? You know, how much does a clinic need to budget actually to bring on a PA? You know, one versus in their early career or at the, you know, kind of end of their career later stage.

Rachel Prato (20:38.178)
Yeah, this is a little bit of a hot topic and for physician assistants. We would like to see equivalency to nurse practitioners in terms of wages. Sometimes that can be a little bit challenging. So I'd say for most PAs as new graduates, new graduate starting, they're usually in that 85 to $90,000 a year kind of salary range. And then as you kind of step up through experience and along with the pay scale,

that could be anywhere between 120 plus.

Jordan Vollrath (21:12.27)
Right on. What's an NP make these days? I actually have literally no idea.

Rachel Prato (21:18.088)
It depends if they're being paid to the PCN, but oftentimes they're in the high, you know, I know more so in terms of hourly, they're making kind of the high 50s to 60s per hour, where for PAs that's more looking like the mid 40s to 50s an hour.

Jordan Vollrath (21:35.214)
Okay, so a little bit of catching up there to do. So in terms of scope of practice, PA versus an NP, then where really does that difference lie? Is it sort of they have a little bit more autonomy? Is there anything else in there?

Rachel Prato (21:37.57)

Rachel Prato (21:49.674)
Yeah, so absolutely nurse practitioners are independent practitioners, so they don't have to have that collaborative arrangement or supervising physician. There were also nurses before they became nurse practitioners, and so they had four years of, you know, they did an RN degree as well as two years of clinical experience before becoming nurse practitioners. So the

Training itself is a little bit different as well as the model of care that they work under. So we are trained more under that medical model where nurse practitioners may be more so than the nursing model.

Jordan Vollrath (22:23.282)
Okay, right on. I'm kind of running out of questions here. I mean, this is fantastic. I've learned a lot already. Is there anything else you think the medical community needs to know about PAs and how you guys integrate within that team-based care model?

Rachel Prato (22:38.082)
Yeah, I think in this time where, you know, there's such a shortage in health care providers, whether you're a nurse practitioner, a PA and MD, we're all essentially working for the same, you know, common goal. We want our patients to be seen and cared for and to improve accessibility. So I really would like to see all of our professions kind of working collaboratively together.

Jordan Vollrath (22:57.998)
Fully agree right on. Okay, well, Rachel, thank you so much for joining us today. Really appreciate it and very insightful. And a shout out to the Moose and Squirrel Clinic in Sundry, Alberta.

Rachel Prato (23:07.805)
Yeah, thank you so much. This was a really excellent opportunity.

Jordan Vollrath (23:11.182)
Thank you.

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