A “physician assistant” is a health care professional who works under the supervision and authority of a physician to provide health care – to do everything from take patient histories, conduct physical examinations, order and interpret tests, diagnose and treat illnesses, counsel on preventive health care, assist in surgery, conduct research and teach.   Some post-secondary schools have started offering programs to train physician assistants.  However, because physician assistants are unregulated, foreign trained doctors and other medical professionals may be used by doctors, medical professional corporations and medical practice groups as physician assistants.

As doctors look for new ways to increase their productivity and bottom line, individual doctors, medical professional corporations and medical practice groups are taking a serious look at physician assistants.  Moreover, the use of physician assistants by doctors will only become more prevalent now that schools, such as McMaster University, are offering Physician Assistant Educational Programs.

The Regulated Health Professionals Act (RHPA) prohibits performance of controlled acts by those not specifically authorized to perform them.   The following is a list of “controlled acts”, the first 13 of which may be performed by a physician and may, in appropriate circumstances, be delegated.  Basically,  “dele­gation” occurs only when a physician directs an individual to perform a controlled act that the individual has no statutory authority to perform.

Controlled Acts under the RHPA:

1. Communicating to the individual or his or her personal representative a diagnosis identifying a disease or disor­der as the cause of symptoms of the individual in cir­cumstances in which it is reasonably foreseeable that the individual or his or her personal representative will rely on the diagnosis.
2. Performing a procedure on tissue below the dermis, below the surface of a mucous membrane, in or below the surface of the cornea, or in or below the surfaces of the teeth, including the scaling of teeth.
3. Setting or casting a fracture of a bone or a dislocation of a joint.
4. Moving the joints of the spine beyond the individual’s usual physiological range of motion using a fast, low amplitude thrust.
5. Administering a substance by injection or inhalation.
6. Putting an instrument, hand or finger,
   1. beyond the external ear canal,
   2. beyond the point in the nasal passages where they normally narrow,
   3. beyond the larynx,
   4. beyond the opening of the urethra,
   5. beyond the labia majora,
   6. beyond the anal verge, or
   7. into an artificial opening in the body.
7. Applying or ordering the application of a form of energy prescribed by the regulations under the RHPA.
8. Prescribing, dispensing, selling or compounding a drug as defined in the Drug and Pharmacies Regulation Act, or supervising the part of a pharmacy where such drugs are kept.
9. Prescribing or dispensing, for vision or eye problems, subnormal vision devices, contact lenses or eye glasses other than simple magnifiers.
10. Prescribing a hearing aid for a hearing impaired person.
11. Fitting or dispensing a dental prosthesis, orthodontic or periodontal appliance or device used inside the mouth to prevent the teeth from abnormal functioning.
    
12. Managing labour or conducting the delivery of a baby.
13. Allergy challenge testing of a kind in which a positive result of the test is a significant allergic response.
14. Treating, by means of psychotherapy technique, deliv­ered through a therapeutic relationship, an individual’s serious disorder of thought, cognition, mood, emotion­al regulation, perception or memory that may seriously impair the individual’s judgement, insight, behaviour, communication or social functioning.

The PA’s scope of practice is determined on an individual basis and formally outlined in a practice contract or agreement between the supervising physician(s), the PA and often the facility or service where the PA will work. Activities may include conducting patient interviews, histories and physical examinations; performing selected diagnostic and therapeutic interventions or procedures; and counseling patients on preventive health care.  See CPSO Policy re Delegation of Controlled Acts.

The Policy sets out various requirements relative to the delegation of “controlled acts”.

According to the Policy it is the physician’s responsibility to evaluate and confirm delegate has appropriate knowledge, skill and judgement to perform the delegated act and the requirement to obtain informed consent from patients.  Note, the delegating physician can’t rely exclusively on the credentials of the delegate.  Specifically, the Policy states as follows:

Footnote 10 of the Policy states:

The Policy also includes the guidance regarding delegation to a PA.  Since a physician assistant is essentially an extension of the delegating physician, responsibility, accountability and liability remain with the physician.

Before engaging foreign trained doctors or other medical professionals as physician assistants, we advise our doctor, medical professional corporation and medical practice group clients to carefully review the Policy and establish clear, well documented processes and practices to ensure their compliance.