The True Value of PAs

I have been a Pathologist’s Assistant for over 30 years and although this issue had occurred to me before, never have I been so certain of its validity.

Not long after I departed oh-so-comfortable Ottawa, my home, and The Ottawa Hospital (TOH) and came to BC to help the Interior Health Authority (IHA), along with two other well-trained PAs, deal with a crisis which was generated out of a contractual disagreement involving the Ministry, IHA and the Pathologists, I realized the true value of PAs.

Insofar as I had been around at the very beginning, I obviously knew what PAs contributed to a patient’s care. But the gradual evolution which I participated in had created such a comfortable relationship between PAs (of whom there are now a dozen at TOH) and the Pathologists that our contribution had become something of a ‘given’. I took it for granted and did not truly understand its value. Here, in BC, I have had the chance to put it all into perspective. I now recognize that the contribution which PAs provide to the functioning of Anatomical Pathology has far greater value than I had ever known. I find it fascinating to recount the day when the Interim Medical Director (who had not been involved in the actual negotiations in sourcing PAs for IHA; but who had been convinced of the value of PAs) stated that he and I were among the highest paid staff in pathology. I had to stifle a laugh. I hazard to guess that on an annual basis, the Medical Director will be paid in excess of $300K. Boy, was he wrong!

It is worth listening to pathologists who all believe, rightly, in the importance of the Gross Description in the provision of a high quality surgical pathology report. This is understandably a facet of a pathologist’s job which s/he takes very seriously; it is the first step towards arriving at an accurate diagnosis. It is completely understandable that a pathologist should feel that only a pathologist ought to be the prosector of surgical specimens. If the prosector fails to examine a specimen appropriately or completely; fails to describe an important lesion or even an important negative finding; fails to take sections of a lesion or fails to take sections in an appropriate fashion, the pathologist performing the Microscopic Description may not ever see a slide of the lesion. This would have a permanent (but invisible to the latter pathologist) effect on the diagnosis, and ultimately the treatment and prognosis of that patient. If different individuals will be performing the Gross and Microscopic Descriptions (regardless of their credentials), a level of trust must exist between them. I would not feel comfortable if I were the pathologist if I did not trust the prosector (I sympathize deeply with the pathologists who feel that they have been forced to accept PAs into the IHA). An experienced, knowledgeable PA (or other individual) is essential (if the pathologist her/himself isn’t doing the Gross Description).

Almost any employee in the hospital can arrive at a valid explanation why their occupation or profession, if not performed, would be detrimental to the quality of the healthcare that the institution was able to provide to its patients. If the Housekeeping department does not maintain a high standard of cleanliness in the entire hospital, patient’s will suffer. If the dieticians do not maintain healthy menus and properly prepared foods, patient’s will suffer. If the plumbers…well, you get my point, I hope. The difference between all of these individuals and PAs, is that physicians have never scrubbed the floors, made beds, prepared meals or repaired toilets. A number of para-medical professions have been introduced over the last three decades the members of which are performing tasks which have heretofore been the sole responsibility of physicians. PAs are among them. What they do (like Nurse Practitioners, Physician Assistants, Midwives, etc.) has an even greater level of importance to the provision of high quality healthcare than that of those who perform the myriad necessary tasks elsewhere in the hospital. Just ask a doctor who used to do these things how important they are. Ask her/him what the impact of error is.

A significant amount of pathologists’ time used to be dedicated to performing Gross Descriptions. It is a part of the job, regardless of who performs it, which ought not be rushed. A high quality Gross Description results in superior patient care. I don’t know of any pathologist or PA who would knowingly compromise the examination of a specimen by allowing exterior influences to rush or distract her/him from examining the specimen as fully as it deserves.

Published papers have shown that PAs are better at examining gross specimens than pathologists because it is their primary responsibility; their raison d’etre. PAs don’t have to rush through a ½ dozen specimens so that they can get to their office to sign-out yesterday’s surgicals. PAs can dedicate more time to finding every last lymph node in that peri-colic fat. Surgeons and oncologists want the specimens from their patients examined by a PA because they know that a PA will probably find more lymph nodes and will abide by a protocol which has been set for the examination of that type of specimen, every time. There will not be variation from one PA to the next.

Pathologists are very well paid for their time. They are paid roughly five times what a PA is paid (when you factor-in benefits). I think that there is a sound argument, when viewing the value of what PAs do and comparing the salaries of PAs and pathologists, for paying PAs a significant amount more than what they are now receiving. I have always contended that a PA is worth roughly ½ of a pathologist.

Yes, there are more-experienced, and there are less-experienced PAs. Yes, there are more dedicated, or more knowledgeable PAs, as there are those who are less so. Yes, there is no formal training, no certification and no regulation of PAs (and yes, it’s high time that this happened). The importance of what PAs do NOW however cannot be ignored. Putting it off until later simply ignores the reality and, from a PA’s perspective, makes the situation only more of an insult. PAs are grossly underpaid and I sincerely hope that the process begun by the CAP results in a situation where PAs can finally be remunerated in a manner more commensurate with their responsibilities (at the glacial rate that things are ‘progressing’ however, I doubt that I will ever benefit personally by any of the issues currently being considered).

Slotting PAs into a unionized pay grid is, I believe a mistake; it was a mistake when first forced upon yours truly in Ottawa many years ago and it is still a mistake. ‘You get what you pay for.’ There will always be exceptional individuals, regardless of the profession, just as there will always be those who are less exceptional. They all get paid the same amount when slotted into a pay scale. The training of Medical Laboratory Technologists does not prepare an individual to be a PA. There are insights into disease processes, physiology, inflammation and repair, neoplasia, etc. that are simply not taught to Technologists. They don’t need that type of training and they’re not paid to have that knowledge. It ought come as no big surprise that the best PA in many ways is a physician. Foreign-trained MDs who are not yet licensed to practise in Canada are well worth considering for PA positions. A potential drawback might be, however, that these individuals might be somewhat less compliant, or accepting, of the status quo; they might not be enough like MLTs to fit in. Wouldn’t it be nice if there was a position roughly mid-way between MD and MLT?!

PAs cannot exist in their role (performing a task which was heretofore the sole responsible of a medical doctor) without a foundation in medicine. If a PA could not be trusted to competently examine a specimen, even the simplest of specimens, s/he would require hands-on supervision by the pathologist. This would obviously take the pathologist away from her/his even more important duty of performing Microscopic Descriptions and rendering diagnoses and would make the PA redundant.

PAs are a part of the majority of pathology departments on the continent. They need to be trained to a minimum level of competency using an accredited curriculum so that the public, the employers and they themselves can be protected against errors. They need certification and regulation and the recognition that they deserve. It would appear that the movement currently is to mirror the model in the USA when training PAs; namely post-graduate training. I am inclined to agree.

I believe that it is well past the time that the employers of Canadian PAs ought to take a look at what they have and what they are paying for it. They need to examine the impact of error of each of their employees and pay an appropriate salary for each of those individuals. The task of performing Gross Descriptions is no less important to the provision of quality healthcare now than it was when pathologists were performing them.

CIHI, and other things

I just realized that my last post was way back in June. I should apologize to the masses (ha!) who no doubt were wondering whether something ill had befallen me. No such luck! I'm still here! I guess I've been busy is all.

I have probably mentioned at some time in the past that I had submitted a rather lengthy Request for Unit Values to the Canadian institute for Health Information (which is the federal body empowered with, among a ton of other things related to healthcare in Canada, the administration of the MIS Guidelines; which as all Lab Techs know is the reference to which our bosses refer, ideally, when doing things like billing or perhaps comparison studies of workload between groups, etc.). This Request (actually multiple Requests included in the same package) was submitted by myself and my Manager at the time, Mr. Roy Neifer, in 2002. After an initial period of enthusiasm and false optimism, I soon realized just how slowly the bureaucratic wheels turn in Ottawa. After a couple of calls within the first year inquiring as to the state of progress of my Request, I was told (my words) to stop calling. There are two issues (at least) at play here. First is the fact that all of the duties which PAs perform go essentially unnoticed (as far as workload units are concerned). As a result, any institution which employs PAs and which depends upon accurate reporting of workload units is not getting an accurate picture of its staff's workload. In essence, PAs are being supported by the efforts of others; or, an alternative view...the provincial Ministry is not receiving accurate accounting of that institution's workload.

Anyway, I figured that I had been patient enough after three years. I couldn't contain myself any longer so I contacted the CIHI and they were good enough to return my call. They were very polite and, as they had 3 years previously, assured me that my Request had been lumped together with a number of other major Requests; now part of a 'reform' of workload units. I shuddered at the thought of having my Request being considered along with a number of others. I told the CIHI that I believed, insofar as this Request, unlike most others, was a totally new Request, not a revision of existing workload units. I told them that although I did not expect any special treatment, that 1. some urgency ought to be given this because it was totally new and 2. that the process which was being used to consider other Requests ought not be applied to this Request because it would be doomed to fail. I elaborated upon the evolution of PAs and that they perform duties which have heretofore been the sole responsibility of physicians. I got silence; then a promise that I would receive a call from the CIHI in the fall (this fall). I'll be patient but I'll also be realistic. I don't think that this Request can honestly be considered until PAs have the recognition that they deserve; until they achieve national certification. Which brings me to my next subject...

If memory serves (I don't know...time sure does seem to fly!), it was in the 2003 CAP summer Newsletter wherein a Position Statement was published that recognized that PAs exist; that they provide a valuable addition to healthcare; that they should have an accredited training program; should be certified nationally and regulated provincially. Dr. Cook circulated nationally a questionnaire to all pathology departments with an aim to compiling a list of all of Canada's PAs (every PA to whom I have spoken within the last 6 months or so has told me that they have their name on the CAP's list. This is indeed encouraging). The CAP AGM was held in June, 2005 and one of the ad hoc meetings concerned PAs and the strategy to achieve their certification. My offer of volunteering to sit on a committee was well received. I have yet to hear any news (and would dearly appreciate hearing something).

On a more positive note, UBC is working on drawing-up a curriculum for PAs, with the assistance of a PA! Now that IS good news, I think. I believe that several universities will have curricula drawn up long before PA certification actually takes place considering the glacial pace at which this important issue is 'progressing.'

If, as I expect, the final curriculum will be something like a 4-year BSc with, perhaps, an internship year added afterwards, it will be interesting to see what becomes of The University of Manitoba's PA program, which was expected to graduate its first 2 (Masters-level) PAs this past spring.

Things at Kelowna General Hospital are going very well. I have almost completed the first draft of a surgical pathology manual. Once a Medical Director is hired, we'll be able to proceed on approval of a final version of the manual (after consensus amongst the pathologists is achieved). The addition of an autopsy manual for Interior Health would be a welcome addition to ensure consistency throughout the Authority. I've started writing it but am a long way from completion on this one. With the prospect of QMPLS-like BC lab accreditation becoming a reality within the next 2-3 years, a Quality Manual will need to be a high priority very soon.

I was glad to receive an email from a fellow PA who was moving to BC from Ontario and was planning to look for employment in Vancouver or Victoria; he having found my address via this blog. I wish him luck (and welcome!).

Not bad; not too bad

I thought I should check in; just in case some of you were wondering whether I had dropped off the face of the earth.

I am pleased to report that I am alive and well, living in the Okanagan (I even spelled it right!). I have been working at Kelowna General Hospital for just over a month. I am now doing all of the gross descriptions of the surgical specimens and am filling my spare time with writing a policy and procedure manual for surgical pathology (autopsy to come next). Some time after the Interior acquires a permanent Medical Director and s/he gets settled, etc. I'll present the manual for her/his amendments and/or approval. The manual was originally written -- by me -- (in the 80's) using Ackerman/Rosai but has undergone many amendments and improvements since that time. This manual will of course encorporate BCCA requirements which are specific to this province.

I am very pleased to report that things seem to be running rather smoothly. At first, there were a few administrative hiccups which briefly hampered optimal operations but now that procedures have become somewhat more routine, I dare say that day-to-day operations seem to be going smoothly and the turnaround time, from the clinicians [and patients'] perspective, is at least as good as it was prior to the enactment of the contingency plan at the beginning of May.

I am slowly but surely making friends (I sincerely hope that they see it this way also) amongst the Histotechnologists and the MLTs in the other labs at least recognize me now. I think I am convincing the Techs, and hopefully the Pathologists (if not others) that Pathologists' Assistants are not the ogre that they may have been made out to be. It is regrettable I suppose that the PAs were perceived to be the 'instrument of change,' at least in the eyes of the Pathologists and Techs. I am very appreciative of the maturity, professionalism and restraint shown by everyone in giving this new wrinkle a fighting chance. PAs, with the tolerance and support of the staff of the hospitals making up the IHA have made the difference, at least from where I sit, between keeping the division of anatomical pathology open for business, and closing the service completely. The latter scenario clearly would have been enough to induce genuine panic amongst the entire community, not to mention the staff of the entire hospital. Although I still sense some resentment on the part of some of the staff, I feel that they are realizing that the PAs are there, like them, primarily for the patient.

I think that the IHA ought to thank Marty Woods and Jennifer Rice BIG time for their efforts on behalf of the population of the Okanagan. They have, with amazing calm, managed to piece together a plan which is actually working and which will see us through until the IHA acquires sufficient personnel to once again stand alone and move ahead to a bright future of superlative care, academia and research. I see great things for the IHA as in the future it becomes a centre of excellence in British Columbia; training medical Residents in other services and (I hope) laboratory medicine for UBC. The production of papers for publication in peer-review journals is what, in part, will move the IHA ahead in the future. The staff will benefit by their collaboration with Residents in the production of these papers, regardless of how basic the papers may be. The involvement of the Technical staff (resulting in acknowlegements and co-authorships) induces involvement amongst the other staff and, like a wave over the deparment, convinces other staff to behave in like fashion. The involved staff have a new, revived perspective of their profession and of their routine work.

I expect that there will be other PAs hired at the IHA within the next several months. Hopefully, an intersted Histotechologist or two will come forward and will express an interest in learning how to dissect and describe the more complex surgicals and how to perform autopsies, write clinical histories, take photographs, etc.

A medical autopsy has not been performed in the IHA for over a month; clearly, we need to re-start this much-needed service (before it takes another nail in its coffin). I personally lament how the autopsy service was considered 'expendable.' I am positive that there are enlightened clinicians in the IHA who feel otherwise (although I must admit that I am somewhat surprised that I have not heard any comments to that effect).

I hope that Pathologists, Technologists and Clinicians in the IHA (and for that matter, elsewhere in BC) do not view PAs as a threat, but rather as colleagues who can help to provide the finest level of health care that the population can possibly get.

'Interesting' Times

It's true; I've accepted a position as a PA at Kelowna General Hospital. I'm in my 2nd week. There are PAs in Vernon and Penticton as well.
Anyone who is interested in helping out, please contact me ASAP (william.stinson@interiorhealth.ca).

We're surviving without the use of the slide digitizer and without the use of the web cam. Pathologists are providing frozen section service, at least for the time-being. A temporary Medical Director is in place. Replacement Pathologists are being sought (including an offer to the out-going Docs to accept a revised contract which stipulated, among other things, the use of PAs).

Since I have arrived, I have been interested (but not surprised) to learn that Cytotechnologists have not been utilized in this region for screening to the extent that they are everywhere else. FNAs are accessioned as surgicals and the slides [used to] go directly to the Pathologist. The utilization of Cytotechs for screening will likely be a permanent change for the future, much like the use of PAs.

There are other, more far-reaching changes that will be put into place as a result of the recent failed negotiations; affecting the other clinical labs.

There was a rumour that the PAs at Interior Health were not being paid within the union grid. This is not true. They are being paid at the level III.

I am glad that slowly-but-surely, I am being accepted among the group. The emotion built up as a result of this issue is not surprising at all. I'm pleased to see that I have not been specifically targetted by the Technologists (although I'd be lying if I told you that I'm immune to the obvious feelings surrounding me each day).

Please contact me if you are an experienced PA who would like to help us out for a few weeks or more and would like to find out what the Okanagan is like; possibly on a more permanent basis.

PAs in BC

PAs are all the buzz in BC these days. Fraser Valley Health Authority and The Interior Health Authority are both 'looking.' It seems that the Pathologists are reducing or nearly-eliminating their level of service in the two regions and the hospitals are scrambling to find some experienced individuals capable of dissecting more complex surgical specimens. Histotechs are currently handling the less-complex specimens.

The Interior HA has a really novel idea (has been done in a few centres; mostly in the USA) about using telepathology to perform frozen sections. It's a natural (if it works well) for multi-site hospitals which may not have Pathologists on staff. The scenario is one where a PA (possibly accompanied by a Histotechnologist) will go to the frozen section room (in the OR usually) instead of the Pathologist, who may be many miles away. Via a secure web cam, the PA will describe and dissect the specimen under the watchful eye of the Pathologist. Either the PA or the Histotech will perform the frozen section and the slide will be reviewed remotely by the Pathologist; manipulated on the stage at her/his direction. The PA will write (and sign on behalf of the Pathologist) the microscopic description and the diagnosis. Pretty neat, eh?! For the hospitals, this presents an opportunity for a significant saving in that the PA, rather than the Pathologist, will be travelling (and waiting if necessary); will be present at the F/S and will be paid substantially less per unit time. For the majority of cases wherein there is a single slide, the healthcare system stands to save substantially. There will be no discernable reduction in turnaround time or quality control.

I haven't discussed how autopsies will be handled yet but will soon learn what their plans are.

Fraser Valley HA is in a slightly less frantic situation wherein the Pathologists are reducing their level of service. As a result, they are looking at starting from the grassroots level and plan, in full consultation with the BC health ministry, to set-up a PA training program. It is my understanding that they hope (unlike Winnipeg which has a Masters-level program) to set-up a BSc-level program, probably with a 1-year post-grad practicum. I think they hope to do this at UBC.

Needless to say, the PAs will justifiably achieve a higher standing than MLTs; I believe their intent is to pay the PAs at least two levels higher on the same (unionized) pay scale. All of this is in its infancy and subject to considerable change as time progresses. The time line, however will seem to go at the speed of light compared to anything that has happened elsewhere in the country over the last 30+ years.

I sincerely hope that the organizers in BC keep the CAP apprised of their progress, especially in regards their training program. The CMA Accreditation Office can provide important direction in the formulation of a curriculum based upon the core expectations (essentially the job description) of PAs. As a result, BC may have the first nationally-accredited PA training program.

I may have more to say on the subject of telepathology in a week's time. A demonstration is being held in Kelowna in a few days' time and I'll be there with the Director of The Interior HA. I'll be able to consider trying to 'sell' my own Director at The Ottawa Hospital on the idea of telepathology as we too are a multi-site hospital with numerous client hospitals at a distance from Ottawa.

It has been good to make contact with several PAs across the country recently. I feel a slow re-kindling of enthusiasm for the certification issue. I am very very appreciative of the CAP's efforts thus far. Please remember to ask every PA who you know whether or not they have received and replied to the letter from Dr. Cook (Pres. of the CAP).

Spreading The Word

Surprise! All hospitals and referral centres have yet to hear of Pathologists' Assistants (and their merits). It seems there are still some places where Pathologists are spending hours (and their employers paying their salaries) performing tasks which can easily be handled by PAs. Interestingly, the Pathologists are complaining about how hard they're working; are threatening job action unless additional resources are provided, and yet they have not considered delegating significant portions of their work to PAs and Technologists.

I have come to the conclusion (much like London HSC) that a fully-trained PA ought to spend most of her/his time handling the more complex surgicals and performing medical autopsies. The less-challenging surgicals (eg. GI biopsies) can easily be handled by Technologists. I also believe (again, London's way ahead on this one) that PAs ought to have a minimum of a BSc (whereas obviously, MLTs are college-trained).

I have a meeting with a representative of a British Columbia hospital pathology department in a week's time. They have never used PAs and are investigating their value. My job, based on The Ottawa Hospital's 30 year experience (and London's), will be to convince them that they should hire PAs with a BSc and to save the small surgicals, etc. for their Junior Prosector (rather than training the Junior Prosector to be a PA). Time is of the essence; the province is pushing for a major revision in the structure of healthcare and managers are mandated to cut costs.

I have to wonder how many other major centres continue to have highly-paid MDs performing the tasks which, at many centres, are delegated to PAs? Please let me know if you are aware of any by submitting a comment to this post.

I Stand Corrected

I received an interesting call yesterday from the CSMLS. I was informed that, in fact, they had not 'dropped the ball' on the PA certification issue (ie. did not fail to retain the mailing list). I was set-straight and informed that this was not what they were mandated to do. The mailing list was actually, I was told, received from the CAP.

This mailing list referred to was (and is) the mailing list for the Pathologists, not for PAs and, yes, it would be improper to retain same.

To not compile (and retain with permission) a mailing list for Canada's PAs however, while carrying-out the questionnaire (at considerable expense) was rather short-sighted. This may not have been the mandate of the CSMLS but, had PAs been involved at the outset, this would have been pointed-out as being, at the very least, rather important. It is unfortunate that the CAP are having to re-do this important step.

Also discussed during the telephone call was the fact that it is more appropriate for the CAP (and the CMA) to be carrying the certification issue forward. This was actually my thinking from the start.

The fact that the credentials and the expectations (learned in the responses to the questionnaire by the CSMLS) put upon PAs is 'all over the map' simply serves to illustrate the crying need for at least SOME regulation. Pick an issue if you will: will it be minimun educational standards? How about expectations of PAs based upon those, or other, standards? What about a nationally-recognised curriculum? Fellowship exams? Continuing medical educational standards? Equivalency criteria for foreign-trained PAs? Grand-mothering/-fathering criteria? Who is going to decide such weighty issues as these? Who knows the answer, if no one is asked in the first place? Clearly, someone lost sight of the real purpose of the process; the real 'mandate' if you will.

I find myself repeating myself (yet again; please forgive me). The Pathologists (at least those at The Ottawa Hospital) have become SO dependent upon the support provided by PAs, that if PA numbers are depleted (through sickleave, vacation, etc.) and the routine work doesn't get done at quite the usual pace, the Pathologists complain. They do this rather than recognizing that the PAs are doing THEIR (MDs') work. The PAs are not regulated, licensed or insured to perform these tasks. The volume (of surgical specimens, for instance) increases; necessitating re-prioritizing some of the traditional, routine tasks performed by PAs, and the Pathologists complain about poor turnaround times; about 'lack of support.' They will even on occasion enlist the support of various clinicians to help argue the need for PA support of their service. Some will even threaten to seek-out greener pastures if the situation doesn't change! Maybe the PAs should be flattered by all of this. Unfortunately, they don't see in all of this that their excellent work is appreciated. The PAs are doing MDs' work! What would happen if suddenly there were NO PAs? Would the Pathologists sit and wait for THEIR work to get done? Is this only obvious to ME?! I'd like to hear an opinion or two from the Pathologists.

I realise that many physicians appreciate the work of their support staff a great deal and that a special relationship is often created over the years that they work together. It is interesting to me to see, in different areas, the different ways in which this relationship 'appreciated' by the physician. Some physicians will passionately argue that their support staff deserve more; higher classification; more money; etc. Other physicians simply demand more. I wish I knew how to lobby the pathologists to argue passionately in favour of the advancement of PAs.

ALL of the jobs that PAs perform do not (since they are MDs' jobs) have workload unit values (through the MIS Guidelines maintained by the CIHI). This way, an employer cannot use units to justify hiring additional PAs. Instead, the few units that they do produce go into justifying the hiring of (usually) Histotechnologists. This isn't necessarily a bad thing but if one thinks about it for a second...if the Histology Lab is busy, who was busy first? Answer: the PAs (and their trusty support staff -- Technicians and Clerical staff).

It is HIGH time PAs were recognized. I am getting impatient. Now that I sit in the manager's seat, I see even more clearly the necessity for progress on this front. I can't believe that it has been 30 years and that virtually nothing has been done. Ontario's Anaesthetists are suggesting that Assistants would help their cause. I'd bet that if they are successful, they will set-up a curriculum, exam, certification process, clearly-defined job description and even suggest appropriate levels of remuneration BEFORE ever allowing an AA (Anaesthetist Assistant) to set foot in an OR. Why the heck wasn't this done for PAs? Do PAs perform tasks any less valuable to patient care than would AAs? I think not. Why the heck can't it be done NOW? Good for U of Manitoba for starting. Thank goodness they didn't listen to all of the nay-sayers who believed that it wouldn't be worth their time or money.

As I said to the representative of the CSMLS, going as far as they did and not continuing is like climbing 3/4 of the mountain and giving up. It is lamentable that direction was not (or so it appears) sought when it was clearly needed. I can only pray that the CAP / CMA does not get bogged down but rather forges ahead with a clear view to the reason behind furthering PA regulation: that is, the protection of the public, the patient, the institution, themselves, and yes, the Pathologists.

CAP's Address?

It would appear that the CAP neglected to include a return address on the letter mailed out to all of the pathology departments in the country. The Ottawa Hospital PAs are going to put all of theirs together and will mail their names, addresses, signatures, etc. to the CAP office (774 Echo Drive, Ottawa, ON.).

Workload

Alright! I've had it!

On behalf of myself and the dedicated PAs with whom I work, I submitted an application for workload units to the Canadian Institute of Health Information (CIHI) in 2003 and I have yet to hear from them (despite diplomatic reminders, by yours truly, and inquiries since that time). I see my colleagues suffering under the weight of many, many complex, important surgical specimens while having to deal with insufficient space, insufficient technical assistance, insufficient staff, insufficient time and insufficient patience to get the work done in good time.

I see The City of Ottawa free-up the substantial money to hire 28 new Paramedics. Good idea; let's get more patients into the institution so that their presence can have a ripple effect upon every other department within the hospital. But don't bother to ask us! I see tons of Registered Nurses being romanced into seeking employment at The Ottawa Hospital. At the same time, I see the Anaesthetists taking a job action on Feb 11th as a result of the increased OR volume being inflicted upon them by the provincial government -- primarily as a result of not being consulted. Right on! Good for you! I don't see anyone asking if there should be more Lab Technologists or PAs to handle the additional volume of surgical specimens. What the heck is the point of doing the surgery if there's no diagnosis (FYI - for the uninitiated - the 'diagnosis' comes from Pathology ... nowhere else)? If all the government is doing is rushing a bunch of sick patients in one door; having the surgery performed; then shoving them [prematurely] out the other door, they're not helping health care one bit. They are, in fact, hindering good health care by 1. overwhelming the PAs, the Lab Med Technical staff and the Pathologists and 2. shortening post-op length of stay and thus risking a certain percentage of post-op deaths (which they are evidently willing to accept on your behalf -- nice of them eh?). To what end? I'll tell you why: to dupe the voting public into thinking that shorter waiting lists for surgery = better health care. Neither the politians nor the public know. Healthcare workers know. Too bad they don't ask.

I submit that if the CIHI would get off there duffs and process the application for workload units for PAs, the amazing volume of work that PAs perform could be easily tracked such that additional resources, including staff, could be easily justified in the next budget. As it is, the PAs are forced to console themselves in the knowledge that they are doing the best they can, for their patients, in spite of what seems to be the entire system ignoring them, if not taking advantage of them. I don't blame them at all for being 'irritable' from time to time. I'm talking about people who, more than anyone I know, have their hearts in the right place. Collectively, they have the highest work ethic of any group I know.

PAs, unlike Nurses of the 21st century, have the very lucky advantage, when it comes to patient care, of being separated from what is becoming a truly ugly situation. If you have had the misfortune to partake of the services of an ER, or heaven forbid, an in-patient ward, recently you know all too well that Canadian healthcare has taken on a completely different colour than when we were kids. I would not want to be a Nurse working in an ER. Pain aside, unless you are dying, you get 'stabilized' and then flushed out the door (and sometimes even if your ARE dying). This must be a real eye-opener for Nurses who started out with a more traditional idea of what nursing was all about. I'm glad I don't have to succumb in such a way to the immediate constraints of funding; I'd rather just supply the very best care that I can. I'm glad I'm a PA.

I see a number of PAs are less than glad however; and I don't blame them at all. We're having to really scramble to continue to provide even a reduced level of care to that which we have been accustomed. The ever-present, and growing, mountain of specimens is truly daunting. I don't blame the PAs for looking like they're caught in the headlights. I don't blame them for looking for a temporary change of venue. It's difficult to maintain your dedication to the patient under circumstances like these.

Rest assured however that your profession is a truly honorable one. You are set apart by what you do; by what you know; by how you do it. This is not BS. You are perceived by your fellow Technologists with respect, awe and envy. You deserve more and WILL receive it; it is just a matter of time. Be patient (this too sets you apart). It will come. In the meantime, I know you will continue to do the best you can for your patients; because that's part of what sets you apart from the rest.

Hang in there. You're the best.

CAP's PA mailing list

It has been a couple of weeks since the CAP sent out it's first correspondance asking that Canada's PAs respond with their mailing address (and written permission). Please take a moment to think of a PA who you know who may not have received this letter. Include even those who work at large centres. There are a number of reasons why the letter, addressed to "The Director" may not find its way to the PAs. If these people are examining surgical pathology specimens, rendering Gross Descriptions and/or performing autopsies (at a level above Morgue Attendant or deiner), they are performing duties which are those generally considered within the job description of Pathologists' Assistant.

Give her/him a call to enquire. If they got one, that's great, if they didn't, please make sure that they do. This is a very important first step. The CAP must have everyone's permission to proceed to the next step.

More on the issue of what constitutes a PA: let there be no misconception; a Morgue Attendant is NOT a PA. For the Morgue Attendants out there, please understand that I am in no way denigrating you, your occupation or the much-valued assistance that you provide. Generally speaking, the prerequisite for employment as a Morgue Attendant include a Grade 12 (in Ontario) high school diploma. Currently, the minimum prerequisite for employment as a PA is a Medical Laboratory Technologist diploma and registration with the appropriate provincial college. It is very important that at this juncture PAs force themselves to take the hard line and, at the risk of alienating the MAs with whom they work day in and day out, clearly define to themselves and to their colleagues, Pathologists included, the criteria which define "Pathologists' Assistant."

Another problem which will need to be addressed is that concerning PAs who are not involved in all aspects of Pathology. Consider PAs working at a forensic science centre, assisting at autopsy; performing the dissection on behalf of the Forensic Pathologist. They never see or handle surgical pathology specimens yet they are, as much as the Forensic Pathologists are Pathologists, PAs. To clarify, these are not Morgue Attendants. They are performing the dissection of the organs, examining tissues, interpreting their findings and communicationg these to the Pathologist. On the other hand, there are PAs who never do autopsies, but who handle surgical pathology specimens. Same story; just like the Pathologists who they assist, they too are PAs.

Some Pertinent Philosophy

I keep having to remind myself that there may be some poor souls reading this who haven't a clue what a PA is; what they do; and what they mean in the 'grand scheme' of the monstrous machine that is our healthcare system. So here goes with some more ramblings, some of which may help the uninitiated to understand where PAs fit in.

I was talking to a fellow PA today concerning a seemingly small but oh so important fact about PAs. Once you're a PA and you get some training, your new-found knowledge allows you to do things which only MDs are allowed, or are mandated, or are paid, or are licensed, or are insured, to do; namely, identify (this is going to sound stupid to those not acquainted with the field) normal tissues. Please allow me to explain; I'll try to not insult the PAs out there and I'll try to not be overly simplistic. If you think of it for a second, how is one to know what normal looks like if you don't know what abnormal is? I've seen this tons of times through the years with wet-behind-the-ears Pathology Residents who unknowingly embarass themselves when, at rounds, they proudly point out a particular 'lesion' in an organ which is, in fact, completely normal. Conversely, something which is grossly abnormal can be glossed over as being unremarkable if that's the only thing that this newby has ever seen. I'm probably not getting this across with as much accuracy as I'd like but suffice it to say that the simple act of confidently identifying even normal, let alone lesional, tissue is a feat reserved for an elite group of individuals and although PAs take this ability for granted, it is something that only they, and medical doctors can, with confidence, do. You'll not be very surprised that my next thought is that PAs don't get paid anywhere near what they're worth. You'll likely say, yah sure, everyone says that and I admit that I am biased (how'd you guess?) but I assure you that it definitely applies in this case. Don't take my assurance though, take the word of various surgeons and oncologists who know that their patients are best served when their specimens are handled by PAs and no one else (I think I'm beginning to repeat myself! Sorry).

I was spouting to a colleague earlier today (a different individual than the fellow PA mentioned above) that PAs, somewhat like Cytotechs should have a feature built-in to their registration or license (when that occurs) which prescribes a limit to the number of complex surgical specimens which can be examined in a day (In Ontario, Cytotechnologists have a 60 slide/day limit). If one realizes that the profession of PA is akin to an art rather than a pigeon-holed assembly line type of occupation doing the same thing hour after hour and day after day, the idea of placing a limit on the number of examined specimens, in order to ensure that the last one is examined with the same level of expertise, application of knowledge and use of judgement as the first, is indeed a very good idea in my opinion -- for the patient's sake. I was also saying to this colleague that PAs will do well to continue to diversify their interests in the service of the Pathologists, if not insist upon it. That is to say that they should include things like brain-cutting, sectioning and reporting (incl. opportunities for learning with the Neuropathologist) as well as heart sectioning and reporting (incl. similar teaching opportunities with the Cardiovascular Pathologist). Just like Pathologists who have a portion of their work week allocated for CME activities or other academic pursuits, so should PAs. It is in the interests of not just the patients or the institutions to have well-trained PAs. It is in the interests of the Pathologists to have interested, well-informed, well-rounded, alert PAs acting on their behalf. It is the Pathologist's signature that goes at the bottom of the report but they had better be confident that the PAs who are working for (or with, if you prefer) them are doing the job at least as well as they could do themselves. That level of trust MUST be present in the relationship between PA and Pathologist. If not, the PA need not exist. I'd hate to be a Pathologist who couldn't trust the PA. I would like to think (and I'm not kidding myself) that there isn't one of the twenty-seven Pathologists at The Ottawa Hospital who wouldn't honestly admit that the 9 PAs are doing at least as good a job as they could do themselves. I know that they would say, if asked, that the PAs are the greatest. Regrettably, words don't buy that Mercedes I've had my eye on!

Welcome!

Many of you know by now that the CAP is circulating a letter asking that you identify yourselves and give permission for them to forward a questionnaire to you and that they proceed with the process of certifying PAs. I encourage you to respond forthwith.

Further, I'd suggest that you forward this information to any PAs who may not have received the CAP's communique. This is very important. They may not be called "Pathologists' Assistants" but if they're describing surgical specimens and/or performing autopsies (the dissection of the organs) then they are PAs in the view of the CAP. Part of the process is going to be rationalizing the definition of the profession. It will be far better for as many individuals as possible to be involved at the outset rather than after the fact.

Please use this site as a common site for your comments and responses. It is high time that the PAs of this country begin this necessary process. It is time for you to get involved.

Think of it...a few AGMs from now, we could be meeting in Florida, in February!

A Little Background

For those of you who are reading this who may not be familiar with Pathologists' Assistants and what they do, I thought that a little background, history really, might be appreciated.
In the late '60s, as a result of decreased medical school class sizes, the number of medical residents in all specialties, Pathology included, decreased dramatically. This was a continental phenomenon. At the same time, partially due to deficit financing, tertiary care hospitals were growing in leaps and bounds. The number of surgeries was climbing and the number of in-patient beds grew considerably. With the increase in surgeries, the number of specimens to be examined in Surgical Pathology also increased. The examination of these was, in teaching hospitals, traditionally a task assigned to pathology residents.

Very soon after the creation and recognition of the profession of Physician Assistant (Duke University, 1965), the profession of Pathologists' Assistant was also created (also at Duke U.). Post-baccalauriate curricula (2-yr) for the training of PAs was at 5 American universities at that time and successful graduates wrote a fellowship exam and became Registered PAs. However, national certification did not exist and the American Association of Pathologists' Assistants (AAPA) has been working diligently for the last several years to gain national certification for PAs in the USA. There are a large number of on-the-job trained (OJT) PAs, possibly more numerous than graduates of the accredited university programs.

The tasks which PAs perform are those which have always been the responsibility of physicians. In Canada the provincial ministries of health continue to mandate pathologists or pathology residents to perform the tasks which at most larger hospitals are performed by PAs. It is important that PAs gain recognition and, with that recognition, regulation for the sake of public safety (indeed for the protection of the PAs themselves, the Pathologists, the departments of Laboratory Medicine and the hospitals). Educational standards and minimum pre-requisites must be set. Provincial regulatory colleges, although recognising the existance of PAs, have not yet been mandated to regulate the profession. PAs, who are largely drawn from Medical Laboratory Technologist stock, realize that they are functioning far beyond the scope that their credentials would ordinarily allow.

To place the profession of Pathologists' Assistant in the rather bewildering heirarchy of para-medical personnel, one might do well to think of professions like Nurse Practitioners, Physician Assistant, Midwife and others who are performing the tasks which have heretofore been solely the responsibility of medical doctors.

I have been fortunate to enter the profession while it was still in its infancy. I have watched -- and have been instrumental in developing -- its maturation. It has been an evolution of sorts wherein over the years, more and more responsibilities were gradually taken on by myself and the slowly-growing number of other PAs at The Ottawa Hospital. As the PAs earned the trust of the Pathologists, the level of responsibility grew and grew. Now thirty years into their evolution, PAs are undeniably an integral, necessary part of the division of Pathology. But there's more; it has been recognised that PAs actually provide a superior level of quality of 'product' than the medical doctors themselves. Oncologists and surgeons realize that their patients are better served if the specimens are examined by PAs.

In many provinces, the degree to which Laboratory Technologists work is monitored by workload units. There is a precise listing of all functions, each given a unit value which is primarily based on time. Despite the 30-existence of PAs, their workload is still not recognised. It is the duty of the Canadian Institute for Health Information (CIHI) to maintain, administer and upgrade the unit structure (called the MIS Guidelines). In 2003, I submitted a lengthy application to the CIHI to have the tasks which are performed by PAs credited. It has been 1 1/2 years and PAs are still waiting. Their recognition which their profession deserves will be advanced significantly if/when the CIHI eventually approves the application. I am truly hopeful that this will happen some time before I retire.

Ontario Lab Accreditation

Somewhat miraculously, we survived the week-long QMPLS Ont. Lab. Accreditation visit last week. Of the 550 odd requirements, we ended-up with 6 major non-compliances and 63 minor non-compliances at the Civic Campus, slightly fewer at the General Campus and even fewer at the Riverside Campus. As many of you in Ontario already know, we now have 90 days to eliminated the majors and to show, at the least, a plan to eliminate the minors, in order to attain a 5-year accreditation before we have to endure another dose of regulatory bureucratic BS.
I guess the accreditors can't help themselves but to eventually become somewhat obsessive; it's the nature of the beast. We shouldn't fault them I suppose. Funny though, of the 27 Pathologists at The Ottawa Hospital, I don't know of one who would ever voluntarily choose to become an OLA Assessor. They, like me, are there to provide the best quality patient care that they can to each and every patient whose specimen is sent to our division. Different strokes for different folks I guess. It's difficult to not 'shoot the messanger' though.
I have no doubt that we will satisfy OLA and will attain a 5-year accreditation, but wow, what a process! I'm sure I have a lot more grey hair now than a few months ago.
I wish anyone who is preparing for an upcoming OLA assessment the best of luck. Don't fool yourself into thinking that you'll be perfect. It's not possible. Just do your best and deal with the hopefully few non-comformances afterwards.
More on OLA later.

Certification Update

I am very pleased to announce that, thanks in no small part to the efforts of Dr. J. Thomas, who sits on the executive of the Can. Assoc. of Pathologists, the President, Dr. Cook (Memorial U., Newfoundland & Labrador) has begun the survey of the nation's PAs. He has circulated a letter to all Directors of Departments of Pathology & Laboratory Medicine asking to identify all those who may be functioning as Pathologists' Assistants. Regrettably, this is re-doing the efforts of the CSMLS who, through an independent consultant, already circulated a questionnaire to all Canadian PAs. They dropped the ball on the issue of national certification of PAs however and failed to keep the mailing list.
Once all individuals are identified, a questionnaire will be circulated to Canada's PAs.
The CAP recognises the importance of training and regulation of PAs and it is to this end that they have embarked on this process. The CMA Accreditation office has expressed an interest in PAs and is eager to provide assistance when that stage is reached.
The first step of listing PAs has begun and that's an important step in the right direction.