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.
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.
