Canada: HPRAC Recommends Against Regulating Physician Assistants

Last Updated: January 23 2013
Article by Cathi Mietkiewicz

The Ontario Health Professions Regulatory Advisory Council ("HPRAC") delivered its report entitled, The Health Profession Assistant: Consideration of the Physician Assistant Application for Regulation (the "Physician Assistant Report") to the Minister of Health and Long-Term Care (the "Minister") on August 31, 2012. It was made available to the public in December. The Physician Assistant Report was created in response to a referral by the Minister  on June 24, 2011 requesting HPRAC's advice on whether Physician Assistants ("PAs") should be regulated in Ontario under the Regulated Health Professions Act, 1991 (the "RHPA"), and, "if so, what would be the appropriate scope of practice, controlled acts and titles authorized to the profession."1  The Minister also asked HPRAC to consider what form of regulation, if any, would be the most effective in strengthening interprofessional collaboration between PAs and other health professions

HPRAC's Recommendations

The Physician Assistant Report recommends:

  • Physician assistants not be regulated under the Regulated Health Professions Act, 1991 at this time;
  • A compulsory registry be implemented under the governance and oversight of the College of Physicians and Surgeons of Ontario (the "CPSO"); and
  • Interprofessional collaboration between PAs and other health professionals be enhanced as a by-product of the registry, through encouraging the growth of the profession in Ontario and by instilling confidence among regulators and the practice community about PAs' qualifications.2

Background on Physician Assistants

PAs are an interesting addition to our health care system.  PAs are unregulated health care providers who provide a variety of health care services in a number of different health care settings. PAs work exclusively under the supervision of a physician. Depending on the nature of the physician's practice, PAs may take medical histories, conduct physical exams, diagnose and treat illnesses, assist during surgery, set or cast a fracture of a bone and provide vaccinations.

PA education is comprised of a 24 month university program offered by two of Ontario's medical schools - McMaster University and the University of Toronto. Students must have at least two years undergraduate education in order to be eligible to enter a program. 

Since 2006 HealthForceOntario has been promoting PAs as part of the solution for the doctor shortage.  The CPSO and the Ontario Medical Association have been supportive of this initiative.   

Among the recommendations in the CPSO's 2004 paper, Tackling the Doctor Shortage, was the following:

In the long-term, the College [CPSO] should consider creating a registration category for physician assistants.

If the pilot program is successful and a consensus can be achieved with respect to a defined scope of practice, training programs and stable funding, the College [CPSO] should consider creating a category of registration for physician assistants.3

The Physician Assistant Report

In the Physician Assistant Report, HPRAC explained that its primary criteria when deciding whether to recommend that a particular profession should be regulated is whether:

...the health profession seeking regulation poses a risk of harm to the health and safety of the public.  The criterion acts as a gating mechanism:  The applicant must present a solid, evidence-based argument, based on a preponderance of evidence, that there is a risk of harm to the public before its application moves to the next level.4

HPRAC found that the evidence submitted did not meet its risk of harm threshold.  As such, HPRAC did not move on to address the Minister's additional questions related to how the profession should be regulated and what would be the appropriate scope of practice for PAs. 

HPRAC grounded its recommendations in the views that (i) the performance of PAs is supervised by physicians; (ii) there are very few PAs practicing in Ontario and therefore very few patients that would be exposed to care from PAs; and (iii) the profession is new so it is under a greater degree of scrutiny.5 

HPRAC acknowledged that PAs have access to most of the health care activities that are legislated as controlled acts in Ontario and may perform high risk procedures.  HPRAC found that the risks to patients were adequately mitigated because supervising physicians are responsible for PAs' performance of these procedures.

Although HPRAC found that PAs should not be regulated, it did recommend the creation of a registry for PAs.

HPRAC provided the following reasoning for a mandatory simple registry:

HPRAC weighed the risk of harm of considerations, the newness and current size of the profession, and PAs' close relationship with a supervising physician against the complexity involved in the different registry models.  HPRAC also considered the benefits of mandating participation in a registry that provides more "muscle" than regular registries.  HPRAC believes that model one (simple) is more appropriate for the PA profession in Ontario at this time.  More complex features could be added as the profession matures.6

During the consultation program, CPSO supported a compulsory registry and offered its stewardship in maintaining the registry.  In considering this idea, HPRAC looked at the physician-PA supervisor relationship, which is central to the PA profession as well as CPSO's experience and resources as a regulator of health professionals and its ability to provide support to the PA profession as it integrates into Ontario's health care system.  HPRAC also took into account the greater degree of confidence afforded Ontarians under this model, because PA registry requirements would be aligned with CPSO policies that regulate its member's practice with employing PAs.7

Going Forward

Unlike with some previous referrals, the Ministry of Health and Long-Term Care (the "Ministry") has not requested input from stakeholders on the report. The first recommendation (not to regulate PAs) does not require any action on the part of the Ministry. Whether the Ministry will adopt the second recommendation and put forth the necessary regulatory amendments in order to establish a PA registry or whether the Ministry will maintain the status quo remains to be seen.

In 2006, HPRAC recommended that pharmacy technicians be regulated under the RHPA even though pharmacy assistants only performed activities under the direction and supervision of a pharmacist. Pharmacy technicians are now regulated by the Ontario College of Pharmacists. In the Physician Assistant Report, HPRAC has recommended that PAs not be regulated, but rather a registry managed by the CPSO will provide the necessary public protection. It will be interesting to see what recommendations HPRAC makes in its report on dental assistants which is due in April 2013 since, like PAs and pharmacy technicians, all of the professional activities performed by dental assistants are performed under the supervision of a dentist.


1. June 24, 2011 Letter from the Minister to HPRAC (the "Minister's Referral Letter").

2. The Physician Assistant Report at page 2.

3. College of Physicians and Surgeons of Ontario, Tackling the Doctor Shortage: A discussion paper, May 2004.

4. The Physician Assistant Report at page 7.

5. HPRAC did not explain why being a new profession means that it is under more scrutiny than any other profession.

6. Physician Assistant Report at page 30.

7. Physician Assistant Report at page 31.

The content of this article is intended to provide a general guide to the subject matter. Specialist advice should be sought about your specific circumstances.

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