Physician Assistants are in-demand professionals in Canada. In rural and remote communities in particular, they play an integral role in doctor’s offices, clinics, and hospitals. Yet, the two-year university education required to become a PA was, until recently, only available in major cities and few newly qualified practitioners wanted to return to their hometowns to practice after graduation.
Dr. Maureen Gottesman is the force behind the University of Toronto’s paradigm-shifting Physician Assistant program, an innovative second-entry professional degree that leverages the university’s strengths in digital communication technologies to educate the next generation of practitioners remotely.
“A Physician Assistant is a relatively new health care provider in Ontario and Canada; in the civilian world it’s considered a mid-level health care provider, somebody that works as an apprentice to a physician,” says Dr. Gottesman.
PAs can specialize in particular fields and often cultivate long-lasting relationships with doctors, essentially practicing medicine under supervision. She explains that the role has its roots in the military. “Medics, people who worked in the front lines in providing medical care, finished whatever war was going on and then people said, ‘We need to find something for them to do.’” Military medics trained in the medical model to make quick diagnoses and perform procedures in the field had no equivalent profession to enter after their service. The idea of creating the Physician Assistant designation originated in the United States after the Vietnam War, where one “very small program trained three medics basically to become PAs, more formally, and [the profession has since] grown to about three hundred thousand PAs in the US,” Dr. Gottesman explains.
With about 200 training programs available worldwide, and only a handful in Canada, there is a growing need to train professionals who can support doctors in complex, specialized tasks and sometimes perform minor procedures. Dr. Gottesman founded the University of Toronto program in 2010 and currently serves as its Medical Director. Her role involves overseeing the academic administration of the program and the ongoing curriculum development, but she and her colleagues had to begin from scratch, “designing the program, implementing the program, getting the program through approval of the government, the U of T, all that.” She says, “there’s something like 500 PAs in all of Canada, right now, and we take in about 30 students a year, so it was smaller at the beginning and now it has grown.”
The University of Toronto collaborates on the PA program with the Northern Ontario School of Medicine and the Michener Institute. The Ontario Ministry of Health’s social accountability mandate to provide PAs to serve all regions of the province, especially underserved northern communities was the inspiration for the unique decision to offer the degree primarily by distance education. “We’ve got this great opportunity with Northern Ontario to help train students in northern Ontario, like the medical school does,” says Dr. Gottesman. “So we thought, why don’t we actually develop a curriculum model that’s going to facilitate students to stay in their home communities and potentially advocate for their own jobs?”
Unlike the McMaster PA program, which requires students to be on campus, U of T students can remain in their home communities and learn through the Blackboard learning management system used by many U of T degree programs. The flexibility is ideal for mature students who must schedule their studies around jobs and family obligations. “The point was to train [the students] as much as we can at home, and most of what we learn can be done online. And we bring them to Toronto for specific blocks of time to do the hands-on stuff – because you wouldn’t want your health care provider to learn how to take your blood pressure on a computer,” says Dr. Gottesman, laughing. “So the model really was developed to go with technology, to really allow people to service their community.”
“They can service the community because they know the community,” she adds.
When asked what it was like to get the program up and running, Dr. Gottesman explains that she met with Avi Hyman, Director of Academic & Collaborative Technologies and with the Discovery Commons team, an educational technology group that supports the U of T Faculty of Medicine. They suggested that they use Blackboard, and the administrators and instructors “learned from the ground up about the learning management system,” she says. This allowed each instructor to tailor their unique selection of materials and resources to the platform’s different capabilities, which include video lectures and conferencing, spaces to share notes, diagrams, and links to web resources, internal apps, and direct links to digital library materials. “The result of this product is 17 courses that are actually delivered quite diversely. The intention was not to keep every course exactly the same in terms of how it was presented,” says Dr. Gottesman. There is no typical online class.
“We did this in part because we recognized that students are going to learn differently, and the nature of the material lends itself better in some ways to certain kinds of technology than others,” she explains. “We’re teaching both the clinical content but also the softer skills like communication and clinical critical thinking and those kinds of things, but then, also, we have to teach how to give a needle,” she says. The students travel to Toronto a total of six times throughout the program to practice skills that require face-to-face teaching.
“We have this love-hate relationship with Blackboard,” she confides. It took instructors and students some time to acclimate to the web environment, and they experienced some glitches with delivering online tests in the early years. “Sometimes we just use paper ‘cause it’s a pain,” she says, laughing, “and makes everyone calm down a bit. But there are times when literally we have students writing an exam online at the same time and they’re in seven different places across Ontario.”
“We had some criticism at the beginning about whether medicine can really be taught online,” she says, “but I think we’ve been very thoughtful in the way we’ve done it and I think we’ve come up with a hybrid model that works very effectively.” And the data is conclusive. Dr. Gottesman is proud that U of T students recently had a 100% pass rate on the knowledge-based licensing exam, a testament to the effectiveness of online learning. She suggests that students doing very well on the national exam must mean they are learning well. Plus, as she also points out, “they all have jobs; if they don’t have jobs it’s because they went to medical school instead.”
Dr. Gottesman also claims that training in the online environment helps prepare new PAs for the reality of contemporary digital health care systems in Ontario and the increasing use of online resources during medical consultations. “The anecdote in medical education is that patients coming in have already checked with doctor Google,” she jokes. But the truth is, “the way we actually communicate face-to-face in the clinical setting has changed.” New graduates are well prepared to communicate with patients in person and to provide them with additional apps, online tools and information right from the examination room.
Dr. Gottesman says her favourite part of her role as Medical Director is seeing the students through to graduation, employment and in some cases having them return to teach in the same program. She adds, “I’m a mom, so it’s kind of like seeing them grow up.”