Challenges with Medical Directives for Physician Assistants in Ontario


  • Ken Crosby Consortium of Physician Assistant Education (University of Toronto)
  • Natalie Dies McMaster University



Physician Assistants (PAs) in Ontario are unregulated health professionals with no legislation directly authorizing them to perform controlled acts.  PAs have the legal authority to perform their healthcare role primarily through a process of delegation known as medical directives (MedD).  This process of delegation and requirement for MedD was set in a policy written by the College of Physicians and Surgeons of Ontario (CPSO) before the introduction of PAs into Ontario.  Through examination of MedD currently in use, several challenges have been identified when this policy is applied to create MedD for PAs.  The primary issue is the large number of permissible orders a PA requires to fulfill their job requirements.  Each order within the MedD requires a corresponding comprehensive list of indications and contraindications.  The resulting document is exceptionally long and time consuming to create such that every organization employing a PA cannot reasonably devote the resources necessary to create such a document.  A second issue identified is that the CPSO policy was written to reflect situations where the clinical context is fixed.  In actuality, PAs work in a variety of clinical contexts and often with evolving clinical context.  Additional problems identified include ambiguity in the criteria outlined for MedD in the CPSO policy, and an inherent delay when clinical practice guidelines are updated before they can be reflected in the MedD.  To cope with some of these challenges, several approaches have been observed.  Ultimately it seems that PAs in Ontario function in a role with less autonomy and a smaller scope of practice when compared to PAs in Manitoba, New Brunswick, or the Canadian Armed Forces.  It is reasonable to conclude that differences in legislation and the massive administrative burden to create thorough MedD would lead to a diminished scope of practice and less autonomy.  We recommend either updating legislation to specifically address controlled acts performed by PAs in Ontario or updating the CPSO policy to reflect the level of training and role(s) of PAs.  As an interim improvement, a group of PAs in Ontario will work towards developing standardized MedD to alleviate some of the administrative burden on employers.  With these proposed changes, the aim is to reduce barriers such that PAs may function in their intended healthcare role and thereby increase the medical services provided to Ontarians.

Author Biographies

Ken Crosby, Consortium of Physician Assistant Education (University of Toronto)

B.Sc., B.Sc.PA, CCPA 

North Bay Regional Health Centre, Critical Care Unit

Natalie Dies, McMaster University


University of Alberta Hospital, Division of Otolaryngology Head and Neck Surgery


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How to Cite

Crosby, K., & Dies, N. (2018). Challenges with Medical Directives for Physician Assistants in Ontario. The Journal of Canada’s Physician Assistants, 1(1).



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