Recruitment and retention

Difficulty attracting PAs to rural areas Initial exposure to PA was not positive (personality, communication issues) Lack of continuous supply or not enough PAs available for hire in the province Maternity leave or medical leave (no one to replace PA)

Lack of regulation Concern about delegated acts, CPSO standards Concern about being audited Lack of clear information about delegated acts and medical directives

Training and supervision Amount of supervision needed until comfortable with PA skill level or experience Need for compensation for supervising or training Inconsistencies among PAs in education and experience

Funding Lack of long-term plan from MOHLTC Frustration with application system for MOHLTC grant funding Initial loss of income waiting for PA to become efficient or attend additional training; funding is therefore instrumental to integration Needing to sign up or roster additional patients to cover PA expenses Affordability under MOHLTC guidelines or meeting salary standards Physicians “too greedy” to pay for PAs out of their own pockets

Integration Resistance from other health care providers Lack of hospital privileges restricting use of PA Concerns about orientation, integration, and phasing in role of PA

Lack of knowledge about PA role Lack of interest owing to lack of knowledge or understanding of PA role Fear of being upstaged by the PA Concern about liability and insurance Inconsistencies about appropriate level of autonomy

CPSO—College of Physicians and Surgeons of Ontario, MOHLTC—Ontario Ministry of Health and Long-Term Care, PA—physician assistant.