Chair's Column: The Six W’s of the Clinical Associate Role

In this month’s Chair’s Column, I want to talk about Clinical Associates. At the PGY2 retreat at Niagara on the Lake this fall, I was surprised at the number of questions asked by our trainees about the CA role. It was clear that there was a lack of clarity about this role, and many of our trainees take on CA positions after completion of their clinical training.

Clinical Associates are appointed to a hospital to provide clinical service. There are two official CA positions: CA - Covering, used when a physician is brought on to fill a temporary clinical or academic need, such as locum coverage for a faculty member on parental leave, and CA - Term, which enables physicians to provide service to meet clinical and/or academic needs. CAs may be appointed for up to 12 months with potential for renewal based on performance. They cannot hold a full-time University appointment, but they may hold an adjunct or part-time clinical faculty appointment depending on the academic commitment

So, with the help of Nathan Stall, a Clinician Scientist Training Program trainee currently working as a CA while he completes his PhD in clinical epidemiology, we surveyed current CAs to help answer these questions. Here’s what we learned:

WHO?

A survey was sent to a list of CAs generated by the fully-affiliated teaching hospitals. We heard from 51 CAs; five from family medicine/general practice and 46 in internal medicine or its subspecialties (Figure 1). Unfortunately, we have no idea how many CAs are currently in the system and cannot speak to the representativeness of our sample.

Almost half of the respondents (47%) were enrolled in a graduate training program, like Nathan. Folks enrolled full-time in a graduate training can’t also hold a faculty appointment.

Respondents had worked as CAs for a median 16 months, but with wide variability (Figure 2). As is evident below, some had worked as CAs for years. A few even described their CA role as a “career,” a freelance doctor, if you will. 

WHAT?

CA respondents were working across all clinical environments, as shown below. About half worked less than once a week. Most (about 70%) had signed a formal contract as a CA and had been integrated into the local hospital division (e.g. they were included in local divisional meetings). More than half (57%) had their OHIP billing done by the hospital where they were working, 25% did their own billing, and 18% used an independent billing service. Two-thirds (63%) were paying overhead to cover their expenses at the clinical site. We did not ask how much or what percentage, but it’s important to understand there is variability from site to site and based on the type of clinical work being performed.

WHEN?

Scheduling of clinical work was also highly variable. About 40% indicated that their clinical time was scheduled similar to the full-timers. In other words, they had a regularly scheduled clinic or filled in-patient or emergency shifts on a first-come-first-served basis. About 30% indicated that they picked up whatever was available after full-time physicians had been scheduled. The remainder indicated something between these two options. For example, some were able to schedule clinical work around their coursework. Most indicated they could work as much as they wished.

WHERE?

Respondents were working as CAs in one or more of 10 affiliated teaching hospitals; of the 49, 39 (85%) were working at a UHN site.

WHY?

This might be the most important question to gain insight into the CA position: when asked why they had decided to work as a CA, 83% said it was to earn some money, keep up their clinical skills, and/or garner teaching evaluations while completing advanced training with the hope of a future academic career. Some of the other reasons given include:

• As a stepping stone to a future academic position;
• To keep teaching in a team setting while working in the community;
• Because it offered flexible scheduling; and,
• To give themselves time to figure out what they want to do longer term. 

WHAT ELSE?

When asked if they had any advice for residents or fellows thinking about taking on a CA role, our respondents had quite a lot to say. They noted that the CA role may be helpful in one’s career development as it is an excellent opportunity to:

• Make important contacts;
• Clarify medical interests;
• Remain active in your division post-residency (e.g., teaching, journal clubs, rounds);
• Gain/maintain clinical skills while pursuing other scholarly activities;
• “Try out" a work location before committing to starting a full practice;
• Earn extra money (final year of residency);
• Have freedom; and,
• Do interesting things - the work is gratifying.

They had the following words of advice for prospective CAs: 

• Consider it (CA role) for a time-limited period;
• Think about your long-term plans and whether it fits with that plan;
• If you have a particular site or two in mind of where you want to work, speak to people at those sites about trying to get locum work there;
• Don't do it at more than 1 or 2 sites (2 is absolute max);
• Ask how many weeks you can expect and what overhead they take. Ask if it's negotiable; and, for those using the CA role as a stepping stone to academic appointment…
• Make sure you have a good understanding and appreciation of the division's expectations and potential future for you.

They also had some cautionary tales and advice:

• Have an honest and open conversation with your division about your availability while completing graduate school training and the needs of the division. Establish expectations before starting and have frequent discussions with the division/department head about your plans;
• Know what you want to get out of the CA role. If you don’t, you can get caught in its clutches as you are very vulnerable;
• Focus on inpatient opportunities if these are available (out-patient opportunities lack overhead support);
• Consider overhead costs and administrative support;
  • Overhead is steep at most places for what it actually gets you (i.e. you might pay 25% and get no office, pay extra for an admin and billing agent).
  • Know what you are agreeing to;
• Make sure you can dictate under your own name;
• Office space (lack thereof) can hamper productivity;
• Be careful not to sign up for too many shifts. It’s easy to overbook and get exhausted; and,
• Don't expect regular work.

A number of our trainees take on CA positions while preparing for their future roles in medicine. A particularly important sub-group of these individuals are those undertaking advanced training with the hope of an academic position down the road. From survey responses, the CA role allows for flexibility in scheduling, which may be very useful while growing a family or completing graduate studies. However, ensuring clarity with respect to expectations on both sides is important and should be captured, ideally in a written contract. We did not ask respondents about their involvement in teaching or formal evaluation of trainees, nor if they had been registered in POWER or MEDSIS and thus able to receive teaching evaluations. A greater understanding of the role of CAs in our teaching and education mission would be important.

Next Steps

In order to better understand the CA position as it relates to the Department of Medicine, we will establish a working group to address and make recommendations on the CA position as a stepping stone for academic appointment. Thanks in advance to the CA respondents who agreed to participate!