Ensuring Competence: Changing Scope of Practice and/or Re-entering Practice


Policy Category: Registration
Under Review: No
Approved by Council: February 2018
Reviewed and Updated: June 2000, April 2008, December 2015
College Contact: Registration Inquiries

Downloadable Version(s): Ensuring Competence: Changing Scope of Practice and/or Re-entering Practice | Ensuring Competence FAQ


Executive Summary

This policy sets out the College’s expectations related to reporting and demonstrating competence prior to changing scope of practice and/or re-entering practice. It also outlines the College review process for ensuring competence when physicians change their scope of practice and/or re-enter practice. Key topics and expectations include:

  • Reporting: Physicians must report an intention to change their scope of practice and/or to re-enter practice after an absence of two years or more. The policy sets out the definitions of scope of practice and change in scope of practice.
  • Participating in a College Review Process: All physicians who wish to change their scope of practice and/or re-enter practice must participate in a College review process to demonstrate their competence in the area in which they intend to practise.
  • College Approval: Physicians must not practise in a new scope of practice or re-enter practice unless the College has approved their request.

Introduction

Physicians may wish to change their scope of practice if they become interested in a different area of medicine or if their personal circumstances change. Physicians may also be absent from practice for a period of time for a variety of reasons. They may go on an extended parental leave, take a sabbatical, or take on a teaching role, for example.

Physicians are responsible for maintaining the medical knowledge and clinical skills necessary to provide the highest possible quality of care to patients. All physicians who wish to change their scope of practice and/or re-enter practice must participate in a College review process to demonstrate their competence in the area in which they intend to practise.

Principles

The key values of professionalism articulated in the College’s Practice Guide – compassion, service, altruism and trustworthiness – form the basis of the expectations set out in this policy. Physicians embody these values and uphold the reputation of the profession by:

  1. Acting in the best interests of their patients by ensuring that they have acquired the necessary training and knowledge prior to changing their scope of practice and/or re-entering practice.
  2. Demonstrating continued professional competence by meeting the standard of care and acting in accordance with all relevant and applicable legal and professional obligations.
  3. Being committed to lifelong learning and maintaining the medical knowledge and skills necessary to provide the highest possible quality of care to patients.
  4. Upholding professionalism and trust and protecting patient safety by only practising in the areas in which they are both educated and experienced.
  5. Participating in self-regulation of the medical profession by complying with the expectations set out in this policy.

Purpose

This policy sets out the College’s expectations for reporting and demonstrating competence with respect to changing scope of practice and/or re-entering practice and outlines the applicable College process related to ensuring competence.

Scope

This policy applies to physicians who wish to change their scope of practice or who wish to re-enter practice after an extended absence, even if they have continuously maintained their certificate of registration during their absence. The policy also applies to physicians who would like to both re-enter practice and change their scope of practice simultaneously.

This policy does not apply to physicians who intend to change their scope of practice or intend to re-enter practice in positions focused on teaching, research, or administration, where there is no assessment or treatment of patients.1,2

Terminology

Scope of practice: Scope of practice is a term that describes a physician's practice at a particular point in time. A physician’s scope of practice is determined by a number of factors including:

  • education, training, and certification;
  • the patients the physician cares for;3
  • the procedures performed;
  • the treatments provided;
  • the practice environment.4

Change in scope of practice: A change in scope of practice occurs when there has been a significant change to any of the factors set out in the description of scope of practice above. A change in scope of practice also occurs when physicians wish to return to a scope of practice in which they have not practised for two consecutive years or more.5 For information regarding whether a change is significant and must be reported to the College please refer to Appendix 1.

Policy

The College expects physicians to practise medicine competently. As such, physicians must only practise in the areas of medicine in which they are educated and experienced.6

Physicians may wish to change their scope of practice and/or may take a break from practising for a variety of reasons. In order to ensure that physicians are able to practise competently, the following expectations will apply to physicians before they change their scope of practice and/or re-enter practice:

  1. Reporting to the College; and
  2. Participating in a College Review Process.

Physicians must not practise in a new scope of practice or re-enter practice unless the College has approved their request.7

Reporting to the College

Physicians must report to the College when they:

  • wish to re-enter practice and have not been engaged in practice for a period of two consecutive years or more; and/or
  • wish to change their scope of practice. This includes physicians who are making a significant change in scope of practice or who wish to return to a scope of practice in which they have not practised for two consecutive years or more.8

Reporting can be initiated by completing the applicable application form.9 Physicians must also indicate in the Annual Renewal Survey that they have made this report.10

If physicians are uncertain about whether they are required to report an intention to change their scope of practice or an intention to re-enter practice, they should contact the Inquiries Section in the Applications and Credentials Department of the College for further guidance at 416-967-2617 or by email at inquiries@cpso.on.ca.

College Review Process

All physicians who wish to change their scope of practice and/or re-enter practice must participate in a College review process to demonstrate their competence in the area in which they intend to practise. The process for re-entry and change in scope of practice will be individualized for each physician but, in general, includes a needs assessment, training, supervision, and a final assessment.

During the College review process, consideration will be given to the physician’s specific situation including prior experience, any training the physician has undertaken, the continuing professional development the physician has engaged in, the potential risk of harm to patients, the length of time the physician has been away from practice, and the degree to which the discipline has advanced during the physician’s absence.

For greater detail on the requirements for changing scope of practice and/or re-entering practice, please refer to Appendix 2.

Appendix 1: Description of Significant Change in Scope of Practice

Scope of practice is defined in the Ensuring Competence: Changing Scope of Practice and/or Re-entering Practice policy. The policy states that scope of practice is a term that describes a physician's practice at a particular point in time. It states that a physician’s scope of practice is determined by a number of factors, including:

  • education, training, and certification;
  • the patients the physician cares for;11
  • the procedures performed;
  • the treatments provided;
  • the practice environment.12

The policy states that a change in scope of practice occurs when there has been a significant change to any of the factors set out in the description of scope of practice above or when physicians wish to return to a scope of practice in which they have not practised for two consecutive years or more.13 Physicians may have questions about whether a change in scope of practice would warrant reporting to the College (i.e., is significant) or whether the change would simply be considered an evolution in practice.

Significant Change in Scope of Practice

Significant changes in scope of practice are all determined on a case-by-case basis. A change in scope of practice has been considered by the College to be “significant” in the following circumstances:

  1. Physicians completely change their type of practice (e.g., a surgeon wants to practise in family medicine); or
  2. Physicians are adding something to their practice that
    1. they have not done before, and
    2. is not something that is considered a usual part of the discipline (e.g., a pediatrician who wants to start working in an emergency department caring for adult patients); or
  3. Physicians begin to practise in a location where the health-care system is significantly different from where they had been practising previously (e.g., an urban setting versus a rural setting).

Physicians who have undergone the Changing Scope of Practice process do not practise in the same capacity as specialists. Changes in scope of practice are only permitted once the physician has demonstrated their competence to the College with respect to the specific changes they intend to incorporate into their practice.

Examples of changes in scope of practice that have been considered significant by the College include but are not limited to: 

  • A family physician who wishes to perform cosmetic surgical procedures;
  • A family physician who wishes to primarily practise and receive referrals for psychotherapy, disorders of the skin, or palliative care;
  • A family physician who wishes to practise components of fertility medicine;
  • A physician who practises in chronic pain management but who wishes to practise in interventional pain management;
  • A psychiatrist who wishes to practise in sleep medicine;
  • A neurosurgeon who wishes to practise in palliative care;
  • An orthopedic surgeon who wishes to practise in family medicine;
  • An emergency medicine physician who wishes to practise in sports medicine;
  • A physician who has been working in primary care in a developing country wishes to return to Ontario;
  • A physician who wishes to relocate from an urban, academic practice to a rural, underserviced area.

Evolution in Practice

When there is a change to one of the factors set out in the definition of scope of practice but the change is not significant, the College considers this to be an evolution in practice. An evolution in practice is characterized by the gradual development or progression of a physician’s practice within a certain area in keeping with the direction of the specialty. An evolution in practice may include narrowing or limiting a practice, performance of innovative techniques or procedures or prescribing new medications within the context of a specialty.

Examples include:

  • a family physician who, within their general area of training, decides to narrow the focus of their practice to women’s health issues;
  • an emergency medicine physician who is incorporating bedside ultrasound into their practice; or
  • the transition from a solo practice to a Family Health Team.

If physicians are uncertain about whether a change of scope is considered significant or is an evolution in practice, they should contact the Inquiries Section in the Applications and Credentials Department of the College for further guidance at 416-967-2617 or by email at inquiries@cpso.on.ca.

Appendix 2 Process for Changing Scope of Practice and/or Re-Entering Practice

The changing scope of practice14 and/or re-entering practice process is composed of four stages: a needs assessment, training, supervision, and a final assessment. Decisions about the specific stages that must be undertaken will be determined on an individual basis. Physicians must not practise in a new scope of practice or re-enter practice unless the College has approved their change in scope of practice and/or re-entry request.

A description of the four stages of the process is set out below.

Needs Assessment

After physicians report their intention to change their scope of practice or to re-enter practice, they are required to submit an application.15 The College will review the application and consider which stages of the College’s process require participation by the physician; in particular, whether the physician requires supervision and/or training. Decisions regarding training and/or supervision will be informed by a number of factors, including the physician’s prior experience, any training the physician has undertaken, the continuing professional development the physician has engaged in, the potential risk of harm to patients, the length of time the physician has been away from practice, and the degree to which the discipline has advanced during the physician’s absence.

Training

Completing relevant training is an important part of ensuring competence. The College will review the physician’s application and determine whether the physician requires training.

If the College determines that the physician requires training, the physician must provide the College with a proposed Individualized Education Plan (IEP), to be approved by the College. The IEP must include a description of the training the physician will undertake. If the physician has undergone training prior to reporting to the College, they must provide the College with evidence of the training.

Physicians should note that the College has developed frameworks which set out the training that is required for areas of clinical practice where there are no recognized Canadian specialty training programs. These frameworks inform the College’s decisions about the training a physician will be required to undertake. More information about the frameworks that have been developed can be accessed under Reference Materials in the sidebar.16

Supervision

Where the College determines that supervision is required, physicians must find one or more physicians who will act as their Clinical Supervisor. The Clinical Supervisor must be approved by the College and the supervision must take place in accordance with the Guidelines for College-Directed Supervision.

As competency is gained and demonstrated, the level of supervision will decrease and the physician will be afforded a greater level of autonomy. There are three levels of supervision. Physicians typically start out under high level supervision, and then will move on to moderate and then low level supervision. The level and duration of supervision will be at the discretion of the College with input from the Clinical Supervisor, and will be dependent on the content and duration of the training completed, if training was required.

A description of the different levels of supervision is set out below.

High Level Supervision

A physician must arrange to work in another physician’s practice. This physician will act as Clinical Supervisor and must be practising in the same discipline in which the physician wishes to practise. During high level supervision the Clinical Supervisor is the Most Responsible Physician (MRP) for all patients.

The physician will continue to practise under a high level of supervision until the Clinical Supervisor is satisfied that the physician can work as the MRP under a moderate or low level of supervision.

The Clinical Supervisor will notify the College when they are of the view that the physician has the required knowledge and skills to practise in a less supervised environment (moderate and low level supervision). The College will review the recommendation from the Clinical Supervisor and determine whether the physician may move on to a lower level of supervision.

The length of high level supervision will vary depending on the circumstances of each individual physician. It may be brief if the physician is capable of practising independently or it may be longer if the physician is not yet capable of practising independently.

Moderate and Low Level Supervision

In moderate and low level supervision, the physician works in his or her own practice, makes decisions independently and is considered the MRP. The Clinical Supervisor will periodically visit with the physician to review charts and cases, and discuss patient management to ensure appropriate care is provided. The Clinical Supervisor will submit written reports to the College on a periodic basis. The frequency of visits from the Clinical Supervisor is initially weekly, but will become less frequent when the College determines that physician competency has been demonstrated. Once the Clinical Supervisor is satisfied that the physician is able to practise independently, the Clinical Supervisor will notify the College. The College will then determine whether the physician is ready for their final assessment.

The length of the periods of moderate and low level supervised practice will vary, but generally they will be longer than the time spent under high level supervision.

Final Assessment

Once physicians have completed the required training and/or supervision, they generally will be required to undergo a College-directed assessment of their practice. There may be an observational component to the assessment. For example, where the care involves performing new procedures the assessor may observe the physician performing the new procedures. Assessments may also involve interviews with colleagues and co-workers to provide feedback on care provided.

The College will review the final assessment report and will make a determination as to whether the physician is competent to practise independently.

Costs

The physician undergoing the changing scope of practice and/or re-entering practice process must pay for the costs related to training, supervision, and the final assessment.
 

Endnotes

1The College requires all physicians to maintain competence regardless of type of practice. For those physicians changing their scope of practice or re-entering practice in positions that involve teaching, research or administration there are separate processes at universities and hospitals for ensuring competence.

2Physicians who are intending to change their scope of practice to an area which involves reviewing medical records for individuals with whom the physician does not have a treating relationship for the purpose of providing third party reports (i.e., Independent Medical Examiners) are captured by this policy and must report their intention to change their scope of practice.

3This would include populations (e.g., where a physician is practising as a Medical Officer of Health).

4Practice environment may include colleague supports, access to resources, payment systems, geographic or health system demands.

5For example, a family physician focusing in emergency medicine who wishes to return to family medicine after an absence from this clinical area for two or more years.

6The requirement that physicians practise in the areas of medicine in which they are educated and experienced is a term, condition and limitation on a physician’s certificate of registration. The Professional Misconduct regulation 856/93 under the Medicine Act, 1991, S.O. 1991, sets out that it is professional misconduct for a physician to contravene a term, condition or limitation on their certificate of registration (Section 1(1)1).

7Physicians are reminded that when they work in areas of medicine that are different from their area of primary certification they must comply with the Use of Specialist Title regulation. For more information on the requirements under the regulation please refer directly to Section 9 of O. Reg. 114/94 under the Medicine Act, 1991 S.O. 1991, C.30 and the College’s article, Describing your credentials in advertising and promotional materials.

8This expectation applies even if the physician has previously trained and had experience in the scope of practice to which they are returning.

9The application to request a change in scope of practice can be found here. The application to request re-entry to practice can be found here.

10In accordance with section 51(3) of the College’s General By-Law.

11This would include populations (e.g., where a physician is practising as a Medical Officer of Health).

12Practice environment may include colleague supports, access to resources, payment systems, geographic or health system demands.

13For example, a family physician focusing in emergency medicine who wishes to return to family medicine after an absence from this clinical area for two or more years.

14This process only applies to changes in scope that are significant.

15The application to request a change in scope of practice can be found here. The application to request re-entry to practice can be found here.

16Frameworks that are currently developed include expectations for: cardiologists intending to interpret nuclear cardiology studies in independent facilities, physicians intending to practise sleep medicine, physicians intending to practise as Medical Officers of Health, physicians who intend to change their scope of practice to include endo-colonoscopy, physicians who intend to change their scope of practice to include interventional pain management, physicians who intend to change their scope of practice to include surgical cosmetic procedures, radiologists intending to interpret and supervise nuclear medicine studies in Independent Health Facilities, physicians who intend to change their scope of practice to include caesarean section for non-obstetricians.

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