Approved by Council: November 2008
Reviewed and Updated: April 2009, May 2017
Companion Resource: Advice to the Profession
Policies of the College of Physicians and Surgeons of Ontario (the “College”) set out expectations for the professional conduct of physicians practising in Ontario. Together with the Practice Guide and relevant legislation and case law, they will be used by the College and its Committees when considering physician practice or conduct.
Within policies, the terms ‘must’ and ‘advised’ are used to articulate the College’s expectations. When ‘advised’ is used, it indicates that physicians can use reasonable discretion when applying this expectation to practice.
First-Come, First-Served Approach: An approach whereby new patients are accepted on a first-come, first-served basis, when the patient’s needs are within:
- the physician’s clinical competence and/or scope of practice;
- the physician’s focused practice area1; and/or
- the terms and conditions of the physician’s practice certificate and associated practice restrictions, if applicable.
Higher Need and Complex Patients: Patients who may be categorized as higher need and/or complex include, but are not limited to, those requiring urgent access to care, those with chronic conditions, particularly where the chronic condition is unmanaged, an activity-limiting disability and/or mental illness.
- Physicians must employ the first-come, first-served approach when accepting new patients into their practices.2
- Notwithstanding this requirement, physicians are permitted to make decisions about whether their practice is accepting new patients. Such decisions must be made in good faith.
- Physicians must not refuse to accept patients based on any of the prohibited grounds of discrimination set out in the Ontario Human Rights Code3,4
- Physicians must not use clinical competence and/or scope of practice as a means of discriminating against prospective patients or to refuse patients:
- with complex or chronic health needs;
- with a history of prescribed opioids and/or psychotropic medication;5
- requiring more time than another patient with fewer medical needs; or
- with an injury, medical condition, psychiatric condition or disability6 that may require the physician to prepare and provide additional documentation or reports.
- Where a physician refuses a patient based on clinical competence, scope of practice, and/or a focused practice area, the physician must:
- do so in good faith;
- consider the impact on the patient; and
- clearly communicate the reasons for the refusal to the patient (or referring practitioner, where appropriate).
- Given the broad scope of practice of primary care physicians, there are few occasions where scope of practice would be an appropriate ground to refuse a prospective patient. Once accepted into a primary care practice, should elements of the patient’s health-care needs be outside of the physician’s clinical competence and/or scope of practice, the physician must not abandon the patient. Physicians must make a referral to another appropriate health-care provider for those elements of care that they are unable to manage directly.
- Physicians must not use introductory meetings, such as ‘meet and greet’ appointments and/or medical questionnaires7, to vet prospective patients and determine whether to accept them into their practice but are permitted to use them to share information about the practice and obtain information about the patient after a patient has been accepted into a practice.8
- Physicians who provide specialist care must employ the first-come, first-served approach by accepting new patients in the order in which the referral was received. Physicians must only depart from this practice to accommodate patients requiring priority access to care, for example, due to urgent health-care needs.
- Where a referral is outside of the specialist’s clinical competence or scope of practice, the specialist must promptly communicate this information to the referring health-care practitioner, and/or patient where appropriate, to facilitate timely access to care.
- Physicians are advised, where possible, to provide the referring health-care practitioner with suggestions for alternative care provider(s) who may be able to accept the referral.
- Physicians who maintain a waiting list of prospective patients must accept patients in the same order in which they were added to the list.
- Physicians are advised to use wait-lists cautiously, and to manage patient expectations by clearly communicating the expected waiting period.
Potential Exceptions to First-Come, First-Served Approach
- Physicians are permitted to depart from the first-come, first-served approach to prioritize access to care for higher need and/or complex patients. Decisions to prioritize a patient’s access to care must be made in good faith.
- Physicians must use their professional judgment to determine whether prioritizing or triaging patients based on need is appropriate, taking into account the patient’s health care needs, and any social factors, including education, housing, food security, employment, and income that may influence the patient’s health outcomes.
- The College acknowledges that caring for patients and their family members may assist in the provision of quality care. Accordingly, where a primary care physician’s practice is otherwise closed, physicians are permitted to prioritize the family members of current patients. When doing so, physicians must consider whether accepting that family member would reasonably assist in the provision of quality care.
1. Physicians with a ‘focused practice area’ may include those with a commitment to one or more specific clinical practice areas, such as geriatrics, psychotherapy or adolescent health, or who serve a defined target population.
2. This policy applies to all physicians, and those acting on their behalf. For instance, physicians may rely upon clinical managers and/or office staff to accept new patients on their behalf. Organizations may also act as a physician’s representative in this context.
4. Prohibited grounds of discrimination include, but are not limited to, race, ancestry, place of origin, color, ethnic origin, citizenship, creed, sex, sexual orientation, gender identity, gender expression, age, marital status, family status or disability. For more information see the College’s Professional Obligations and Human Rights policy.
6. Physicians should be aware that under the Code, the term ‘disability’ is interpreted broadly and covers a range of conditions. ‘Disability’ encompasses physical, mental and learning disabilities, mental disorders, hearing or vision disabilities, epilepsy, drug and alcohol dependencies, environmental sensitivities, and other conditions. The Code protects individuals from discrimination because of past, present and perceived disabilities.
8. For instance, introductory meetings and/or medical questionnaires may be helpful to identify a new patient’s needs and expectations, to disclose information about the physician’s knowledge area, to advise of after-hours coverage, or to determine whether the terms of the physician-patient relationship are acceptable to the patient. Further, introductory meetings may involve establishing expectations regarding adherence to a prescribed therapy. This may include, for instance, establishing a treatment agreement (e.g., narcotics contract) between the physician and the patient.