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

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Approved by Council: February 2018
Reviewed and Updated: June 2000, April 2008, December 2015

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.

 

Definitions

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;1
  • the procedures performed;
  • the treatments provided;
  • the practice environment.2

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. 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.3  Additional information regarding whether a change is significant and must be reported to the College is set out in the companion advice document.

 

Policy

  1. Physicians must only practise in the areas of medicine in which they are educated and experienced.4

Reporting to the College

The following expectations do not apply to physicians who intend to change their scope of practice or re-enter practice in positions focused on teaching, research, or administration, where there is no assessment or treatment of patients.5

  1. Physicians must report to the College when they:
    1. wish to re-enter practice and have not been engaged in practice for a period of two consecutive years or more6; and/or
    2. 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 more7.8
  2. As part of the process of reporting, physicians must:
    1. complete the applicable application form;9 and
    2. where reporting an intention to re-enter practice, indicate in the Annual Renewal Survey that they have made this report.10
  3. Physicians who are uncertain about whether they are required to report an intention to change their scope of practice or an intention to re-enter practice, are advised to 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

  1. All physicians who wish to change their scope of practice and/or re-enter practice must participate in an individualized College review process to demonstrate their competence in the area in which they intend to practise.11
  2. Physicians must not practise in a new scope of practice or re-enter practice unless the College has approved their request.12
 

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

The changing scope of practice13 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.14 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 here.15

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

Physicians who wish to change their scope of practice and/or re-enter practice must pay for all costs associated with training, supervision and assessment. The cost of the training and supervision will be quite variable depending on the training taken, the length of the training necessary and the cost of supervision.

 

Endnotes

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

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

3. For 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.

4. The 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).

5. The College requires all physicians to maintain competence regardless of type of practice and 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.

6. This includes physicians who have continuously maintained their certificate of registration during their absence.

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

8. This includes physicians 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).

9. Application to request a change in scope of practice and application to request re-entry to practice can are available online.

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

11. The process generally includes a needs assessment, training, supervision, and a final assessment. For greater detail on the requirements for changing scope of practice and/ or re-entering practice, please refer to Appendix 1.

12. Physicians 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.

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

14. Application to request a change in scope of practice and application to request re-entry to practice can are available online.

15. Frameworks 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, and physicians who intend to change their scope of practice to include caesarean section for non-obstetricians.