Advice to the Profession: Changing Scope of Practice and/or Re-entering Practice

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. When they wish to return to practice, they may wish to practise in a different area of medicine.

This advice document is intended to help physicians interpret their obligations as set out in the Ensuring Competence: Changing Scope of Practice and/or Re-entering Practice policy and provide further guidance around what constitutes a significant change of scope of practice. It also serves to address some frequently asked questions about the application of the policy to changes in practice environment.

Description of 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; hospital versus office setting; developed country versus developing country).

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.

A transition from residency to independent practice does not constitute a change in scope of practice as long as you are practicing in the area in which you were trained.

Description of 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.

However, when a physician focuses their scope of practice in a way that is no longer in keeping with the direction of the specialty and to such an extent that they are practicing in a significantly different way than their peers, it is likely that the changing scope of practice process would be required.

Furthermore, in instances where physicians are accepting new referrals for an area in which they have not previously practiced (or have not practised in the preceding two years), and for which there is an expectation that they have a specific or focused skill set that the referring physician is unable to provide, it is likely that a changing scope of practice process would be required.

As with all applications for changing scope of practice and re-entering practice, each physician’s situation is considered individually, and the process is designed to provide support to the physician as well as an assurance of oversight to the public during this transition.

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 via the Member Portal message center.

Application of policy to changes in practice environment

The College receives many questions about how the policy applies in specific scenarios. Answers to some frequently asked questions are set out below.

Is a change in practice environment (a move from an urban-based practice setting to a rural practice setting, for example) considered a significant change in scope of practice?

Not always. Not all changes in practice environment will be considered a significant change in scope of practice.

Whether a change in practice environment constitutes a significant change in scope of practice will depend on a number of factors including whether there are significant differences in access to resources, in the availability of support from colleagues, or in the health system demands between the urban and rural practice settings. Differences in these factors may present unforeseen changes in the way that physicians practise. For instance in a rural setting, physicians may not have the same access to specialists, facilities, diagnostic or social services that are available in an urban setting.  If physicians are moving to a rural community from an urban practice and there are no differences in the way they would be practising, the change would not be considered significant.

When the College considers a change in practice environment to be significant, what is the process required to facilitate this change?

There are four general stages of the College’s Changing Scope of Practice process: needs assessment, training, graduated supervision and a final assessment. However, not every stage of the process is required for all change of scope cases. The specific stages of the process that a physician is required to undertake are tailored to each physician’s specific situation.

For example, if the treatments and procedures you are intending to perform are generally consistent with your current scope of practice, and the College feels there are appropriate supports to assist you in your transition to a rural setting, the College may decide after the needs assessment, that no further stages of the process are required. The College may instead suggest you find an informal supervisor to act as a mentor or resource person with whom you can meet or chat on a regular basis, to help you settle into your new environment.

The College has developed frameworks which set out the training that is required for certain areas of clinical practice. For physicians who are not certified in Emergency Medicine and are intending to include Emergency Medicine as part of their rural practice, please refer to the College’s framework that sets out the specific requirements for this change and the FAQ that accompanies this framework.