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Physician Assistants Policy

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Policies of the College of Physicians and Surgeons of Ontario (“CPSO”) set out expectations for the professional conduct of physicians and physician assistants (“Registrants”) practising in Ontario.Together with Essentials of Medical Professionalism and relevant legislation and case law, they will be used by CPSO and its Committees when considering a Registrant’s practice or conduct.

Within policies, the terms ‘must’ and ‘advised’ are used to articulate CPSO’s expectations. When ‘advised’ is used, it indicates that Registrants can use reasonable discretion when applying this expectation to practice.

Additional information, general advice, and/or best practices can be found in companion resources, such as Advice to the Profession documents.

Definitions

Professionalism: the words and actions that foster trust and respect with patients, colleagues, and the public.

Unprofessional behaviour: words, actions, or inactions that interfere with (or may interfere with) the delivery of quality care, public trust in the profession, the safety or perceived safety of others, or the ability to collaborate. Unprofessional behaviour may be demonstrated through a single act, a pattern of events, or a number of separate events.

Boundary: Defines the limit of a safe and effective professional relationship between a registrant and a patient. There are both sexual boundaries and non-sexual boundaries within a physician-patient relationship

Conflict of interest: A conflict of interest is created any time a reasonable person could perceive that a registrant’s judgments or decisions about a primary interest (e.g., the patient’s best interests, unbiased medical research) are compromised by a secondary interest (e.g., direct financial gain, professional advancement). A conflict of interest can exist even if the registrant is confident that their professional judgment is not actually being influenced by the conflicting interest or relationship.

For the purposes of this policy, conflicts of interest also include those circumstances defined in Part IV (ss. 15-17) of Ontario Regulation 114/94 (“the General Regulation”) under the Medicine Act, 1991

Critical test result: Results of such a serious nature that immediate patient management decisions may be required.

Clinically significant test result: A test result which requires follow-up in a timely fashion, urgently if necessary.

Virtual care: Any interaction between patients and/or members of their circle of care that occurs
remotely, using any form of communication or information technology, including telephone, video conferencing, and digital messaging (e.g., secure messaging, emails, and text messaging) with the aim of facilitating or providing patient care.

Personal health information: any information relating to a person’s health that identifies the person, including, for example, information about their physical or mental health, family health history, information relating to payments or eligibility for health care, and health card numbers.

Policy

  1. Physician Assistants must comply with the Regulated Health Professions Act, 1991, and the Medicine Act, 1991, and must practise under delegation in accordance with applicable regulations and CPSO’s Delegation of Controlled Acts policy.
Professionalism
  1. Physician Assistants must meet the expectations for professionalism set out in CPSO’s Essentials of Medical Professionalism including:
    1. considering each patient’s well-being and acting in their best interests; and
    2. working respectfully and collaboratively with other members of the health-care team, even when their personal beliefs and/or professional opinions differ.
  1. Physician Assistants must comply with the expectations set out in the Professional Behaviour policy, and must:
    1. uphold the standards of medical professionalism and conduct themselves in a professional manner; and
    2. not engage in unprofessional behaviours, as set out in the policy.
  1. Physician Assistants must comply with the expectations set out in the Boundary Violations policy, and must:
    1. establish and maintain appropriate boundaries with their patients;
    2. not engage in sexual relations with a patient, touch a patient in a sexual manner, or engage in behaviour or make remarks of a sexual nature towards a patient; and
    3. ensure appropriate procedures are followed before, during, and after physical and intimate examinations.
  1. Physician Assistants must comply with the expectations set out in the Social Media policy, and must:
    1. consider the potential impact of their conduct on social media on the reputation of the profession and the public trust; and
    2. not engage in unprofessional behaviour while using social media.
  1. Physician Assistants must only provide treatment to themselves, family members, or others close to them in accordance with the expectations set out in the Treatment of Self, Family Members, and Others Close to You policy.
  1. Physician Assistants must comply with the expectations set out in the Human Rights in the Provision of Health Services policy, and must:
    1. take reasonable steps to create and foster a safe, inclusive, and accessible environment in which the rights, autonomy, dignity, and diversity of all people are respected.
  1. Physician Assistants must comply with the expectations set out in the Conflicts of Interest and Industry Relationships policy, and must:
    1. maintain their clinical objectivity and professional independence in all interactions with industry and when making decisions regarding patient care; and
    2. meet their obligations regarding conflicts of interest in the General Regulation.
  1. Physician Assistants must comply with the expectations set out in the Advertising policy, and must:
    1. only advertise in a manner which is dignified, accurate, and upholds the reputation of the profession; and
    2. not advertise in a manner which is false, misleading, or deceptive.
Clinical Care
  1. Physician Assistants must comply with the expectations set out in the Consent to Treatment policy and the requirements in the Health Care Consent Act, and must:
    1. ensure that valid consent has been obtained before treatment is provided.
  1. Physician Assistants must comply with the expectations set out in the Prescribing Drugs policy, and must:
    1. only prescribe a drug if they have the knowledge, skill, and judgment to do so safely and effectively; and
    2. not prescribe narcotics or controlled substances.
  1. Physician Assistants must comply with the expectations set out in the Virtual Care policy, and must:
    1. continue to meet the standard of care and the existing legal and professional obligations that apply to care that is provided in person, when providing virtual care.
  1. Physician Assistants must comply with the expectations set out in the Complementary and Alternative Medicine policy, and must:
    1. conduct conventional clinical assessments of patients in accordance with the standard of practice; and
    2. practise in their patient’s best interests and in a manner that is informed by evidence and scientific reasoning.
  1. Physician Assistants must comply with the expectations set out in the Infection Prevention and Control for Clinical Office Practice policy, and must:
    1. undertake infection prevention and control practices, in line with the Provincial Infectious Diseases Advisory Committee’s Infection Prevention and Control for Clinical Office Practice
  1. Physician Assistants must comply with the expectations set out in the Medical Records Documentation policy, and must ensure that:
    1. documentation in the medical record is legible, accurate, complete and comprehensive; and
    2. patient encounters are documented as soon as possible.
  1. Physician Assistants must comply with the expectations set out in the Managing Tests policy, and must:
    1. appropriately track, communicate, and follow up on test results which are, or are likely to be, clinically significant and/or critical in nature.
  1. Physician Assistants must comply with the expectations set out in the Transitions in Care policy, and must:
    1. keep patients informed about who has primary responsibility for managing their care and about their role on the patient’s health-care team;
    2. ensure that patients have the information they need prior to being discharged from hospital to home.
  1. Physician Assistants must comply with the expectations set out in the Protecting Personal Health Information policy, and must:
    1. only collect, access, use, or disclose a patient’s personal health information:
      1. in situations where:
        1. the patient or Substitute Decision Maker has provided consent, and it is necessary for a lawful purpose; or
        2. it is permitted or required by law without consent;and
      2. where they need the personal health information to carry out their duties.
Reports
  1. Physician Assistants must comply with the expectations set out in the Reporting Requirements policy, and must:
    1. take appropriate and timely action when they have reasonable grounds to believe that another regulated health professional is incapacitated or incompetent, and
    2. fulfil their legislative reporting requirements, which include those that are highlighted in CPSO’s Guide to Legal Reporting Requirements document.
  1. Physician Assistants must comply with the expectations set out in the Disclosure of Harm policy, and must:
    1. ensure that the Most Responsible Physician (MRP) is aware of harmful and no-harm incidents; and
    2. ensure that harmful incidents and no-harm incidents are disclosed to patients.

Endnotes

  1. The term “patient” is used to refer to patients and their loved ones, including but not limited to caregivers, family members, friends, and substitute decision-makers.
  2. Remotely means without physical contact and does not necessarily involve long distances. Patients, patient information and/or physicians may be separated by space (e.g., not in the same physical location) and/or time (e.g., not in real time).
  3. This definition was adapted from Shaw, J., Jamieson, T., Agarwal, P., Griffin, B., Wong, I., & Bhatia, R.S. (2018). Virtual care policy recommendation for patient-centred primary care: findings of a consensus policy dialogue using a nominal group technique. Journal of Telemedicine and Telecare, 24(9), 608-615.

  4. Applicable regulations include regulations under the Medicine Act, 1991.

  5. Please also see the Frequently Asked Questions regarding Delegation to Physician Assistants for additional information on sub-delegation, orders to other regulated health care professionals, supervision, and prescribing.
  6. “Others close to them” refers to individuals who have a close and/or personal relationship with the physician where the nature of the relationship could reasonably affect the physician’s professional judgment.
  7. The Health Care Consent Act sets out the elements that are required for obtaining valid consent, as well as guidance for emergencies where valid consent cannot be obtained. For further information, see CPSO's Guide to the Health Care Consent Act companion document.
  8. Sections 2(1)(c), 2(5), O. Reg. 865/93, Registration, enacted under the Medicine Act, 1991, S.O. 1991, c.30; CPSO's Ensuring Competence: Changing Scope of Practice and/or Re-entering Practice policy; CPSO's Essentials of Medical Professionalism.
  9. The Controlled Drugs and Substances Act sets out which practitioners are authorized to prescribe controlled drugs and substances. Physician Assistants are not authorized practitioners under the Act.
  10. Ontario Agency for Health Protection and Promotion (Public Health Ontario), Provincial Infectious Diseases Advisory Committee. Infection Prevention and Control for Clinical Office Practice. 1st Revision. Toronto, ON: Queen’s Printer for Ontario; April 2015.
  11. Generally speaking, activities associated with the normal course of a physician’s or physician assistant's practice as they relate to the provision of health care will be for a "lawful purpose".
  12. These situations include specific permissions and requirements set out in Personal Health Information Protection Act, 2004, and other legislation, such as reporting requirements outlined in CPSO’s Guide to Legal Reporting Requirements. See CPSO's Advice to the Profession: Protecting Personal Health Information document for further guidance.
  13. “Incapacitated” means that a regulated health professional is suffering from a physical or mental condition or disorder that makes it desirable in the interest of the public that their certificate of registration be subject to terms, conditions, or limitations, or that they no longer be permitted to practise.
  14. “Incompetent” means that a regulated health professional’s care of a patient displayed a lack of knowledge, skill, or judgment of a nature or to an extent that demonstrates that they are unfit to continue to practise or that their practice should be restricted. See s. 52(1) of the Health Professions Procedural Code.
  15. A “harmful incident” is an incident that has resulted in harm to the patient (also known as an “adverse event”).
  16. A “no-harm incident” is an incident with the potential for harm that reached the patient, but no discernible or clinically apparent harm has resulted.