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The definition of competence in chronic pain management in general, and interventional pain management ( IPM) in particular require a complete review.
Current requirements for IPM, reflect competence in regionl anaesthesia, which is NOT synonymous with competence in managing chronic pain.
The hours of training required for changing scope of practice to IPM may reflect those required for regional anaesthesia training including high risk neuraxial blocks, but are excessive for individuals aiming to learn optimal chronic pain interventions employing only low risk interventions.
I appreciate the acknowledgement that Family Practice which is broad in scope will be maintained and would not like to see a change. The statement: Performance of innovative techniques or procedures within the context of a specialty or family medicine, while new, may not constitute a change in scope of practice.
As medicine evolves and our patient’s needs evolve we must not undermine CPD by insisting on credentialing for every activity. While I appreciate the need to ensure the public that practitioners are competent, a certificate does not always guarantee this but can impede the ability for primary care physicians to contribute.
I retired from active family practice July 2011 and am doing part time OR assisting and OR on call. Why must I continue CPD as all I do is help and have NO primary care patient contact or decision making responsibilities. Part time is not lucrative but is done to keep me involved in medicine. Can the policy be altered for part time non primary care physicians?
are you kidding me? Your fee to have your CPD registered is going to be increased by about 50% this year, and you want to practice medicine without paying for it?
I am concerned about family physicians who do an on line course in Dermatology( no patient contact during the course) who then set up receiving consultations in Dermatology. The public believes they are seeing a dermatologist. At any issue the patient is then referred on to a properly trained dermatologist(FRCPC)who then has to manage the problems created.The Universities who offer these programs,mainly in the UK,clearly state that these programs are for family physicians to gain extra skills in what they may see in day to day practice, but NOT TO RECEIVE CONSULTATIONS NOR TO CHANGE THEIR SCOPE IN PRACTICE. Yet CPSO allows this practice to continue which is a disservice to patients.
Why would a GP refer a patient with a skin problem to another family doctor when a dermatologist is available ?
Dermatologists have limited their supply, at the expense of the public, to maintain their negotiating power with the government and other providers. It is no secret that dermatologists have excellent income, and have their pick of where to live and work. Unsurprisingly, most, if not all dermatologists in Ontario, practice in larger metropolitan centres.
It is not unheard of for a patient with a concerning melanocytic lesion to have to wait months to see a dermatologist.
The natural reaction to this unmet demand is for family doctors to take courses that may or may not be sufficient for moderately complicated dermatology practice and offer these services to patients.
Dermatologists should thus expand their residency training programs if there is concern that patients are getting insufficient care from family doctors with dermatology interest. The demand is there – patients want to see dermatologists, students want to be dermatologists – the training positions are not.
So you won’t allow UBER to operate as Taxi inspite of the rarity of taxis, but allow a GP to operate as a specialist?
It takes 5 years to train a dermatologist. Talk to the government to fund more training spots.
BTW there is a rarity of neurosurgeons, let’s take an online course and do that!
So the response to the need for specialists is to get an online course? There is a lack of neurosurgeons, let’s get some training online and just do that. Why go through years of training?
You can ask the government to fund more training spots for the needed specialties.
The last comment is upset that some specialties get to choose where they work!!!
Enough doctor bashing from public and politicians, less and less young people will be interested in the profession.
This is called the UBER way, the response to more needed taxis is getting UBER?
Change of scope of practice to a methadone prescribing is an area not paid attention to by the CPSO. An easy CAMH course (100% pass rate) and 4 half-days of orientation are far too little to train someone to get methadone exemption for addiction.
Besides being dangerous and lacking addiction knowledge, many new methadone prescribers wrongly represent and advertise themselves as addiction experts or specialists, which they most certainly are not.
The methadone committee does an audit of all methadone prescribers but not until 1-1.5 years after this doctor has been independently practicing. There are some of the doctors with new exemptions that are practicing dangerously and completely outside the CPSO guidelines. It takes too long for the CPSO’s audit to happen for them.
To get methadone exemption, and more so to advertise one as an “addiction specialist” there must a more rigorous process. Perhaps being supervised by another doctor, until the CPSO audit has taken place, as done in other areas of change of focus of practice (like interventional pain) AND/OR requiring certification by another body. The American Board of Addiction Medicine, just gained subspeciality status in the US by the ABMS. In Canada, its affiliate the Canadian Society of Addiction Medicine, that uses the same rigorous exam can serve as such a body.
methadone and addiction have totally flown under the radar of change in focus of practice policies .
the CAMH course is a joke and the 4 half days are like 8 hours total sitting behind another doctor.
In regards to defining scope of practice, an area of oncology and that seems to produce some debate is the prescription at targeted agents. With immunotherapy playing more of a role, the range of systemic anticancer agents with significant toxicities expands.
It may be worth describing when prescribing a drug class or specific agent falls out of the scope of practice of a physician. Currently, medical oncologist prescribe chemotherapy, though this is not the case for targeted drugs and is to be determined for immunotherapy (ex. Checkpoint inhibitors). Examples where this line becomes blurred is (historically) when Radiation Oncologists prescribe chemo to sensitize the patient to radiation. Gynecological oncologists presently prescribe chemotherapy. Currently, Urologists prescribe targeted agents with minimal toxicities.
My fear is with the current description of scope of practice. Prescribing a drug is reasonably extrapolated to be like a surgeon learning to do a laparoscopic cholecystectomy – the example listed in the policy summary. There is a reason that Medical Oncology is a licensed specialty – these drugs have significant toxicities and interactions. This policy would be a reasonable time to formally suggest when prescribing a specific drug falls outside of someone’s scope of practice.
I do not believe that there needs to be a change with the current scope of practice. I see the landscape in non-chemotherapeutic oncology therapies diversifying. Many of these newer agents have significant toxicities with very specific interactions or dependencies. So I ask for consideration of this policy to help shape the landscape for the future. Ideally, well meaning individuals would have this policy guide them from not stretching their scope of practice to include these newer toxic agents before they are ready. I feel that this policy could have great impact in demarcating the subtleties that exist between oncological specialities.
One area which concerns me is the switch from family medicine to psychotherapy. This is a significant practice change but I’m not sure it’s covered by the current policy. It takes more than a few weekend courses and some supervised practice to be an ef…
Agree in general with the document and proposal however would suggest the College pay for assessments and supervision when change in scope of practice being considered.
Having the individual undergoing change of scope pay for the review,assessment and supervision may discourage use of the process.
physicians pay for the College, which means all members would have to pay higher annual fee.
I received a change in scope of practice assessment in 2012 which had a SUBSTANTIAL COST attached to it.
To be clear, I paid for both a NURSE to inspect my facility and a PHYSICIAN to assess my clinical competence. This was an extremely time consuming process.
I ALSO PAY $ 4,175.00 YEARLY / ON AN ONGOING BASIS for premises inspection ” dues ”
( whatever that means ).
A major concern of mine, as a dermatologist in practice now for 35 years is the glut of untrained physicians entering into cosmetic medicine. I do very little of this, but for those who do, there needs to be stringent standards. It should not be the domain of physicians from family medicine and other specialties looking for no call and lots of cash. If anything, the bar should be set higher than average for MDs doing medically unnecessary procedures. This means both diagnostically and therapeutic standards. I appreciate that testimonials are very poor science, but I once saw a patient whose physician (Dr. XXX) had recently bought a laser, and was treating this patient’s skin. I saw the patient for a return skin cancer check. After examining this patient for his previous cancers, and screening him for new tumours, the patient asked me. “Dr. XXX asked me to ask you what these lesions are called that he is treating on my face.” My response to the patient was that if Dr. XXX did not know the clinical diagnosis, he should not be treating the lesions. I don’t think this sort of action is isolated.
If any physician, especially those from specialties that do not have basic training in skin disease, is working in the cosmetic domain, he/she should need to provide a lot of proof of both diagnostic skill as well as therapeutic expertise.
most cosmetic skin docs don’t do well profit wise so it’s not the cash cow that you have painted. many skin laser clinic go out of business.
Remember your competition is not just from physicians. The regulatory scheme in Ontario is so loose that practically anyone can start doing laser on the skin.
In California, shining laser on the skin is considered a medical act and hence only a physician can do so, but in Ontario, barbers, astheticians, PSWs etc. do so with little or no regulatory oversight.
There are also nurse practitioners that now inject botox independently of a physician.
So if these practitioners with no MD licesne are allowed to do it, I doubt it is rational to bar other physicians who are still bound by the CPSO and insured by the CMPA.
As a physician in my 50s with children moving away to university I am looking towards partial retirement to allow visits or even a move to be closer to them and thus cut down on call and in-patient work but to coninue out-patients. Is this a change in scope of practice? Does this trigger a review even if it means I am not adding new roles but just cutting down? I have not had complaints or investigations
Thank you for the opportunity of contributing to the discussion on scope of practice definition.
I believe it is helpful to distinguish between field of expertise and scope of practice. The former is defined by level of competence. The latter, I believe, is defined by the capability of the physician.
Competence is the finite and measurable standard achieved. Capability reflects the adaption required to meet evolving patient care needs. This adaptation may require the development of a new level of competence by systematic self-directed learning.
In my mind, competence should be regularly appraised to ensure safe and effective care. This will obviate the arbitrary need to validate licensure if practice is deemed to change beyond one’s designated expertise.
Great idea to create new policies as it justifies any increase in funding. Brilliant idea, and expect more to come.
This scope of practice policy, especially for family physicians, needs to be standardized. Family physicians already have a broad-based skill set, and the byzantine measures that the CPSO goes through for changing “scope of practice” is problematic.
Having gone through this myself: Initially having contacted CPSO for informing them of adding more emphasis on a particular aspect of family practice, I had been informed that that was OK, as it was still within the scope of family practice, and what I was already doing. When I called again a few months later, the CPSO informed me that that was erroneous, they had no documentation that the CPSO had informed me that I was still functioning within my scope of practice, and then forced an educational program on me on incredibly short notice, delaying my ability to provide care THAT I WAS ALREADY PROVIDING. So I had to stop providing care in order to participate in this remedial educational plan. I would also say, in formulating an “educational plan” a la CPSO, the sample template sent along was incredibly stigmatizing and insinuated that all physicians changing scope of practice were, in fact, needing to remediate, as their work was deviant from the CPSO’s standards.
I thought this was previously discussed and then it we decided it will be discarded as it was too complex to define the scope of practice for physicians. We are also unable to pay any higher fees that will come out of this.
HAD THE COLLEGE CONSIDERED FREEZING OR REDUCING ITS FEES INLINE WITH WHAT OHIP HAS DONE TO DOCTORS OVER THE LAST FEW YEARS?
a change in direction e.g. pain management, a three day course and a written examination does not an expert make. Or is it enough time to gain a skill and know when to use that skill safely
As a physician retired from family practice who has done only surgical assisting for the last 15 years I am puzzled and annoyed that I am required to do 50 hours of CME’s annually. While they are of interest they do not have any bearing on my competence in the OR where I strictly confine my actions to optimizing the surgeon’s field of vision, doing nothing outside of this such as cauterizing,clamping, excising tissues on my own. Paying hundreds of dollars annually to be in compliance with regulations is unnecessary. This requirement should be dropped for those of us who are phasing out of working life in this manner.
I feel that training in the medical profession must continue to involve all areas of medicine in general so that any doctor in a particular focused area of medicine must incorporate the whole body so that the focused area doctor will not miss serious ailments in the patient. For example a urologist must still recognize an abnormality in other parts of the human body that could be seriously affected by whatever the urologist or other specialist does. I have seen examples of this problem over the years. For example a urologist had forgotten how to take a blood pressure on the patient before surgery. Of course regular clinical updates in other areas of medicine will help the doctor who practices on a focused part of the human body to still be confident treating the rest of the patient or at least picking up abnormalities in the rest of the patient for someone else to handle outside of the focused area.
There should not be an option to change a scope of practice when the expertise is currently learned through an accredited residency program.
An example of this is advanced reproductive technologies. There is a RCPSC approved PGY6 entry program for Gynecologic Reproductive Endocrinology. Only people with this designation or those who had equivalent training before this program was accredited should be allowed to provide ART services.
Providing a change in scope of practice allows a member to circumvent full training, with the approval of the college. This does not benefit Ontarians.
I think that in order to create each area of change of scope of practice guidelines we need an active involvement of members who have in the past have completed particular change in scope of practice. Often the committees that create guidelines for change in scope of practice are comprised of specialists in the field and physicians who don’t practice in the field. This leads to formulation of the regulations for change in scope of practice that are based on theoretical and not practice guidelines.
I welcome further evolution of scope of practice policies for physicians to assure competence over time.
However, I am much more concerned about the evolving scope of practice of other health professionals, quasi-health professionals and non-health professionals trying to mislead patients for their own financial gain.
As has been made clear by multiple recent media reports, naturopaths, homeopaths, lay marijuana sales persons, each should have a far more limited scope.
I have a broad scope of practice, covering all disorders and most ages, though not children.
I agree with the comments above regarding unnecessary CME. I’m leaving the practice of anatomical pathology at the end of this month and will be doing some surgical assisting just to keep active in the medical field. I contacted the RCPSC and they said that I had to keep up the CME in spite of the very indirect contact I will be having with patients as regards their care. They said that any continuing programs were suitable and need not be related to my current or future medical activities. To me this sound like bureaucracy for bureaucracy’s sake and makes no sense at all. The fees paid for surgical assistants are dismal and the incessant demands put on an extra burden financially. This has nothing to do with patient care.
I noted in completing the questionnaire for renewal that the change in scope of practice did not include the option of “reducing scope of practice”. For instance, I will not longer do surgical procedures in my practice but the questionnaire did not provide me with the opportunity to so indicate without appearing to trigger an unintended process.
I feel that when family physicians in particular started meaningfully practice in droves(and the college allowed it)it was dismantling of the provision of family practice that had been in place for many years.
I cannot imagine suddenly becoming a cosmetic (and much more lucrative) surgeon,a dermatologist,a psychiatrist etc overnight
I think there should be a change for scope of practice for Internal Medicine physicians undergoing pathway 4 assessments. My colleagues who are in Family Practice after they finish their assessments have an independent unrestricted license but my other colleagues who undergo assessments in internal medicine pathway 4 still have independent restricted license. I don’t think this is fair given both are supposed to undergo similar pathway 4 assessments. Also, my colleagues who successfully complete Internal Medicine assessments are restricted to practice in a particular setting i.e. hospital only or office only. In the US, an internal medicine license allows independent practice in both settings.
We need a more accurate definition on the change in scope of practice/
For example if a pediatrician limits his/her practice to behavioral issues, become famous as “psychiatrist” though he/she never promoted himself as a psychiatrist, is this a change in scope of practice? or simply it is not because he practiced in a subfield of pediatrics that he received some training in it and enjoys it and good at it??!!!!
I do agree with the concerns about having a few days course on something then switching the practice toward that field. On the other hand, an internist or a pediatrician might do a master’s degree (extensive 2 years study with research) in fields like neurology or allergy… without a royal college residency program and then focus his practice in that specific field, here I do not see a problem since the CPSO allows the physician to practice in the fields of medicine we are trained and have experience in. Having the royal college certification in such a case is not a must since we already have many subspecialists who had the fellowship training but did not pass the RCPSC certification exam and still allowed by the CPSO to practice in that subspeciality field because they have the training.
The CPSO needs to get clear answers when contacted, and to be within weeks (not months) in relation to possible changing scope of practice issue.
Your Changing Scope of Practice really is referring to a physician adding a new area of practice.
I am planning to retire sometime next year. In cutting back my practice, I am changing scope. For example, I’m no longer seeing patients with certain diagnoses that would require long-term follow-up. I’m also referring patients already in my practice with certain diagnoses to other physicians. So my change of scope is a reduction in scope. I don’t think that that is what you meant to include in your policy. Therefore, I think you should explicitly state that changing scope does not refer to voluntary downsizing or hiving off of parts of one’s practice.
It was puzzling when filling in the questionnaire for licence renewal recently. In the end, I said that I was not changing the scope of my practice, although in the broad sense of “change of scope” I am doing so.
I am concerned that the change in scope of practice policy is not reflective of a national standard. Rules/policies should be similar from province to province. The Royal College or College of Family Physicians should set the standard. The Royal College has recoginized that physician practice can change and have developed areas of focused competence giving rise to Diploma of the Royal College of Physicians and Surgeons. Should a physician who has changed scope but is unable to meet the Royal College requirements be permitted to practice in that modified scope? The Royal College would at least guarantee a minimal standard for practice.
There are a profusion of American medical boards which are not recognized by the American Board of Medical Specialties. These are sometimes referred to as “pseudoboards” and have been created to give an aura of respectability to a certain area of practice. These “pseudoboards” are made in America and should have no standing in a Canadian context. This is particularly true when the Royal College as with echocardiography and addiction medicine has an established Diploma Programme.
I am concerned that the role of the Royal College in setting a minimal standard of practice for the country is being ignored.
These comments echo the comments of a physician on May 3. He essentially says that if a Royal College accreditated process exists this should be the preferred route for determining competency.
that would be true except that the Royal College is too slow with the times-often 30 years behind in recognizing new fields of practice, and is more concerned with turf protection than competency.
As an example, the ABMS in the US recentily gave the “pseudoboard” ABAM, sub-specialty status. Many Canadian addictions are certified by this board, for which there is no Canadian equivalent.
Scope of practice does change as careers evolve. We graduate as undifferentiated physicians, I graduated as an oncologist, continued with training in hematology and stem cell transplant. My current practice does reflect this, but the world does continue to change so dramatically that constant training is imperative to maintain patient care. We encourage life long learning. This has to be acknowledged. We will change our practice from what we learned in our early training. that is why we need life long learning. MoComp records the ongoing learning, but is this taken into account when the physician is assessed? This should be included in the physician assessment. The assessor should have access to the details of the physician ongoing training. That would better inform the assessor of the physicians current state of training.
General Practice Psychotherapy AssociationRelated Topics
Changing Scope Application Form
Process and Timelines
Part of the application form – Giving membership. Only the Royal College and CFPC are mentioned. As Doctors do Change their Scope of Practice to Psychotherapy, the General Practice Psychotherapy Association – which is changing its name to Medical Psychotherapy Canada (GPPA/MDPAC)should be listed as that is relevant to the Changing Scope of Practice to Psychotherapy. Please add the GPPA/MDPAC to that Application Form.
College of Family Physicians of Canada: Certificant Yes O No O Year ______ Member Yes O No O
Royal College of Physicians and Surgeons of Canada: Fellowship Yes O No O Year _______ Specialty _______
General Practice Psychotherapy/Medical Psychotherapy Canada
Certificant Yes O No O Year ______ Member Yes O No O
Yes O No O Etc….Mailing Address
Hospital/Facility Name (if applicable) Street and Number Suite Number
Professional Association of Residents of OntarioResponse in PDF format.
I am submitting the following comments on improving the Change of Scope (COS) Policy of the CPSO
I have lived through the change of scope process with many physicians who have trained with us. Therefore my comments apply only to change of scope for interventional pain medicine (IPM).
The Change of Scope process, although well-intentioned, has been a frustrating experience for the user as the “rules” have kept changing over time and the communication from the CPSO has been less than ideal.
It seems that relatively simple decisions take an inordinate amount of time.
For IPM, it has decided that a physician with no prior experience in IPM has to spend a total of 900 hours in supervised practice with 450 of these under close supervision. After discussion with some of the thought leaders in IPM it seems to be that this is quite an arbitrary number of hours with no real evidence to support it. Surely it is more important to demonstrate competence rather than simply listing a number of hours of supervision.
At one time I was advised that relevant CHE taken before or during close supervision would count towards the first 450 hours. This no longer seems the case. The Change of Scope department will give “individual consideration” to previous experience and decisions to move from one level of supervision to another, but my experience has been that the decision process has lacked transparency and in some cases also seems quite arbitrary. I question whether the staff making these decisions have the clinical qualifications to do so, considering there are so many different change of scope scenarios.
In some cases it appears that the COS department accepts the supervisor’s opinion and in others does not. More recently, our trainees have been asked to track the total number of procedures performed. Yet we are aware that in other cases involving other pain clinics this is apparently not required. We are OK either way but the rules should be clear and consistent for all. If the COS process for IPM is going to ask for number of procedures performed as a criterion to move to a lower level of supervision, then a “hybrid” checklist process should be implemented which would allow a physician to be under moderate or low level supervision for some interventions and under high level supervision for others. If some type of checklist system was in place, we could hopefully obtain approval for a change in supervision status on a much more timely basis than is the case currently.
Some of the criteria for approving a clinical supervisor seem arbitrary. The requirements state that one has to be working 5 years in the clinical area before being considered suitable as a supervisor. This seems to disregard the number of hours one has worked in favour of a fixed time period. This has resulted in some physicians being approved to be supervisors with less than 5 years of experience and others with more clinical time to not be approved. When I have asked about this, I have been advised that the reasons for approving an individual supervisor are confidential. Again more transparency and consistent criteria are required.
We have recently received a new directive from the COS department that a recent trainee in IPM is not allowed to see patients for consultation and recommendations for non-interventional pain treatments, prior to having his supervision and training plan approved. A family physician with a general license would be allowed to do so without any restrictions from the CPSO. The restriction should only be not to provide interventional treatments until supervision and a training plan is approved..
When changes to the requirements for COS are being contemplated, these should be communicated well ahead of time and the membership and qualifications of any advisory committees should be known to the relevant professional community ahead of time so that timely feedback can be provided.
Finally, there needs to be some type of timely appeals process when a trainee disagrees with a decision of the COS department.
I am happy to make myself available for further discussion to clarify any of the above observations.
Thank you for the opportunity to respond to the request for current regarding the CPSO Change of Scope of Practice. Clearly this is an extremely complex issue and there are no simple answer because of the large number of factors involved. In regard to the clinical provision of psychotherapy within Primary Care medicine the reality is that there are many factors. Psychotherapy is a diverse clinical service because of variations in theory, also differences in the practice of psychotherapy, also in what could be called formalization of therapy (i.e. “manualized” types of psychotherapy) and in the intensity and frequency of therapy (some forms more than one per week). An additional complication is the mode of therapy (individually group therapy/couples therapy, family therapy).
The OMA Section on Primary care Mental Health has been very involved with many educational programs and CPD programs which educate and train physicians in various attitudes skills, and knowledge in the area of primary Care Medical Psychotherapy.
There are also other teaching organizations which have other educational offering in this area of practice.
These educational offerings are clearly potentially important in regard to the CPSO Change of Scope of Practice requirement(s). Although I will not go into in detailed here, that although some of the programs do not still exist in their original form, I do know of others newer programs that now exist or are in the process of being developed that may help the CPSO in their seeking to develop a basic curriculum for all physicians who choose to change their Scope of Practice to Primary Care Medical Psychotherapy.