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We need a longer than 2 years absence and we need what courses and educational updates indulged in,,we need a Peer review like assesment not a Board exam and situationally applied but appropriately .We need Asses to represent DIVERSITY,No MONO ETHNICITY!!
I think the original policy of 3 years absence/re-entry should remain.
Clarification should be made if someone returns to practice but subsequently returns to a sick status (totalling less than 2 years; how should this be approached?
Alternatives to monitoring by a colleague and practice assessment should be considered. Public safety can be addressed without the degree of intrusiveness suggested re this degree of intervention. For example, a comprehensive review course plus peer review may be appropriate.
The Royal College of Physicians and Surgeons determines the ability to practice in a specialty. This should apply, regardless of whether it is a new physician, a physician trained abroad or a physician changing scope of practice. The RCPSC is well equipped to assess competence for a new skill set. The CPSO provides expertise in assessment for practicing physicians. Allowing a change in scope of practice without a formal examination process may allow for individuals who were not acceptable to the specialty to practice. This would be without formal training or testing. When no RCPSC training exists, this may be the only option. When a residency exists and the scope of practice matches the residency program, the CPSO should endeavour to ensure competence by working with the RCPSC. The CPSO should insist that formal residency programs be used for teaching and RCPSC exams be used to assess competence for all doctors. Physicians personal needs change and practices will need to adapt, but it doesn’t mean that this is always good for patient care.
2) Physicians in part-time practice (physicians who have practised less than six months in the preceding five-year period) are no longer captured by the policy. As I work only two days a month as an OR assistant, does this exclude me from CME requirements? The job never entails any contact with the “awake” patient. So many questions with no answers or direction.
I am writing in regards to the consultations regarding change in scope of practice.
I do not think it is the intention of the policy to have a physican notify the college of a reduction in the scope in practice, although this could be considered a significant change in scope of practice.
i.e. if a family doctor decided to stop doing obstetrics.
I believe the policy should be explicit in excluding a reduction in scope of practice from its change in scope in practice.
Thank you for this opportunity to provide feedback.
Re: Draft policy, “Ensuring Competence: Changing Scope of Practice and/or Re-entering Practice”
First, this email contains two conflicting policies: the one focused on Scope to be discussed in detail below essentially states “do not practice outside your scope,” while the emergency one states, “it’s okay to practice outside your scope sometimes.”
The premise of the Scope draft may be summarized as follows (if you feel this is incorrect, please consider the draft’s language as flawed in that is broad, far-reaching, and prone to misinterpretation): the college must determine every physician’s scope before a physician takes any action, even if it is in a manner which they have been trained and feel safe and comfortable doing, with medical evidence backing their decisions, if said action differs from their current practice in any way temporally, geographically, administratively, systemically, or clinically.
This is in direct conflict with another draft policy in this same email chain, “Physician Services During Disasters and Public Health Emergencies,” which states that physicians can act outside their scope during emergencies. Now, why would physicians be allowed to act out of their scope during an emergency? Perhaps because they are doctors and we generally consider them as competent? Safe? Capable? Genuine? Honest in that they only work in the fields they are trained in? The answers are obvious.
Then why do we put the plethora of blanket restraints on physicians thinking about making the slightest change in their practice (ie. Taking a locum weekend in Sudbury – different practice environment, appendix 1 page 1; taking call at a local hospital after working in outpatient care for >2 years – different practice environment)?
Moreover, while the change from one specialty to another (orthopedic surgeon wants to practice in cardiology) is an example that just about everyone would agree would require some formal training before a scope of practice change is approved, this item is less obvious when it comes to family medicine physicians, who can practice to some degree in any field of medicine, especially when the scope of a family physician overlaps with that of a Royal College specialist. An example of this might be found in the field of pain management, where a family doctor might engage in medical management or minor joint/tissue injections, while an anesthetist might perform an epidural. While nobody would question the anesthetist’s capacity to perform an epidural, few would assume that the average family doctor can do the same competently and safely. This is where the focus of this policy may need some clarification, as the majority of this draft appears to refer to family physicians who have the inherent capacity to dabble in multiple fields, while few specialists are expected to change specialties altogether. Nonetheless, the policy does not state that it’s focus is on family physicians. Perhaps it should, or the CPSO will be inundated with an insurmountable volume of requests from specialists for what they are guessing is a relevant change within their specialty (due to the vague language within the draft), yet is likely not a significant difference (i.e. anesthesiologist moves from Hospital A, where there is a heavy neurosurgery and trauma practice, to Hopsital B, where there is more bariatric surgery – does the Scope department need to approve this change for this specialist? Per this draft, the answer appears to be, “yes, they do, or the physician will suffer consequence,” yet, few anesthesiologists would consider that a relevant change in scope of practice. If you clarify that this is for family physicians, primarily, then this may improve the focus of this draft dramatically.
Furthermore, while the principle of patient safety is to be considered paramount in our collective medical and surgical professions, this draft may result in a massive burden on the scope department in the CPSO if all physicians (how may specialists and FM docs in Ontario?) start sending in scope assessment requests for every little change (locum, call, new hospital/clinic/neighbourhood, and nuance change in patient base). The department will be drowned in requests, inundated with delays, and become exceedingly expensive to maintain, and for what? To promote common-sense safe practice from a profession of people who are generally conscientious, study hard, and follow the rules anyway (even when the CPSO hasn’t spelled out how to do common sense things like, “practice within your scope only.”)
So why would one expect the department to suddenly be so flooded with requests?
This draft screams of over-reaching policy in that it is quite broad, open to interpretation, and puts the onus on physicians to be conscious of any minor practice change months in advance and to report it very early to the college. For a profession (MD’s) that follow rules at baseline, this may be interpreted as, “every time a physician chooses to make a change in life or career, like taking a new job or accepting a performing a ‘new’ procedure (i.e. anesthesiologist confused if she’s allowed to place an IV in the foot after having placed IVs in the arms and neck for the last 4 years straight), physicians should ask the CPSO’s permission and wait several months before making any life choices.” This will swamp the College with requests for Scope assessments (multiple per physician per year TIMES # of MDs in Ontario TIMES estimate of docs who have a dynamic practice – my guess 75% = 10’s of THOUSANDS of scope assessment requests annually!!!!!).
If this happens, the college will likely take many weeks if not months to process each application and meet to make each decision, effectively eliminating all acute care other than in large institutions where there is a great degree of variety of cases (otherwise the cases may not repeat q2-years). Furthermore, this type of draft language would also deter physicians from advancing medicine, of course, if they fear CPSO reprimand for being current or bringing in new technologies or procedures to Ontario.
Specific Examples of Problematic Language in this Draft:
1. Page 5, lists “practice environment” with an associated footnote that are too broad and easily misinterpreted (“colleague supports, access to resources, payment systems, geographic or health system demands”). This needs to be better defined or, better yet, removed from the document. It WILL cause many more problems than it will solve. If you choose to redefine it, please do so exhaustively, with several rounds of peer review for each specialty and practice environment to clarify the details of what constitutes a significant change in “practice environment.” After all, how can you ask a physician to know what is a significant practice environment change if the CPSO does not have a comprehensive continuously updated database for comparison of all practice environments, clinics, staff, or as you stated, “colleague supports, access to resources, payment systems, geographic or health system demands”:
a. Example 1: For example, a family medicine physician may be covering the emergency department and act as the hospital’s chief medical officer in Kingston, ON, while also practicing in an outpatient walk-in clinic in Greater Napanee, where she is from, on Saturdays. She then decides to take a new position at a Scarborough, ON, hospital in hospital-based outpatient family medicine unit with no administrative or emergency responsibilities. To her, it appears that she is narrowing her practice, but per this draft document, she has changed her “practice environment.” Will she now lose her license because the CPSO administrative staff interpreted this bluntly as a move from Kingston to Scarborough, where the population is more “urban” [quoted from Appendix 1, Page 1, last line] and where almost all criteria in the footnote on page 5 of the draft are met (“colleague supports, access to resources, payment systems, geographic or health system demands”)? Or will the CPSO consider this career move as perhaps-temporary narrowing of her practice? Or will CPSO provide us with an exhaustive list of examples not necessitating oligarchic CPSO approval for every life decision a physician chooses to make, which might decrease the number of unnecessary scope assessment demands? Since she did not report it as she did not consider this a change in scope, who will assess her career move (physician or secretary or administrator)? Who will confirm that this is indeed a narrowing of her practice? Will she lose her license? Will it be suspended? Will she be publicly shamed on the CPSO website? Will CPSO’s administrative hang-ups and delays cause her to lose her job? What will the delay be if every physician in Ontario now has to notify CPSO when they move a few streets over to a new clinic or office (technically, this qualifies as a change in “practice environment,” defined in the footnote as “colleague supports,” or “access to resources” [may be a different LIN], or may have different “health system demands” because of greater or lesser preponderance of any type of patient (i.e. young, old, cancer, no cancer, heart disease, lung disease, ….).
b. Example 2: A young anesthesiologist, graduated from U of T, completed a fellowship McMaster. Like many young anesthesiologists, he is having trouble finding stable employment (the MOH isn’t increasing funding for surgeries at some profound rate that necessitates more surgeons, or more anesthesiologists). Hence, he is doing locum tenens in anesthesia. Every 1-4 weeks, he changes his “practice environment.” Sure, it’s an operating room either way, but it’s in a different level of “urban” density, with differing “health system demands,” different “access to resources,” and different “colleague support.” Does this mean he is an incompetent anesthesiologist as soon as he steps foot into a new building or hospital? No. Does this mean that he would practice unsafely? No. Every hospital has a training period (orientation, of sorts) to acclimate to the work environment, to be aware of healthcare system needs, and to be cognisant of the support that is available (or not). CPSO does not need to involve practice environment in this policy. Please remove “practice environment.”
c. Example 3: Young orthopedic surgeon. 2 fellowships (hand and spine surgery). Most pleasant and considerate physician. She can’t get operating room time because the hospital budgets are limited and more senior surgeons are already in the ORs, so she works in several clinics. If she moves from one clinic to take on a new clinic role, will she be reprimanded? Does she even need to report? This policy suggests, “yes, she does!” because she has changed her practice environment. That’s insane. Who will process all of this paperwork every time every physician in Ontario makes any life or career choice? How much will that cost the taxpayers? Or will membership be $47,000 annually simply to fund the scope assessment group?
d. Example 4: Gynecologist who doesn’t take call because she doesn’t want to anymore and takes on administrative duties instead. She’s the Chair of her department and has been working there for 32 years. 4 of her department staff get norovirus and are hospitalized for treatment. She is asked to take call for a day or two while they recover enough to resume their duties. During call, however, the “access to resources” differs, as do the “health system demands,” as well as the “colleage support.” Hence, per this policy, she has to tell her norovirus-ridden colleagues that she cannot take call because she would have to send an application in to the College and wait 2-3 months for processing/meetings/discussion/supervision/supplemental documents, which would make it impractical. Because this CPSO document didn’t allow her to follow safe, common sense, a young 16 year old girl with an ectopic pregnancy and significant occult bleeding was not seen due to a lack of staffing and died during the night. Is that the kind of policy you want to institute? Just get rid of this point re: “practice environment.” It will cause many many more problems than it will solve.
e. Example 5: Family medicine physician doing locums at 2-4 weeks notice. Can’t do them anymore. CPSO cannot process a “practice environment” assessment in that time because this policy has resulted in a backlog after the volume of applications has grown by 25,000 new applications per year and the Scope of Practice department hasn’t gotten more funding (no new people). The public doesn’t want to pay more tax dollars for this. Physicians certainly do not want higher membership fees for something this ill-designed, even if the core idea of patient safety is there. Remember, physicians are inherently rule-abiding, safe, and conscientious people with an immense degree of education and responsibility. We don’t want to do anything stupid and we try very hard to know everything we can to avoid any errors, ever. If you create this rule, we will ALL follow it and it will bog down the entire CPSO organization. It’s just not a great outcome for the spirit of this policy. That part (“practice environment”) should be removed.
f. Example 6: General surgeon. Works in the OR. Walking in the hospital food court when someone codes. He initiates CPR, calls a code and facilitates help with appropriate emergency measures. Patient survives. One of the patrons of the food court works for the Toronto Star, publishes this example of a “hero doctor.” Will he be punished because the food court “practice environment” differs in, “colleague supports,” “access to resources,” “payment systems,” or “health system demands”? According to this draft, what he committed was a crime. Nonsense, right? Perhaps a dramatic example, but it emphasizes the fact that this document is deeply flawed, especially in regard to, “practice environment.” Please remove “practice environment.” It doesn’t help. It will only cause harm.
g. NOTE: If you choose to redefine “practice environment” instead of deleting it, please do so exhaustively, with several rounds of peer review for each specialty and practice environment to clarify the details of what constitutes a significant change in “practice environment.” This means every hospital in every city. You will need to know all of that information anyway if you choose to implement this policy. Otherwise, how could you assess any of us? You have to know all the details yourself, otherwise how could you possibly decree that one hospital is similar enough to another or that one office is sufficiently different from another. Absurd? Yes. So just get rid of this point.
2. Appendix 1, Page 1, Line 23, point iii cites, “A physician is changing the focus of his or her practice to an area in which he or she has not been active for at least two years,” as an example of a condition under which a physician must report to the Scope group to get a Scope assessment. This is a vague statement. How is “focus” defined? Is it related to academia? The research and teaching one does associated with one’s university hospital practice? Is it related to a number (40% female last year; 62% female patients this year)? Does it related to rare diagnoses (i.e. erythromelalgia, complex regional pain syndrome, or lipodystrophy, as examples which are not common enough for the average physician to see such patients every 2 years, even though they will likely be competent enough to treat these patients)? Is it related to procedures (ortho surgeon had an 80% focused practice on Bones X, Y, Z and joints A,B,C, now wants to also focus on Bones Q, R, S and Joints D, E)? I think you get the point. It’s not clear. Please clarify what a focus is. May I suggest that you add a statement akin to “This does not refer to a limitation on management of cases, diseases, fractures, infections that have not been seen by the physician for any period of time.” They will continue to be comfortable treating these conditions/cases/fractures and, if they aren’t, they will consult other physicians to do so. The management doesn’t change and we live in the era of evidence-based medicine, so we all reference new evidence/literature to make our daily decisions.
a. Example 1: Psychiatrist, practicing in geriatric psych only. Her patient’s teenage granddaughter accompanies her to the visit. Being astute and recognizing body language, the psychiatrist asks about home life and how the teenager is doing. She says she’s been depressed for a long time and is now ready to think about suicide. As a psychiatrist, she is well equipped to deal with this, but her patients are geriatric. Per this CPSO draft, can she help this patient, who may need emergent help (note, this draft’s language will leave the psychiatrist whether or not to engage in further conversation or care, but CPSO response time on such matters will take longer than her enounter). Why the confusion? Because this is a pediatric patient, technically, and it has been more than 2 years since this psychiatrist had a teenage patient encounter. Absurd? Yes. The draft should be better defined to clarify that subsets of one’s practice do not require re-training/scope changes.
b. Other examples: A family practice physician sees a case of complex regional pain syndrome for the first time in 7 years. She recognizes it and knows how to treat it. Can she? She should be allowed to. Please clarify this. Another: A dermatologist sees a case of erythromelalgia for the first time in 12 years. Still knows what it is. Another: A cardiologist sees a Brugada ECG for the first time in his career (outside of literature). Knows how to handle the case. Is he allowed? Of course. Who else but a cardiologist? Another: An ortho surgeon hasn’t had a navicular bone fracture in 3 years. One comes in to the ED. He has done the surgery many times before. Can he? Of course he’s competent enough to do this small surgery. An internist sees a case of pulmonary fibrosis, retinal hemangioma, skin infection from travelling to the Caribbean or southeast asia for the first time in a few years. Can they treat? Yes. They know how and are competent. Please change the language to clarify that the 2 year timeline does not reflect subsets or subpopulations of one’s current practice.
3. An entirely different concern regarding the above citation, Appendix 1, Page 1, Line 23, point iii, “A physician is changing the focus of his or her practice to an area in which he or she has not been active for at least two years.” It is currently 3 years. What evidence does the CPSO have that physician competence falters after 3 versus 2 versus 17 years of not performing something or managing something or diagnosing something? If the answer to this question is, “we don’t have any evidence and we just pulled this number out of ****,” well then please leave it at 3 years because you have no idea whether the ideal interval is 2 years, 1 year, 1 month, 5 days, or 20 years. It’s wrong to make arbitrary decisions that cause hardship and extra paperwork for others, limiting patient care with delays in the process. We’re a profession that helps people. Do no harm. Remember that. These policies aren’t benign. Do no harm. Please.
4. Appendix 1, Page 2, lines 36 and 37, cite “physician who practises chronic pain management but who wishes to practise interventional pain management.” There are two points of contention here. The first is directly regarding the lack of definition of “interventional” vs “chronic pain management” WITHOUT mention of specialist training. If you are talking about family physicians who do medical management of chronic pain requesting a change of scope to perform epidurals, which might be the case, then please say so. If you are talking about selective training or privileges earned through peer-education, that`s different than formal fellowship training, and yet that is not clarified in any way. Please clarify and define in detail what “chronic pain management” is an how it differs from, “interventional pain management,” per the CPSO definition. Also, please note, that in many medical circles, these two titles are one and the same (also known as comprehensive pain management, or multidisciplinary, or collaborative to include the psychological support accompanying chronic pain as well as the physiatrist-like patient education about body mechanics and rehabilitation). To the CPSO, apparently, these are very distinctly defined. Please make that distinction public, not just as part of this document but in general on the CPSO website. The second point of contention here reflects the broader issue of publicizing the definition of Scope of Practice for each specialty or field of practice. If this is not formally defined (and it alarmingly may not be), please seek new consultation from each field to do so and then publicize those drafts.
These questions may appear pedantic, but this level of rigor and detail in defining policy should be a standard within the College, if such a document is to be published at all. Further to this point, the documents suggests that physicians contact “Inquires” at the College, which appears to be front-line administrative service that either does not have the capacity to commit to an answer to this sort of question, or have been instructed not to do so. Try it. Use your cell phone, block your caller ID, and call 416-967-2600 ext. 221. Use an example from the draft document. Tell them you are a physician practicing in chronic pain and want to convert to interventional pain as a label. Tell them you thought it was the same thing, especially since you’re an anesthesiologist (or neurosurgeon, or neurologist, or anyone else whose scope logically involves performing nerve blocks or epidurals). See what they say. Record it. The CPSO is known amongst our medical community for not holding the same set of standards for two similarly trained and educated physicians after a request like this is submitted to the college. There is no safety, no oversight, and no pre-defined process for physicians. If you choose to leave these statements as part of the document, please provide an immeasurable amount of definition so that there can be due process and evaluation.
On that note, please do not waste tax dollars. Extra paper means you need more assistants. We get it. Your budget might grow if you give yourselves more work, but these are collective tax dollars. If you waste them for us, then we (Ontarians) don’t have them for something else that truly makes sense, is worthwhile, or something that we genuinely need (like MOH funding for any number of care lines).
I successfully changed my scope of specialty practice in orthopaedics from office and locums to office alone (no further locums). As time went on office work has included an increasing volume of MSK IME work. With a subsequent change in location (with available specialists at hand) my office practice (pts referred by GPs) has dwindled. My IME practice has increased. I still do exactly the same kind of work in IME evaluation (using my clinical skills honed from years of practice) but, beyond written recommendations for rehabilitation, I am no longer involved in providing treatment.
How best may this pattern of work change be considered?
Professional Association of Residents of Ontario
Response in PDF format.
I have read the draft document on Changing Scope of Practice, and have several comments related to its specific application to physicians wishing to change practice to Fertility Medicine (specifically family physicians and gynecologists).
I have completed a RCPSC subspecialty residency in Gynecologic Reproductive Endocrinology and Infertility (GREI). This followed my prior completion of an RCPSC residency in OB-GYN in another province, and several years of independent practice as a general OB-GYN with a focus in fertility medicine. Having practiced in the area of fertility medicine prior to completing subspecialty training, I feel I can provide unique insight to the value of having the necessary training in order to practice safely and effectively.
Prior to my GREI training, my practice was mostly based at a fertility clinic. My experience in diagnosing and treating fertility patients was initially limited to my exposure during my OB-GYN residency, and then added with personal experience during practice. My colleagues at the clinic were a mix of general gynecologists with a focus in infertility (with more than a decade of experience in this area), as well as one US-trained REI physician. Even in that environment with knowledgeable colleagues, my knowledge was inadequate, and my ability to provide appropriate care lessened by this lack of knowledge. When the REI-trained physician retired, the person with the most knowledge was gone, and then it was even harder for me to gain the knowledge I needed. This was one motivating factor for me to complete subspecialty training, so that I had the expertise to provide safe, effective care for my patients. Looking back at how I was practicing and knowing what I would do differently now with appropriate training, I feel very strongly that there is no substitute for formalized subspecialty training, where this is available. It really becomes a case of “you don’t know what you don’t know”.
My point in writing this is to focus on specific circumstances where a physician without comprehensive training in fertility medicine may be unknowingly putting patients at risk. More precisely, these include:
1) Ovulation induction and/or controlled ovarian hyperstimulation with oral agents:
Although ovulation induction with oral agents has historically been a relatively simple treatment for women with ovulatory dysfunction, the indiscriminate use of these medications without monitoring for ovarian response is harmful to patients both from the sense of wasting their time (which in the fertility world is a very real problem for future success), as well as potentially inducing unintended ovarian hyperstimulation, with the increased risk of multiple pregnancy. In the setting of intentional controlled ovarian hyperstimulation, again the potential lack of monitoring (i.e. use of transvaginal ultrasound to assess for ovarian follicular response) can put the patient at risk for no response or over-response, both of which are harmful.
2) Controlled ovarian hyperstimulation with injectable gonadotropins:
Use of injectable gonadotropins is a complex treatment for infertility, with significant risks if used indiscriminately. Namely, the high cost of these medications can place the patients in financial harm if not used appropriately and with appropriate counselling, and the potential for a significant over-response, resulting in both ovarian hyperstimulation syndrome (OHSS) and multiple pregnancy cannot be overstated. The ability to treat patients who have these complications (specifically OHSS) is not something that most physicians have any experience with, as they generally only occur in patients undergoing ovarian hyperstimulation, and safely managing these complications requires both training and experience.
3) Invasive fertility procedures such as intrauterine insemination (IUI) and in vitro fertilization (IVF):
Use of assisted reproductive technology (ART) such as IUI and IVF requires a much more comprehensive knowledge of reproductive physiology and equipment and expertise not usually found outside of fertility clinics. Physicians wishing to utilize these technologies should need to have specific training for processing of sperm, and/or be working under the supervision of REI-trained physicians if performing IVF procedures.
I do not inherently have a problem with physicians wanting to expand or change their scope of practice to include fertility medicine. However, I think it is important to recognize that to receive GREI certification requires completion of a 2 year subspecialty residency and passing a RCPSC examination, after successful completion of a RCPSC OB-GYN residency (minimum of 7 years training). To suppose that this training is superfluous and that one can practice equivalently without such training is to understate the value of a clinical fellowship. I speak from personal experience in knowing that my practice is safer, appropriate, more effective, and more comprehensive with the training I received. If physicians wish to add fertility medicine into their practice model, I think at a minimum, there needs to be processes in place so that patients receiving ovulation induction or ovarian hyperstimulation are monitored for appropriate response, and that use of injectable gonadotropins for the purposes of female fertility treatment be restricted to those with recognized training in reproductive endocrinology and infertility, or be working at a clinic with individuals who have such expertise. To start using these medications in a typical gynecology or family practice clinic without the additional equipment and resources of a fertility clinic is really not meeting the standard of care and setting patients up for potential harm. Certainly in Ontario there are an abundance of well-qualified fertility doctors and clinics who can provide these services, and those wishing to add this area of medical scope into their practices should consider aligning themselves with such individuals/clinics in order to provide the best care possible to the patients of Ontario.
I am writing in response to the changing scope of practice draft.
I would like to express for concern for the process which allows a change in scope of practice without having a rigorous process to ensure adequate training. I practice in gynecologic reproductive endocrinology and infertility, and I have completed a 5 year fellowship in ob/gyn and 2 year subspecialty training. This training is important to ensure the physician is providing the best patient care, and clinical experience in the area does not replace it. For example, training focuses on the medical knowledge of physiology, anatomy and endocrinology of REI but also important aspects such as the ethics and legal issues in this very regulated area of medicine. There are covered in the objectives of training and any training assessed for equivalency should ensure the objectives of training were met in the comparable training which is provided as evidence of ability to practice in this area.
I also believe the Royal College is devising and process to allow for assessment of equivalent training and which would allow practitioners to have their training assessed again the royal college objectives and challenge the exam to receive subspecialty certification for GREI and all of the other specialities. How will this be incorporated and used? I am worried that the CPSO process will serve to undermine the royal college process and allow someone to practice in an area who may not meet the more rigourous royal college criteria.
I have read the document regarding change of scope of practice. I am a Canadian Ob Gyn, with American REI fellowship training. My concern is regarding a family doctor or general Ob Gyn choosing to change scope of practice to infertility that requires the use and monitoring of gonadotropin administration for ovulation induction or controlled ovarian stimulation.
Gynecologic Reproductive Endocrinology and Infertility (GREI) is an accredited and certified subspecialty of gynecology under the Royal College of Surgeons of Canada. To become a certified REI in Canada requires the completion of a 5 year Ob/Gyn residency and an additional 2 year Subspecialty Residency in one of the 8 training centres. Please see
Fertility treatment and management is not without risk in the absence of the required training and experience, including but not limited to risk of (life threatening) ovarian hyperstimulation syndrome and multiple pregnancy. Current REI fellowship of 2 years during require a minimum of 1 year of clinical REI exposure.
It is unclear to me how a FD or general gynecologist can be approved to change scope of practice when subspecialty training requires a minimum of 7 years of Ob-Gyn then GREI training.
I highly agree with this statement, broadening the implications to all Royal College specialties and subspecialties.
How can the CPSO take ownership of the credentialing process to equivocate a family physician’s apprentice-like practice to any supspecialty physician, like an electrophysiologist, GREI, any surgeon or subspecialty surgeon, dermatologist, rheumatologist, oncologist, hematologist, anesthetist or subspecialty interventional pain management trained anesthetist, gastroenterologist, or any number of other specialties/subspecialties that the Royal College requires years of structured education and training for? Aside from being misdirected, it screams lawsuit waiting to happen (…”but CPSO let me do it.”)
OMAResponse in PDF format.
Medical Psychotherapy Association of CanadaResponse in PDF format.
I am concerned that the proposed guidelines do not respect the separation of powers which are that:
1. the CPSO has legal responsibility to protect the public by setting requirements for licensing physicians to practice medicine
2. the clinical Colleges (CFPC and Royal College) are responsible for setting education and training standards, accrediting programs and certifying physicians as competent in specific specialties
3. the faculties of medicine are responsible for devising and delivering education and training programs which meet the clinical Colleges’ standards
4. the hospitals/health services are responsible for granting clinical privileges/credentialing physicians to provide a range of clinical services hosted by their agencies.
There are many problems with the draft document developed by CPSO. In my view, the fundamental problem is that the document exceeds the responsibility of CPSO. Although stated as “guidelines”, these types of documents produced by the licensing authority quickly become absolute rules which are then used by risk averse health service managers to justify limiting or closing services to the disadvantage of people who need the services most in underserviced rural, remote and Indigenous communities.
I suggest a constructive and collaborative approach to ensuring safe emergency medicine care for people everywhere in Ontario. COFM, CPSO and OCFP could agree to hold a symposium on this topic guided by the Directions and Actions set out in the attached Rural Roadmap for Action.
OMA Section on Chronic PainCPSO,
The OMA Pain Section appreciates the opportunity to provide feedback regarding the draft policy “Ensuring Competence – Changing Scope of Practice and/or Re-entering Practice.” We recognize the unique role the CPSO has in ensuring patient safety and physician competence. As many of our members are CPSO Peer Change of Scope Assessors in Interventional Pain Management, we appreciate and strongly support the CPSO’s mandate of self-regulation. From experience, we believe the CPSO currently performs an excellent role in ensuring high standards of Change of Scope into Interventional Pain Management.
We wish to expand on the OMA submission on College Review Process(Page 4). In broad strokes, we agree with the submission that the CPSO should defer to the professional body of a medical specialty (ie. CFPC, RCPSC etc.) and/or other educational experts in determining competence for medical practice. At the present time, there exists no specialty of Interventional Pain Management (IPM). At which time the specialty is established by the CFPC and the RCPSC, the present educational standards and experts should be maintained. As the majority of IPM practitioners in Ontario are currently certified by the CFPC, which has not expressed a desire nor at present has the capability of performing this work, we feel the CPSO processes currently provide an excellent framework. Moreover, in the interests of patient safety, the present experts should at all times, now and in the future, assess practice in community interventional pain clinics.
Moreover, it is our opinion that a change of scope of practice in Interventional Pain Management should be required in the community setting at all times now and in the future for all specialties including anesthesiology. It should be based on regulations and processes presently in place to maintain the current high standards and ensure continued patient safety. This is based on our experience of a lack of training of practicing anesthetists in interventional pain management techniques such as nerve blocks for chronic pain. We believe this is a safety issue and all specialties should be included in the Interventional Pain Management change of scope processes now and in the future.
The OMA Pain Section appreciates the invitation to partake in the consultation. We are pleased to have this opportunity to work closely the CPSO to enhance patient safety and ensure high standards for all Interventional Pain Management practitioners now and in the future.
OMA Section on Chronic Pain
Information and Privacy Commissioner of OntarioResponse in PDF format.
The “significant change in practice” is difficult to define but switching from urban to rural practice odes not appear to be a valid criterion. Throughout 50+ years of practice I practiced in both settings ranging from AHSC to small town practice. The principles of good practice are constant and these principles (arguably) must not change. Compassion, service, trustworthiness and altruism must continue as must patient centred care. The latter takes into account the physical, social and psychological circumstances of the a person’s life and clearly should continue. Every setting has its variances in routines as I learned moving from Toronto to Calgary to London and finally Picton Ontario. What remained immutable were the fundamentals of being a caring and competent physician and surgeon.
The variances note above do not constitute a significant change is scope of practice.