Ontario Medical Association (OMA)

Response in PDF format:

Please see attached. I agree with the CAPA response and would like to point out that a 2 business day timeline for physician oversight is not a marker with any proof of validity for patient safety. Even if we assumed this could be proven in one setting, it would not be a universally appropriate safety measure. For example, in the ER or OR a 48 hour window for oversight could be much too long. In a Primary Care setting if a stable patient needs medication renewal before their new doctor can onboard them, this requirement could cause harm by blocking access to care (unless the patient bogs down the system another way). 

I  appreciate the attempt to standardize things for public safety, but I don't think the nuance of different medical fields and situations can be so simplified. I worry that this rule could set back my profession,  and set back the Healthcare system for Ontarians. 

The College is charged with maintaining public safety and arbitrary guidelines raise the question - is standardizing rules unjustly to attempt to prevent theoretical risk worth creating absolute risk for patients that will subsequently have problems accessing care. 

I hope we put patient care first. 

Peel Public Health

Good evening,

Thank you for the opportunity to comment on this consultation. I am providing comments on behalf of Peel Public Health based on our experience with inspecting non-healthcare settings that have delegation of controlled acts to non-regulated individuals for cosmetic purposes. Public Health Units do inspect non-health care settings like personal service settings (e.g. medi-spas), where non-regulated individuals may be providing a delegated service involving a controlled act under a medical directive and there are no regulated health professionals onsite.  Please find below comments related to this consultation:

General question about applicability

Are delegations to non-regulated people who perform controlled acts for cosmetic services, such as botox and dermal filler injections, in a non-health care setting such as a personal service setting, in scope for this document? If yes, we recommend that it is stated in an applicability section. If not, we recommend to add a specific section regarding delegations to non-regulated people in non-health care settings.

Definitions: Delegation

For the section “Delegation is a mechanism that allows a regulated health professional (e.g., a physician) who is authorized to perform a controlled act to temporarily grant that authority to another person (whether regulated or unregulated) who is not legally authorized to perform the act independently.” We suggest a time-limit be specified in the written medical directive for the delegation to a non-regulated person in a non-health care setting.

How to delegate, Use of direct orders and medical directives

For the paragraph “Physicians must delegate either through the use of a direct order or a medical directive that is clear, complete, appropriate, and includes sufficient detail to facilitate safe and appropriate implementation (see the Documentation section of this policy for more information).” We suggest that the wording specify that the delegation under a medical directive must be in writing. We also suggest specifying in this section or the documentation section that the written delegation must be kept on-file in the physician's office and that the written delegation must be kept onsite where the person with the delegation is performing the service. We recommend that the section specify that the written delegation should be made available to anyone who requests to see it (e.g. client/patient, employer, public health inspector, etc).

Delegating in the context of a physician-patient relationship

We suggest to clarify how the physician-client relationship is to be established for non-health care settings like personal service settings (e.g. medi-spas), where non-regulated people with a delegation are providing the service to a client (aka “patient”) and there is no regulated health professional onsite. We also suggest to clarify how, in a non-health care setting, the physician ensures patients/clients are being informed of who is the delegating physician, such as stating that the delegating physician information must be posted publicly in the setting. We also recommend to clarify whether controlled acts in a non-heath care setting are one of the “instances” where it is not necessary for a physician to be onsite to supervise and support the delegate.

Supervising and Supporting Delegates

We noted the statement that physicians must be available to delegates for consultation and assistance (e.g. in person with short notice, or by telephone). Public health inspectors have observed delegations from surgeons and anesthesiologists to non-regulated people to provide cosmetic injections in a retail business (a non-heath care setting). For this type of delegation, could the policy outline how physicians performing this type of practise be readily available to provide consultation and assistance to the delegates? For non-healthcare settings, it would be useful to clarify how physicians could ensure the delegate is providing information with respect to the delegation to the delegate’s clients.

Documentation

Could the CPSO provide a delegation medical directive template with all the required documentation elements listed? This will facilitate consistency.

Comments related to the CPSO Advice to the Profession: Delegation of Controlled Acts 

Considering and Evaluating Delegates

The document provides little advice regarding delegation to non-regulated people, such as lay people injecting botox and cosmetic fillers, applying energy to skin tags and “zapping” spider veins using electrocoagulation. We suggest adding a specific section to the Advice to the Profession: Delegation of Controlled Acts document regarding delegations to non-regulated people in non-health care settings.

Appropriate supervision and support

It would be helpful to specify whether controlled acts performed for cosmetic services in non-health care settings, by non-regulated people are considered low risk. 

Quality Assurance      

The Advice to the Profession notes “Tracking or monitoring when medical directives are being implemented inappropriately or are resulting in unanticipated outcomes can help monitor the effectiveness of the delegation process.”  We suggest to provide more specific direction in the delegation for the person who is delegated to report lapses, breaches, unanticipated outcomes. How can a physician monitor this in a non-health care setting?  

It would be helpful to outline who has jurisdiction or responsibility to follow-up in situations where non-regulated people are performing a controlled act without a delegation?

Training never seems to be mentioned in detail in the delegation process.  The focus is usually on the delegation process and then oversight pieces.  It would be nice to have some explicit language around minimum on the job training for delegated acts (i.e who is responsible for training, evaluating/auditing, documenting training scope, etc). 

Ontario Trial Lawyers Association (OTLA)

Response in PDF format:

The CMPA suggested Delegation of Controlled Acts reference advising physician to discuss liability protection for members of staff.  I agree.

Dear CPSO Policy Committee,

I write to express serious concerns regarding the proposed amendments to the Delegation of Controlled Acts policy, specifically the restrictions on delegation in the absence of a physician-patient relationship and the proposed requirements for recent clinical assessments. While patient safety must remain paramount, these amendments risk causing substantial harm to healthcare access, system efficiency, and patient outcomes across Ontario.

1. The Healthcare Crisis Context

Ontario's healthcare system faces unprecedented pressures. Emergency departments report record wait times, surgical backlogs continue to grow, and physician shortages affect communities across the province. Against this backdrop, restricting delegation mechanisms that safely extend healthcare delivery capacity is counterproductive and potentially harmful.

The proposed amendments appear driven not by evidence of patient harm, but by complaints from select physician groups seeking to protect professional turf—particularly in aesthetic medicine where delegation has functioned safely for decades. Policy changes should be evidence-based and serve patient interests, not facilitate professional monopolization.

2. Delegation Has Proven Safe and Effective

The current delegation framework, when properly implemented, has delivered safe patient care across multiple settings for many years. Registered nurses, nurse practitioners, and physician assistants are extensively trained, regulated by their own professional colleges, and held to rigorous standards of practice. These are not unqualified individuals—they are licensed healthcare professionals with specific expertise and accountability mechanisms.

In aesthetic medicine specifically, nurses have safely administered neuromodulators and dermal fillers under medical directives for decades. In palliative care, home care, and primary care settings, delegation enables continuity when physicians cannot be physically present. The evidence shows that properly trained healthcare professionals working under appropriate protocols deliver safe, high-quality care.

The proposed restrictions are not supported by evidence of widespread patient harm. Rather than restricting a proven model, CPSO should focus enforcement efforts on actual problems: unlicensed individuals performing controlled acts illegally, and physicians who delegate inappropriately without proper oversight.

3. Rural and Remote Communities Will Suffer Most

The proposed requirement for recent physician assessments and restrictions on delegation without conventional physician-patient relationships will devastate healthcare delivery in rural, remote, and underserved communities. In many northern Ontario communities, nurse practitioners and physician assistants provide essential primary care services with physician supervision conducted remotely or periodically.

Requiring physicians to be physically present or to conduct frequent in-person assessments is simply not feasible in these settings. The choice is not between physician-delivered care and delegated care—it is between delegated care and no care at all. These amendments would effectively eliminate healthcare access for vulnerable populations who already face significant barriers.

This disproportionate impact on marginalized communities raises serious equity concerns. Urban residents with easy access to physicians should not receive policy advantages that deny healthcare access to rural and remote populations.

4. Physicians Must Focus on High-Acuity Care

Ontario's physician workforce is a precious, limited resource that must be deployed where clinical expertise is most needed: emergency departments, operating rooms, intensive care units, and complex diagnostic cases. Requiring physician presence or frequent assessments for routine procedures that qualified nurses can safely perform under delegation is an inefficient use of healthcare resources.

In aesthetic medicine, for example, requiring physicians to personally oversee every neuromodulator injection diverts them from patients with serious medical needs. In home care and palliative settings, demanding frequent physician visits for routine medication administration or wound care creates unnecessary barriers and delays.

The proposed amendments would force physicians to spend time on tasks that other qualified professionals can perform safely, exacerbating existing access problems. This benefits no one except physicians seeking to protect lucrative service areas from qualified competition.

5. Professional Regulation Already Provides Accountability

The proposed amendments appear to reflect an assumption that nurses and other healthcare professionals cannot be trusted to perform delegated controlled acts safely. This is both incorrect and insulting to highly trained professionals who are already subject to extensive regulation by their own colleges.

Nurses are accountable to the College of Nurses of Ontario. Physician assistants are now regulated by CPSO itself. These professionals face discipline for incompetent practice, must maintain continuing education, carry professional liability insurance, and work within defined scopes of practice. Multiple layers of accountability already exist.

Rather than creating additional physician-oversight requirements that assume incompetence, CPSO should support interprofessional collaboration that respects the expertise and accountability of all regulated healthcare professionals. The proposed amendments undermine the collaborative care models that Ontario's healthcare system desperately needs.

6. Focus Enforcement Where Problems Actually Exist

The legitimate concern underlying these amendments appears to be instances of inappropriate delegation to unqualified or unregulated individuals, and physicians who delegate without proper oversight or competence assessment. These are real problems that warrant attention.

However, the proposed solution—broadly restricting all delegation—is like burning down the house to eliminate a small pest problem. It punishes the vast majority of physicians and healthcare professionals who delegate appropriately while doing little to stop bad actors who will likely continue inappropriate practices regardless of policy language.

CPSO should instead strengthen its investigations and enforcement capacity. When physicians delegate to unqualified individuals, investigate and discipline those specific physicians. When unlicensed individuals perform controlled acts, pursue them aggressively. When medical directives lack appropriate safeguards, require corrections. Targeted enforcement addresses actual problems without harming the entire healthcare system.

7. Economic Access and Class Implications

While aesthetic medicine may seem like a luxury concern, the economic implications of these amendments extend far beyond cosmetic procedures. Requiring physician presence for all controlled acts will inevitably increase service costs as physicians charge for their time and expertise.

For elective procedures, this creates a two-tier system where only wealthy patients can afford services that were previously accessible to middle-income Ontarians. For essential services in home care, palliative care, and primary care settings, increased costs and reduced access fall hardest on low-income patients, seniors, and marginalized communities.

The proposed amendments would function as a regressive policy that restricts healthcare access based on income and geography. This contradicts principles of equity and universal access that should guide healthcare regulation.

Recommendations

I urge CPSO to reject the proposed amendments to provisions 7 and 8 of the Delegation of Controlled Acts policy. Instead, I recommend:

1. Maintain current delegation framework that has proven safe and effective across multiple healthcare settings.

2. Strengthen enforcement against actual problems: physicians who delegate inappropriately, unlicensed individuals performing controlled acts, and inadequate medical directives.

3. Develop guidance on appropriate delegation practices rather than blanket restrictions that harm healthcare access.

4. Consider expanding delegation opportunities where evidence supports safe practice by qualified healthcare professionals.

5. Ensure rural and remote communities maintain access to essential healthcare services through appropriate delegation models.

6. Resist professional protectionism that seeks to monopolize services under the guise of patient safety.

Conclusion

Healthcare regulation should be driven by evidence of patient benefit and harm, not by professional turf protection. The proposed amendments to the Delegation of Controlled Acts policy lack evidence of widespread patient harm from current practices, while threatening substantial harm to healthcare access, system efficiency, and patient outcomes.

Ontario's healthcare system needs more collaborative, efficient delivery models—not additional restrictions that assume incompetence of regulated healthcare professionals. CPSO should focus its limited enforcement resources on actual bad actors while supporting the interprofessional care that enables healthcare delivery across this province.

I strongly urge the College to reject these proposed amendments and instead pursue targeted solutions that address genuine problems without harming patient access to care.

Note: Some content has been edited in accordance with our posting guidelines. 

Hello,

As a mature member of the public living in Guelph, I recall previously reviewing and commenting on this draft topic.  Today I have again reviewed most of the draft policy, the advice document, several discussion comments as well as the introduction sharing recent CPSO communications and meetings.

Draft policy appendix A, #14, line 207-210, the extent of nurse provided psychotherapy described examples which are significant and I caution that subjective nurse / patient dynamics and assessment would be challenging.  How would this interaction be recorded in office medical records? Is this one event in a general practice setting or several delegated events for this nurse / patient ?  If in a hospital or clinic specializing in mental health, I realize training and other factors would apply and this delegation would be reasonable.

Retail pharmacist diagnosing and prescribing concerns me when I consider who is delegating to them? How are they actually supervised as their roles have expanded to an extent I do not agree with.  Is there any retail pharmacist / communication / with the patient’s doctor?  Is this diagnosis accurate?  Is this the appropriate drug?  Is there a drug reaction?  Is there any quality assurance or audit of accuracy of billing by pharmacist to the provincial health card.  A WalMart or Zehrs or other retail pharmacist in Guelph, without any privacy or adequate patient profile, may not always be accurate.   I understand this serves patients without a doctor and was introduced under pandemic and other conditions.

My background includes graduating as a registered nurse in Ontario decades ago. My position [redacted]. 

Several years ago I was invited to consider reviewing CPSO policies both draft versions as with MAID around 2015 then later policies during review.

I'm writing as a physician assistant. My main point is the scope of this document is much too large. It encompasses both laypeople achieving some very minor degree of delegation, and on the other end of the spectrum physician assistants who are highly trained, registered by the CPSO, and have a wide scope of practice. This policy works sufficiently for simple clinical scenarios involving basic logic (if X, then Y), but is enormously challenging to apply to clinical scenarios that are more complex. Attempting to apply this policy to PAs and other highly trained healthcare professionals creates a great deal of confusion. The policy is both ambiguous in some areas and overly specific and strict in other requirements. In my experience reviewing medical directives from many different hospitals it is clear that hospitals vary widely in their interpretation and application of the delegation policy. I appreciate how difficult it would be to write a policy such as this one, and commend the CPSO on their work to date on this. 
 

My recommendation is to have a separate delegation policy for CPSO registered physician assistants. Physician assistants function under a delegation model, therefore this policy essentially dictates the PA role in Ontario. Versions of this policy were written before PAs were introduced in Ontario, and the PA role was made to fit this policy rather than having a policy that reflects the PA role. For example, almost all PAs function under medical directives, which under the current policy requires an itemized and detailed list of the specific clinical conditions that the patient must meet before the directive can be implemented, an itemized and detailed list of any situational circum­stances that must exist before the directive can be implemented, and a comprehensive list of contraindications (among other requirements). These PA medical directive documents are extremely onerous and not able to accommodate changes in evidence or new therapies. A separate policy which provides a mechanism for delegation and a description of appropriate level of supervision would be more appropriate for CPSO registered physician assistants. 
 

With regard to the most recent changes, the new requirements of a clinical assessment within 48 hours will disrupt many current clinical practices for physician assistants. There are many PAs who function with responsible high quality physician supervision where the clinical assessment within 48 hours requirement is not currently met, and changing practice will mean a marked reduction in patient flow with little to no additional benefit. However, this is how I interpret the wording. It is ambiguous what is meant by “clinical assessment.” The associated footnote references billing procedure which generally requires a in-person physician visit, this suggests a new CPSO requirement of needing an in person visit. If the clinical assessment definition includes reviewing and discussing the patient’s visit in low risk scenarios then I withdraw this last portion of my comment.

MESSAGE FROM ADMINISTRATOR: During the consultation period, we received 9 responses from individual respondents, containing the content published below with varying levels of personal content or information included. While each individual response is not being published here in full, these responses are all being read and considered as part of the public consultation. 

To Whom it May Concern,

I am writing as a Physician Assistant (PA) practicing in Ontario to express my strong support for the Canadian Association of Physician Assistants (CAPA) submission regarding the proposed amendments to the Delegation of Controlled Acts Policy.

PAs have been safely and effectively extending physicians’ reach in Ontario since 2007, improving access to timely, high-quality care for patients across diverse settings. The current draft policy’s requirement for a physician clinical assessment within two business days of a new patient encounter, while well-intentioned, remains impractical in many environments such as urgent care, walk-in clinics, newborn assessments, and outpatient hospital services. This could create bottlenecks, delay care, and negatively impact patient safety.

I support CAPA’s recommendations to:

• Clarify that a physician’s clinical assessment may include chart review and consultation with the delegate, rather than requiring an in-person or virtual patient visit.
• Align the definition of clinical assessment for delegation with the existing definition for re-assessment.
• Explore a dedicated delegation framework for PAs, recognizing our unique role as CPSO registrants.

These changes would uphold patient safety while preserving the operational realities of team-based care. Thank you for considering this feedback and for your commitment to improving access to care for Ontarians.

Canadian Association of Physician Assistants (CAPA)

Please find attached CAPA’s feedback regarding the Draft Policy for Public Consultation – Delegation of Controlled Acts.

We appreciate the opportunity to provide input on this important policy and look forward to continued collaboration to ensure clarity and support for the PA profession in Ontario.

If you have any questions or require further information, please do not hesitate to contact us.

Thank you

Thank you for the opportunity to comment on the proposed revisions to the Delegation of Controlled Acts policy. I appreciate the CPSO’s ongoing efforts to clarify the framework, ensure patient safety and support interprofessional care. As a Physician Assistant (PA) with long-standing experience in a specialist medicine environment and collaborator with supervising physicians, I would like to submit the following concerns regarding how the draft policy may undermine the physician-PA relationship, impact the care and provision of care and not optimally serve patients, and introduce unintended adverse consequences in clinical practice.

1. Impact on the physician–PA collaborative relationship

a) Erosion of clearly defined roles and trust.
The delegation framework has traditionally allowed physicians to delegate specific controlled acts to PAs under direct order or medical directive while retaining ultimate responsibility. The proposed policy appears to increase ambiguity about supervision expectations, accountability lines, and control of scope, which can erode the trust and operational clarity required for efficient physician–PA collaboration.

b) Increased administrative burden.
Imposing a two-business day requirement for a “clinical assessment” after initial contact, without a clear definition of what constitutes such an assessment, does not reflect the realities of clinical practice. In multi-site and subspecialty environments, this mandate would create operational bottlenecks without measurable improvements to patient safety or outcomes. 

c) The definition of a clinical assessment should be expanded to include activities such as chart review, consultation, or discussion with the delegate, rather than requiring a face-to-face or virtual physician assessment in every instance. We commend the CPSO’s inclusion of the definition of re-assessment, as stated in paragraph 8, sub para 10 – Delegation of Controlled Acts, (In some circumstances, an assessment might take the form of a chart review or consultation with the delegate rather than an in-person assessment.) and support the recommendation that periodically, physicians and PAs engage in collaboration to review patient status. Collaboration is integral to the physician-PA relationship and updating the definition of a clinical assessment to reflect and align with the re-assessment definition would ensure that patient care is not delayed and greater reflects the relationship between PAs and physicians. Further, as PAs are now regulated under the CPSO and thereby held accountable to professional standards, including knowing when to consult or refer to their supervising physicians, making this additional oversight clause

2. Impact on patients and patient care

a) Potential delays in access and efficiency.
In many specialty fields where access is already limited and wait times for initial consultation are prolonged, effective delegation to physician assistants can significantly improve patient flow, enhance satisfaction, and strengthen confidence in the healthcare system. Implementing rigid supervision rules, such as requiring the physician to personally establish care within a set timeframe (e.g., 2 business days), undermines these efficiencies, creating unnecessary bottlenecks and ultimately compromising the timeliness, overall access, and quality of patient care which will lead to delays and negative impacts on patient safety. 

b) Continuity of care and team-based care weakened.
The effectiveness of PAs often lies in their ability to provide consistent, longitudinal support under physician oversight. If delegation is restricted or supervision burdens increase, the PA may be used in a more fragmented or reactive way rather than as an integrated partner in care. This will reduce continuity of care, frustrate patients when wait times increase and access to care decreases and diminishes the team-based care model.

3. Recommendations to improve the policy

To address these concerns while preserving patient safety and regulatory clarity, I suggest the following adjustments:

a) Design supervisory requirements that reflect the realities of clinical practice, such as permitting remote consultation, chart review or periodic review, rather than mandating constant onsite physician presence, especially in outpatient and multi-site environments.
b) Retain flexibility for physician-led tailoring of PA scopes based on demonstrated competence, experience and setting.

In summary

While I acknowledge and support the CPSO’s goal of maintaining high standards of patient safety in the delegation of controlled acts, I am concerned that the proposed policy, by imposing greater ambiguity in supervision expectations, increasing administrative burden, and reducing the practical flexibility of physician-PA teams, which may inadvertently undermine the benefits of the physician-PA relationship, reduce accessibility and efficiency of patient care, and stifle innovation in team-based models. I urge the CPSO to revise the policy to better balance risk management with the operational realities of contemporary inter-professional practice, so that delegation remains a safe, efficient, and effective mechanism to support patient care.

Thank you for consideration of these comments. I would welcome the opportunity to engage further in consultation and provide concrete examples from my own practice if that would be helpful.

Canadian Medical Protective Association (CMPA)

Response in PDF format

I recently saw an email regarding a new CPSO policy on the delegation of controlled acts which requires physicians to be physically on site to supervise delegates. I don’t usually comment, but this one was important to me. 

I strongly support the proposed policy that would prohibit physicians from extending their licenses to non-physicians without being physically present in the clinic. Frankly, I am surprised this practice has been allowed until now, as it poses serious risks to patient safety and undermines public trust in medical regulation.

Allowing physicians to delegate their license to non-physicians—such as estheticians and nurses—while being absent from the facility has led to unsafe and unethical practices. In Toronto alone, there are numerous medispas and at least one hair transplant clinic operating under such arrangements. In these settings, non-physicians routinely inject Botox and filler or perform procedures that should legally and ethically require direct physician oversight.

As you know, Botox and dermal fillers are prescription drugs that can only be ordered under a physician’s license. In my opinion, they should also be administered only by a physician. I frequently treat patients who have suffered complications after being injected by unqualified individuals operating under delegated physician licenses. Cases of necrosis and even blindness following filler injections are not rare. Physicians who are not present at these clinics are unable to properly assess patients or manage emergencies when such complications arise.

Similarly, hair transplant clinics often use significant amounts of local anesthetic. If these anesthetics are inadvertently injected into an artery, the results can be catastrophic, including death. Performing these procedures without a physician physically present is completely unacceptable.

I commend the College for taking action on this issue. It is long overdue. Ensuring that physicians are present and accountable within their clinical environments is essential for maintaining professional integrity and protecting patients from preventable harm.

Professional Association of Residents of Ontario (PARO)

Thank you for the invitation to provide feedback on the Delegation of Controlled Acts CPSO draft policy. We found the draft policy to be thorough and provide clear direction. We have reviewed the document and do have some suggestions.

Under the exceptions for delegation outlined in section 2b we would suggest you add learners as residents do Distributed/Rural Medicine as well. 

The footnote to Section 10 states nurses of all classes are authorized to perform psychotherapy. The phrase “nurses of all classes” is  broad and risks misunderstanding as not all nurses are trained to deliver psychotherapy safely. We would suggest this footnote be updated to include more specific guidance, such as:

“This does not prohibit health professionals who are independently authorized and competent to perform the controlled act of psychotherapy, such as psychologists, social workers, occupational therapists, nurses and registered psychotherapists, from doing so within their respective College’s standards of practice”
 

Once again, we truly appreciate being included in the CPSO's consultative process.

Several proposed elements are blunt instruments that will reduce access, worsen wait times, and are not supported by outcome evidence. We are already struggling with access times in Ontario. The areas that will be impacted and suffer the most are underserved, rural and high-need areas. Requiring the physician to be physically onsite in “most instances” disregards strong evidence that team-based care with indirect/remote supervision is safe and can improve quality metrics, and patient satisfaction. It also undermines the training that licensed NPs and PAs have undergone. There are many tele-supervision models (e.g., oncology, emergency medicine) that demonstrate safe remote oversight and positive training outcomes. Over-prescribing onsite presence will throttle capacity in established specialized hospital programs, clinics and EDs where PAs/NPs/RTs/APPs already deliver routine, protocolized care with indirect supervision. Additionally, a 2-day clock for a physician assessment after a delegate’s first contact is operationally unrealistic (subspecialties; part-time sites; rural/itinerant care; vacation; demanding on-call schedules) and not outcome-linked. It will manufacture bottlenecks and defer care that delegates could safely continue under protocol and review. Not to mention this will further add to the administrative burden to the physician and goes against the province's guidance and results that argue for acuity-based SLAs, which is referenced on the CPSO website (i.e. Ontario’s ED Medical Directives Kit)! Time and time again, it has been shown that alternate or we can call it 'modernizing-to-fit-patient-needs' practice models can absorb low-acuity demand with appropriate escalation. There should be more best practice guidelines on this. Ask those who have been using physician extenders/APPs/physician associates for the last 2 decades! It should be bottom up approach. Overall, we should prioritize strengthening and funding evidence-based, team-based care models, while supporting ongoing research and ensuring appropriate compensation and resources to sustain these roles long term. Critical research gaps remain, particularly the need for Ontario-specific, high-quality data. Implementing rigid supervision models in the absence of such evidence risks over-correcting and undermining effective care delivery without a justified clinical or operational basis. 


Some references:
https://pmc.ncbi.nlm.nih.gov/articles/PMC11287093/ 
https://caep.ca/periodicals/Volume_11_Issue_5/Vol_11_Issue_5_Page_455_-_461_Ducharme.pdf 
https://www.researchgate.net/publication/349483670_Effect_of_a_physician_assistant_on_quality_and_efficiency_metrics_in_an_emergency_department_Population_cohort_study 
https://mspace.lib.umanitoba.ca/server/api/core/bitstreams/2df7fda2-193d-45ee-b7a2-37b519773d3c/content