Changing Scope of Practice – A User's Guide

Changing Scope of Practice – A User's Guide
Changing Scope of Practice – A Physician’s Guide
In accordance with the annual renewal form, physicians must report to the College when
they have changed their scope of practice or that they intend to change their scope of
practice. The College’s Changing Scope of Practice policy outlines the College’s
expectations of physicians who have changed or will be changing their scope of practice
and who do not have the necessary training and/or experience to practise competently in
the new area of practice. The College has put together this guide to help you understand
how it determines whether a physician has undergone a change in scope of practice and
what the College expects of physicians who are contemplating a change or have changed
theirs scope of practice. This guide is organized by a series of Frequently Asked
Questions (FAQs) followed by some examples of changes in scope of practice and the
training required.
FAQs
How does the College define scope of practice?
What does the College consider a significant change in scope of practice?
How do I know if a potential change is significant or if it is simply a normal evolution of
my practice?
I received my general license before 1993. Doesn’t a general license allow me to practice
in any area that I want?
What will happen if I am required to submit a Change in Scope Application?
I have determined that I have changed my scope of practice since 2002 and I have to fill
out the Application for Physicians who HAVE CHANGED their scope of practice. What
will happen next?
I am planning to change my scope of practice and I have to fill out the Application for
Physicians who are PLANNING TO CHANGE their scope of practice. What will
happen next?
How will the College determine if proposed or completed training is adequate?
How long does the training need to be?
How do I find a supervisor?
Do I have to pay for my change of scope?
I want to move from my urban practice to a rural one. Why might the College consider
this a change of scope?
Can you give me some examples of what physicians have gone through to change their
scope?
How does the College define scope of practice?
The definition of scope of practice is as follows:
1.
2.
Every physician’s scope of practice is unique.
A physician’s scope of practice is determined by the patients the physician
cares for, the procedures performed, the treatments provided, and the practice
environment.
A physician’s ability to perform competently in his or her scope of practice is
determined by the physician’s knowledge, skills and judgment, which are
developed through training and experience in that scope of practice.
3.
What does the College consider a change in scope of practice?
A change of scope of practice occurs when there have been significant changes to any of
the elements set out in part 2 of the definition. If the patient population you care for, the
procedures that you perform, the treatments you provide, or the environment in which
you see patients has changed in a significant way, the College may find that you have
changed your scope of practice. Key to this concept is what the College considers
“significant.” In general, if you have changed your practice such that you are practising
outside of what would be considered the usual scope of practice for your discipline, then
your scope of practice may have changed significantly.
How do I know if a potential change is significant or if it is simply a normal evolution of
my practice?
The College has an algorithm on-line that you can go through to determine whether or
not you should submit a Change in Scope of Practice application. In general, the
algorithm will identify a change as significant if:
i.
You are completely changing your type of practice (For example you are a
surgeon who wants to go into general practice)
OR
ii.
You are adding something in to your practice that you have
a. not done before AND
b. it is not something that is considered a usual part of your discipline
AND
c. Most physicians in your discipline are not changing their practice in
this way. (For example you are a pediatrician who wants to start
working in an Emergency Department caring for adult patients)
OR
iii.
You are focusing your practice in an area in which you have not been
active for at least three years. (For example you are a GP who was
previously trained in sigmoidoscopy, but have not done any for the past
five years and want to start doing it again.)
The algorithm is simple and should take you no more than a few minutes to go through.
Alternatively, you can speak to a staff member of the College in the Physician Advisory
Service at (416) 967-2606 or (800) 268-7096 Ext. 606, who will help you go through the
algorithm.
I received my general license before 1993. Doesn’t a general license allow me to practice
in any area that I want?
This is a common misconception. Every member of the College has restrictions to their
certificate of registration (license). In fact, every certificate has terms and conditions that
states that the member may practice only in the areas of medicine in which the member is
educated and experienced. Thus, there is no such thing as a “general license” regardless
of how long you have been a physician in this province.
What will happen if I am required to submit a Change in Scope of Practice Application?
Currently, there are two applications. One application is for those physicians who have
changed their scope of practice since 2003 and didn’t realize that they had to report this
change. The other application is for physicians who are intending to change their scope
of practice. Every application will be individually reviewed in order to assess the
training and experience that a physician has or needs in order to practice safely in their
new scope of practice.
Ultimately, all physicians who have made or are intending to make a significant change
in the scope of their practice will have a College-directed assessment of their practice by
a peer to ensure that the physician is practicing to the expected standard in the new scope
of practice. The path to this assessment, however, will be slightly different for the two
scenarios.
I have determined that I have changed my scope of practice since 2002 and I have to fill
out the Application for Physicians who HAVE CHANGED their scope of practice. What
will happen next?
Every application is reviewed by staff and physicians at the College. If you have already
made a change in your scope of practice, you can expect that the College will direct an
assessment of your new scope of practice. Some physicians may have already had an
assessment of their new area of practice through other College processes or by previously
reporting a change in the scope of their practice. These physicians need not expect
another assessment.
The College anticipates that as a result of the new mandatory questions in the annual
renewal form regarding Change in Scope of Practice that there may be quite a number of
physicians who report that they have changed their scope of practice. As such, we
anticipate that there may be a large number of assessments to be completed. College staff
will prioritize the assessments based on the following factors:
i.
ii.
iii.
The “risk” of the new area of practice;
The amount (duration and type) of training undertaken;
The degree of ongoing collegial support or mentoring.
It may be at least a few months before an assessment takes place. The assessment is
likely to be similar to the College’s peer assessment program, where a peer comes to your
office or clinic and reviews documentation and discusses care with you. For procedural
changes, there may also be an observational component to the assessment, where the
assessor will observe you performing the new procedures.
I am planning to change my scope of practice and I have to fill out the Application for
Physicians who are PLANNING TO CHANGE their scope of practice. What will
happen next?
Ultimately, physicians who are planning to change their scope of practice will need to
undergo a College-appointed assessment. Before this occurs, the College will review the
application to determine if the physician requires training in the new area of practice.
If training has already been completed, the College will review the training to ensure it
seems adequate. If the training is determined to be inadequate, further training and/or
supervision may be required before the assessment can take place.
If training has yet to be completed, the physician will have to submit a training proposal.
Once approved, training must be completed before the assessment can take place.
How will the College determine if the proposed or completed training is adequate?
Training will be reviewed on an individual basis. Determining that training is adequate
will be based upon the accepted educational principle of graded responsibility. This
model is similar to that which is used in undergraduate and postgraduate education. As
supervisors determine competence, trainees are given more and more independence.
Training generally will involve some initial educational experience where you are
learning in an environment where someone else is the patient’s Most Responsible
Physician (MRP). This is called High Supervision.
Once the supervisor is content that the learner is competent to practice in a less
supervised environment, the trainee will be allowed to engage in the practice, as MRP
with supervision. After a period of time, the supervisor will recommend to the College
that the physician is ready for independent practice in the area and the assessment will be
arranged.
For example, let’s say you have been practicing Emergency Medicine for your 15-year
career and want to change to family medicine. While there are many areas of overlap
between the two disciplines, some training would be required. The College would
require you to work with a family physician supervisor in their practice, with the
supervisor acting as MRP until the supervisor is content that you can safely practice in a
less supervised environment.
Once you receive the go-ahead from the supervisor, you may start practicing in your own
practice under supervision. This means that a supervisor will review your practice on a
regular basis (generally every two to four weeks) and ensure that you are practicing
safely, as well as act as a resource for you to help you settle into your new practice.
These practice reviews will generally consist of reviewing documentation on some
random charts to provide you with feedback on care and documentation. For procedural
changes in scope, the supervision may also involve observing you perform the procedure
in your own environment.
Once the supervisor is content that you are practicing safely, s/he will submit a final
report to the College and an assessment will be carried out. If that assessment is
satisfactory, then your change of scope is complete.
Although usually training takes place in a “linear” fashion such as this (High supervision,
low supervision, independent practice), there may be situations where training and
practice can take place at the same time. All cases will be considered individually.
How long does the training need to be?
As every case will be reviewed individually, this question is impossible to answer.
Obviously the bigger the change in scope, the longer the training will be. For example, if
you are a pathologist and want to start working in a walk-in clinic, your training would
have to be significant – along the lines of a family medicine residency. On the other
hand, if you are a general surgeon and you want to start performing hysterectomies as
you are moving to a smaller community, the training would be different. Having
mastered concepts and principles of surgery, learning a new procedure from a surgical
colleague would be much simpler.
Key to determining the length of training will be the input from the supervisor. The
supervisor has a big responsibility in determining that their trainee is capable of
practicing in a less supervised environment and then independently. Ultimately, the
validity of the supervisor’s assessment will be tested through the College-directed
assessment.
Keep in mind that once the supervisor has determined that you are capable of working in
a lower level supervision environment, you will be working as the patient’s MRP. At this
point, the supervisor meets regularly with you to not only ensure that you are practicing
safely, but to assist and mentor you in your new area of practice. The supervisor will
have the ability to identify and recommend areas which need improvement, as well as
recommend educational resources for you.
How do I find a supervisor?
Physicians who wish to change their scope of practice are responsible for finding their
own supervisors. A supervisor should be a colleague who practices in the same scope
into which you are trying to change. They must be in good standing with the College. In
general they should be respected in the field, experienced and willing to help you.
Desirable qualities of supervisors are outlined in the College’s Guidelines for
Supervision, which are available on the CPSO website. These guidelines are currently
being updated and once ready, the revised version will be posted on the website.
Supervisors will have to sign a supervisor’s agreement or undertaking, in which they
commit to providing you with ongoing education and the College with regular feedback
on your progress. While supervisors have the right to expect remuneration, often
supervisors will agree to these duties as an act of professional courtesy.
Do I have to pay for my change of scope?
Physicians who wish to change their scope of practice must pay for all costs associated
with training, supervision and assessment. The cost of the training and supervision will
be quite variable depending on the courses taken, the cost of supervision and the length of
the training necessary.
Physicians are responsible for paying for their College-directed final assessment, which
currently stands at $1,400.
I want to move from my urban practice to a rural one. Why might the College consider
this a change of scope?
Our ability to practice in a safe and competent manner depends on many variables.
Moving from an urban to a rural environment may present unforeseen changes in the way
that you practice. For example, you may not have easy access to specialists, facilities,
diagnostic or social services that you are likely used to in an urban practice. While the
patients and their problems may be similar, you may be forced to practice in a different
way. While the College would likely not expect you to retrain in any way in this
scenario, the College would expect that you obtain a supervisor to carry on another role.
In this scenario the supervisor would act more as a mentor or resource person with whom
you could meet or chat on a regular basis in order to help you to settle in to your new
environment.
Can you give me some examples of what physicians have gone through to change their
scope?
1.
A physician practiced as an Emergency Physician for 20 years and decided to
change his practice to psychotherapy. The physician obtained training through a
University psychiatry residency program and spent one year as a fellow in a selfdirected program. During this period there was a high level of supervision. The
physician then opened his own practice and there continued to be supervision, but
a lower level than there was in the residency program. After a period of time, the
physician was assessed by the College and was found to be practicing
competently in the new area of practice.
2.
An Emergency Physician wished to change his scope of practice to
psychotherapy. Prior to requesting the change in scope of practice, the physician
had done a fair amount of training in psychotherapy. As part of the change in
scope of practice process, the physician worked a few times with a supervisor in
an environment where there was a high-level of supervision. The supervisor was
quickly convinced that the physician was performing adequately. The physician
quickly moved to an environment where there was a lower level of supervision.
During this period the physician met with his supervisor/mentor regularly until an
assessment was recommended. The results of this assessment demonstrated that
the physician was practicing competently in the new scope of practice.
3.
A senior surgeon retired from her surgical practice and wanted to change her
scope of practice to family medicine where she would practice part-time in a
small, under-serviced community. In order to do so, the physician would be
required to practise in an environment of high supervision for an extended period
of time because the surgical specialty in which she had been practising was not
similar to family practice. The surgeon decided to abandon the change in scope
of practice request.
4.
A family physician had been working in an administrative position for more than
10 years. The physician decided to go back to clinical practice. During the
administrative time, she had worked approximately once per month in a walk-in
clinic. As the physician had grounding in family medicine, she entered into a
supervised practice at a low level of supervision after only a few days of high
supervision. The supervisors were the physicians with whom the doctor would be
working in her new practice. After a few months of low supervision, the
physician was assessed and was practicing without any difficulties.
5.
A family physician had been assisting surgery in a free-standing surgical facility
that specializes in one type of surgery for a couple of years. Both the surgical
staff at the facility and the family physician proposed that the family physician
had enough experience that he could be trained to be the primary surgeon in the
most common and least risky form of the procedures done at this facility. Thus
the family physician desired to change his scope of practice to one that was
primarily surgical.
A training proposal was accepted that provided for an initial high-level of
supervision, followed by ongoing supervision of pre-operative, intra-operative
and post-operative care for this procedure. Once the supervising surgeons were
content that the family physician had acquired adequate knowledge and skills, the
physician was assessed by a College-appointed surgeon who deemed that the
family physician was performing that procedure competently. As such, the family
physician was granted the change of scope to perform only that specific procedure
in only that facility.
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