Advice to the Profession: Changing Scope of Practice and/or Re-entering Practice

Physicians may wish to change their scope of practice to a different area of medicine or expand their scope of practice to include treatments or procedures generally under the scope of another specialty. Physicians may also take a break from practice for a variety of reasons. They may go on an extended parental leave, take a sabbatical, or take on a teaching role, for example. Additionally, when they return to practice, they may wish to practise in a different area of medicine.

This document is intended to help physicians interpret their obligations as set out in the Ensuring Competence: Changing Scope of Practice and/or Re-entering Practice policy and provide further guidance around what constitutes a significant change in scope of practice. It also addresses the application of the policy to changes in the practice environment.

Examples of Significant Changes in Scope of Practice

Some examples of a significant change in scope of practice for physicians who have not had formal residency or fellowship training in these areas include:

• adult chronic pain management;
• addictions medicine (excluding opioid agonist therapy);
• cosmetic surgery; or
• advanced procedures not generally part of a specialist’s practice (e.g. colonoscopy, bronchoscopy, abdominal liposuction).

Other examples of significant changes in scope of practice include:

• physicians completely changing their type of practice (e.g., a radiologist wanting to practise in medical psychotherapy or a general surgeon wishing to perform gynecological surgery); and
• physicians adding something new to their practice that is not considered a usual part of the discipline (e.g., a family physician wanting to perform Caesarean sections).

Examples that are not considered a significant change in scope of practice include¹:

• use of point-of-care ultrasound; 
• minor dermatological procedures (e.g., punch biopsy);
• obesity management; or
• introducing novel equipment to assess or treat patients.

Changes in scope of practice are generally determined on a case-by-case basis.

A change in scope of practice is not an alternative route to practise as a specialist in Ontario. Physicians who have undergone the College’s Changing Scope of Practice process do not practise in the same capacity as specialists. Changes in scope of practice are only permitted once the physician has demonstrated their competence to the College with respect to the specific changes they intend to incorporate into their practice.

Examples of Evolution in Practice

When there is a change to one of the factors set out in the definition of scope of practice, but the change is not significant, the College considers this to be an evolution in practice. An evolution in practice is characterized by the gradual development or progression of a physician’s practice within a certain area, in keeping with the direction of the specialty. An evolution in practice may include narrowing or limiting a practice, performance of innovative techniques or procedures, or prescribing new medications within the context of a specialty. Examples include:¹

• a family physician who, within their general area of training, decides to narrow the focus of their practice to women’s health issues;
• a general surgeon who decides to incorporate robotic assistance for selected abdominal procedures; and
• a psychiatrist who decides to start patients on a novel class of drugs for treatment-resistant depression.

However, when a physician would like to focus their scope of practice in a way that is no longer in keeping with the direction of the specialty, and to such an extent that they would be practising in a significantly different way than their peers, it is likely that a Changing Scope of Practice process would be required.

Application of Policy to Changes in Practice Environment

The College receives many questions about how the policy applies to a change in the practice environment. A change in the practice environment, for example from an urban practice to a rural practice, is not generally considered a significant change in scope. The physician needs to be prepared to adapt to the new environment with regards to access to resources (e.g., imaging, community services), availability of support from colleagues, and the local health system demands. To adapt to a new practice environment, physicians may need to upgrade their skills and/or adjust office processes to facilitate timely quality care.

Re-entering Clinical Practice

Physicians must report to the College when they wish to re-enter clinical practice after an absence of two consecutive years or more. Clinical practice includes the assessment and treatment of patients. Physicians may re-enter practice into the clinical area in which they were previously engaged or into a clinical area in which they have not previously practised.

Upon receipt of a Re-entering Clinical Practice Application, a needs assessment is conducted to determine the need for supervision and the level and duration of supervision required for individual circumstances. Factors considered can include but are not limited to:

• Length of time away from the practice of medicine and how much the specialty/scope has evolved during the absence;
• Support systems and resources available to the physician in the clinical practice environment they intend to re-enter; and
• Risk to patients, including the risk of any proposed procedures.

It is important to note that:

• Professional responsibilities focused on teaching, research, or administration where there is no assessment or treatment of patients is not considered clinical practice.
• Physicians may re-enter into a focused or limited portion of their previous clinical practice. For example, a family physician who decides to only practise in medical psychotherapy.
• There is no set minimum number of days physicians need to practise in order to maintain competence. Physicians need to keep up with their continuing professional development requirements and any competency requirements stated by institutions in which they work (such as hospitals). Otherwise, physicians need to engage in self-reflection with respect to their own limitations and use their professional judgment to determine if they remain competent within their scope.

Assessment of Applications

All Changing Scope of Practice and/or Re-entering Clinical Practice applications are considered individually. The process is designed to provide support to the physician as well as an assurance of oversight to the public.

If physicians are uncertain about whether a change in scope of practice is considered significant or is an evolution in practice, or have re-entering practice questions, they should contact the Inquiries Section in the Registration and Membership Services Department of the College for further guidance at 416-967-2617 or via the Portal message center.