Guidelines to physicians contemplating a change in clinical scope of practice

Preamble

This guideline document is intended to provide guidance to physicians contemplating a change in their clinical scope of practice and defines scope of practice from a clinical lens. It is based on the College’s policy on Change in Clinical Scope of Practice: Requirements¹ and highlights the difference between changes in scope of practice that would require a formal assessment of competence rather than changes in scope of practice that are a natural evolution of a physician’s practice over the course of their career.

Definitions

Every physician’s practice is unique and may include both clinical and non-clinical responsibilities.

A physician’s clinical scope of practice is defined by the range of patients cared for, conditions encountered, and procedures performed. The environment in which care is provided is an additional, yet equally important, consideration.  Non-clinical scope of practice will typically include administrative, research and educational duties related to the practise of medicine. While important, these non-clinical aspects of scope are not the focus of this guideline.

Responsibilities

It is every physician’s professional responsibility to practice only  within a scope for which they are current² and appropriately trained.

Physicians intending to change their clinical scope of practice must notify the College.³ In these cases, physicians must demonstrate to the College that they have the appropriate education/training and are competent to practise in the identified scope of practice. For this to be satisfied, the Registrar may require the physician to successfully complete a competence assessment.³

Scope of practice at the onset of a physicians career

Newly qualified physicians begin their careers with a clinical scope of practice defined by the knowledge, skills and experience that they have acquired and demonstrated over the course of training. However, a physician’s clinical scope of practice inevitably changes over time as new practice elements are added, and others drop off.

Scope of practice has a broad definition. Through the course of a physician’s career strategies may be used to extend scope and competence (e.g. seeking periodic clinical experience in a colleague’s practice, focused professional development, simulation etc.).

In any physician’s practice there will be rarely encountered, conditions for which they should employ specific strategies to maintain competence (e.g. an Emergency Physician who may periodically practice surgical airway skills in a simulator).

The following definitions and examples are intended to guide physicians who intend to change their scope of practice. Where uncertainty exists, it is the physician’s responsibility to seek clarification from the College (at registration@cpsns.ns.ca).

Evolution of clinical scope of practice

Scope of practice will incrementally evolve, typically as a result of shifting patient demographics, emergence of new medical conditions, improved investigative and treatment modalities, evolving physician interest and new practice settings.

In most cases, evolution in scope will involve areas which:

1. Are within the usual or developing scope of practice for physicians in that same discipline; and
2. Can be safely addressed through deliberate professional development, support of experienced colleagues and accumulated experience.

Examples of incremental change in scope include:

• A General Surgeon integrates a new laparoscopic approach to the management of a specific condition.
• An anesthesiologist introduces a new airway device into her practice.
• A General Internist opens a new weekly clinic with a specific focus on the care of patients with diabetes.
• A Family Physician moves his office practice from an urban to a rural area.

It is not generally required that physicians making incremental changes to their scope of practice consult with the College (at registration@cpsns.ns.ca).

Significant or abrupt change to scope of practice

On occasion, a physician may wish or be required to make a significant or abrupt change in their scope of clinical practice. Such transitions may pose a particularly high risk to practice quality and patient safety, particularly when they involve a physician changing their scope to include an area:

• Which is not part of the usual and accepted scope for physicians in their discipline or specialty; or
• For which they have limited or no recent experience or training. As indicated above, the College defines ‘recent experience’ as regular clinical practice within the preceding three years.

Examples of a significant or abrupt change in clinical scope of practice include:

• A Pediatrician who wishes to enter Family Practice based on a past rotating internship.
• A Family Physician who wishes to practice Emergency Medicine after years spent in general office- based practice.
• A  General Surgeon who wishes to practice cosmetic medicine.

Any physician wishing to make a significant or abrupt change to their clinical scope of practice must first consult with the College (at registration@cpsns.ns.ca) and must demonstrate to the College’s satisfaction that they have sufficient training and experience to do so safely and competently. This may  involve either demonstration of qualifications from a recognized training institution, an approved training plan and/or a workplace-based assessment directed by the College.

Reduced scope of practice

A physician may decide to deliberately narrow their scope of practice. A planned reduction in scope of practice is generally considered to be low risk provided:

1. The new scope of practice is a well-recognized and accepted subset of scope for that physician’s discipline or specialty; and
2. Any additional knowledge or skills can clearly be acquired through a physician’s usual continued professional development.

Examples of a safe reduction in scope of practice may include:

• A General Internist who wishes to focus on the care of patients with hypertension.
• A Family Physician who wishes to enter part-time practice providing psychotherapy or well- woman care.

Physicians wishing to narrow their scope of practice according to the above definition are not generally required to consult with the College.

Resources

1. Change in Clinical Scope of Practice: Requirements
2. Currency of Practice Experience
3. Nova Scotia Medical Regulations