Framework for Supervision of Physicians on a Defined Licence

Preamble

A Defined licence is a time-limited licence which may be issued to physicians who lack all of the qualifications required for a Full Licence.^1,2 Physicians on a Defined licence must have a recognized Medical Degree and have adequate discipline-specific postgraduate training. While under a Defined licence, physicians most often practice as the most responsible physician (MRP), under College-directed supervision.

Purpose

The purpose of this framework is to support the planning and implementation of Supervision for physicians on a Defined licence. Areas described include the following:

• Terminology
• Sponsorship
• Duration of supervision
• Principles of supervision
• Approaches to supervision
• Financial relationships
• Costs involved in supervision
• Supervision activities and reports
• Basis for immediate reporting to the College

Terminology

College-directed Supervision is the process under which a Supervisor is engaged as an Agent of the College to formally conduct on-going Workplace Based Assessment (WBA) of another physician’s practice for the purpose of ensuring that the care provided meets the expected standard.

A Supervisor is a physician who enters into a formal arrangement, as an Agent of the College, under which they agree to assess another physician’s practice for the purpose of ensuring that the care provided meets the expected standard. The Supervisor is commonly expected to provide guidance to the supervised physician. A Supervisor must have currency³ in a similar scope of practice to that of the physician they are supervising. Criteria for approving a supervisor is outlined in the policy “Approval of Supervisors for College-directed Supervision”.⁴

Principles of Supervision

When the principles of College-directed Supervision are applied in a consistent and responsible manner, supervision will promote quality physicians, patient safety and public trust.

The principles of supervision are:

1. Safe, quality patient care must take priority in all Supervisory situations.
2. The supervisor’s ultimate responsibility is to the College, and both the supervisor and physician under supervision must adhere to the Terms of Supervision agreement⁵ with the College. 

Sponsorship

A physician on a Defined licence must have a Sponsor at all times.  A Sponsor must hold a Full licence and, unless otherwise approved by the Registrar, hold a senior position in the same Health Authority Zone that the supervised licensee will be practising. It is the Sponsor’s responsibility to put forward the name of the Supervisor willing to provide supervision to the physician on a Defined licence. For each physician sponsored, the Sponsor is required to sign a Terms of Sponsorship.⁶

Should performance concerns arise, the Sponsor may, in consultation with the Supervisor and College, increase the level of supervision required.⁷ The Sponsor may also decide to withdraw sponsorship. Withdrawal of Sponsorship will result in immediate loss of licensure for the physician on a Defined licence. Any decision to withdraw sponsorship is a personal decision of the Sponsor and not subject to College review.

Duration of Supervision

The terms and conditions of a Defined licence will be set out in a Licensing Agreement, specific to the physician’s individual circumstances. Physicians issued a Defined licence will undergo a minimum of six months to a maximum of 24 months of supervised practice. Following six months of supervised practice, the Registrar will make a licensing decision after consideration of the supervisory reports and any other information deemed necessary. Licensing decisions related to the physicians ongoing licensure are outlined in the policy “Pathway to Long-term Licensure via a Defined licence”.²

Scope of Practice Assessed Under Supervision

A physician’s clinical scope of practice can be broadly defined by the patient population served, the range of clinical conditions managed, the medical procedures performed and the clinical environment in which care is provided. It is important that the Sponsor, Supervisor and Supervised physician understand what the intended scope of practice will be on a Restricted licence. During the period of Supervision, the Supervisor and the physician on a Defined licence work together to ensure the breadth of the physician’s intended scope of practice (beyond the period of Defined licensure) is assessed.

At the end of the period of supervision, should the licensing decision lead from a Defined licence to a Restricted licence,² the physician will no longer require sponsorship or supervision. Their practice will be restricted to the location of supervised practice, a scope of practice consistent with competence demonstrated in supervised practice, and any other conditions and/or restrictions the Registrar deems necessary to support safe and effective practice.

It is important to note, that once on a Restricted licence, the physician must practice only within the scope of practice assessed during supervision. Should the physician wish to broaden their scope, they must seek approval from the College and it is likely to require more supervision specific to the added scope of practice.

Approaches to Supervision

A team-based approach to Supervision is sometimes acceptable and desirable.⁸ This approach must be formally approved by the College. In this case, one physician will be identified as the ‘Primary Supervisor’ and will be the primary contact for the College. Remote Supervision, including case discussions and record reviews using secure technologies, is acceptable to the College.

Financial Relationship Between Supervisor and the Physician Under Supervision

The College will set the conditions of and administer all financial matters related to supervision, including costs to the Physician under Supervision and remuneration to the Supervisor. In all circumstances, the responsibility of the Supervisor is to the College.

Costs Involved in Supervision

The fee for College-directed supervision for physicians on a Defined licence is $7500 for the first 6-month period. This includes a CPSNS administrative fee of $1500 and a fee that is paid to the supervisor of $6000, to reflect the additional work and responsibilities of the role. The $7500 is paid by the physician on a Defined licence in two installments. The first installment of $3750 is paid at the time of licensure. The second installment of $3750 is due 3 months after beginning supervision.

The fee for College-directed supervision for those requiring supervision beyond the initial six months will be calculated on a case-by-case basis.

Supervision Activities and Reports to the College

The Supervisor will be provided with a schedule that outlines the dates their reports should be submitted. It is essential that the Supervisor meets this schedule to enable the College to monitor the physician’s performance in practice.

Unless otherwise stated, the expected standards of practice will be those laid out in the College’s policies and guidelines, and those established for the Supervised Physician’s specialty by the Royal College of Physicians and Surgeons of Canada (RCPSC) or the College of Family Physicians Canada (CFPC).

Reports must be objective, fair and impartial, and they must provide sufficient information to allow the College to make a determination as to whether the expected practice standards are being met and patient safety thereby assured.

Supervision Activities

1. Review of Continuing Professional Development (CPD) history – up to 12 months
2. Direct Observation of Clinical Care – 15-25 cases
3. Direct Observation of Medical Procedures (for procedural specialties) – as required
4. Retrospective Patient Record Review – minimum 10 cases
5. Structured interviews with Colleagues – minimum 4 individuals
6. Formative feedback to the physician under supervision – as required
7. Interim and Final Clinical Summary reports

Typical Reporting Schedule

Basis for Immediate Reporting to the College ⁸

Supervisors review patient care in the course of their duties. Instances may arise where the Supervisor’s approach to care differs from that of the Physician under Supervision. As a result, Supervisors may make comments on or offer recommendations intended to improve care. These recommendations are most often of a general nature and do not address any immediate or significant risk to a specific patient.

On the other end of the risk spectrum and in rare occasions, a Supervisor may identify some deficiency in care which, if left unaddressed, may result in serious harm to a specific patient. Similarly, in rare circumstances, a Supervisor may identify a situation in which a previously unknown and real harm has already occurred as the result of improper care. In these cases, the College has outlined a procedure “Managing Patient-Care Concerns Identified During Assessments”.⁹  This procedure is intended to guide College staff and the Supervisor in addressing patient care concerns, whether of a minor or serious nature, identified in the course of their duties.

Resources

1. Defined Licence: Requirements and Conditions for Supervised Practice as the Most Responsible Physician
2. Pathway to Long-Term Licensure via a Defined Licence
3. Currency of Practice Experience
4. Approval Of Supervisors for College-Directed Supervision
5. Terms of Supervision Agreement
6. Terms of Sponsorship
7. Supervision Levels for College-Directed Supervision
8. Guidelines for College-Directed Supervision
9. Managing Patient-Care Concerns Identified During Assessments