CPSO to Regulate Physician Assistants

The Ontario government has introduced legislation that will bring Physician Assistants (PAs) under CPSO’s regulatory authority.

Ontario will be the fourth province to have its PAs regulated by the medical regulator, following in the steps of Manitoba, New Brunswick, and Alberta.

“CPSO is very supportive of the government’s decision to regulate PAs by making them a new class of registrant under our College,” said Dr. Judith Plante, College President. “There is no question that making PAs a member of the CPSO is appropriate, it is in line with CPSO’s commitment to right-touch regulation, and it will ensure safe quality care for Ontario’s patients,” she said.

Dr. Plante says it makes sense for CPSO to regulate PAs.

PAs are health-care professionals that work exclusively under the supervision of a physician and act as physician-extenders. PAs perform controlled acts only through delegation and their scope of practice is therefore highly dependent on the individual PA-to-physician relationship.

Given the relatively small number of PAs — in 2019, there were approximately 500 practising in Ontario — the creation of a stand-alone health regulatory college was viewed as impractical by the government.

PAs have been working in the Canadian Armed Forces for the past 40 years, but were only integrated into the non-military health-care system in 2007. Since the introduction of PAs, successive provincial governments have explored different forms of oversight with CPSO — ranging from a voluntary registry, to the development of a prototype medical directive for PAs, to a full regulatory regime.

In 2019, the Ford government re-initiated conversations with CPSO and indicated it was interested in pursuing a more robust form of regulation. The College proposed a model of oversight in October 2019 and more conversations followed. The result is legislative changes in Bill 283, Advancing Oversight and Planning in Ontario’s Health System Act, 2021. Schedule 3 of the omnibus bill brings forward amendments to the Medicine Act that will regulate PAs under CPSO.

The government’s framework to regulate PAs under CPSO would, once enacted:

• Establish a new physician assistant member class under CPSO; 
• Create title protection for “physician assistant”;
• Ensure physician assistants cannot use the title of physician or psychotherapist, and are not inadvertently captured in the powers/obligations of a physician in statute outside the RHPA or the Medicine Act; 
• Restrict physician assistants from performing a controlled act unless permitted or in accordance with regulations made by CPSO; and 
• Create a new ground of professional misconduct should physician assistants contravene the restrictions on controlled acts.  

Overall, Bill 283 brought forward the expected regime for regulatory oversight and is in alignment with CPSO’s October 2019 proposal. However, the original version of the legislation contained one area of significant concern, which CPSO moved quickly to address— it appeared to be moving away from a delegation model of care to one of ‘ordering controlled acts.’ Under an ‘ordering’ framework, the regulated health-care professional is granted the authority to perform the controlled act through legislation and only needs a triggering mechanism to perform it (i.e., an ‘order’ from another member).

To support implementation, both regulatory and operational work is required.

Currently, and in contrast, PAs are only able to perform controlled acts through delegation — where a physician temporarily transfers their authority to a PA, and ultimately the physician remains accountable and responsible for patient care. This delegation model is also employed in all other provinces that regulate PAs.

Dr. Plante and Registrar Dr. Nancy Whitmore expressed their concerns about the ‘ordering” framework to the Standing Committee on Social Policy, which was considering Bill 283. They also took the opportunity to propose an amendment to the bill that would preserve the delegation framework, ensure alignment with other jurisdictions that regulate PAs, and allow for the nimble development of the necessary regulatory structure.

Fortunately, CPSO’s proposal to amend the legislation was supported by the Social Policy Committee and the concept of ‘ordering’ was deleted from the bill. As a result, PAs will continue to practise under delegation.

The legislative changes that will enable CPSO to regulate physician assistants will take one to two years to come into force.

To support implementation, both regulatory and operational work is required. This includes the development of regulations setting out entry to practice requirements and the performance of controlled acts, and the development of new or modified operational processes, including those for registration and practice assessments.

To expedite the process and improve consistency across jurisdictions, CPSO will look to the practices of the other colleges that currently regulate PAs and, wherever possible, seek to align our standards and approach. This work will be guided by the philosophy and tenets of right-touch regulation.