Approved: June 25, 2008
Revised: June, 2014

The College recognizes that a practitioner has the right to make decisions regarding his or her health, balanced with the College’s mandate to serve the public and guide the profession.

This policy is necessary to establish governing principles on physician health with respect to notification, evaluation and determination of ongoing competence in practice. Part 3 of the Health Professions Act sets out the authority and responsibilities of the Competence Committee to determine the ongoing competence of members.The Physician Health Monitoring Committee Rules establish the requirements for members.

Standards of Practice

Self Reporting to the College

  1. A physician must report the following personal circumstances to the College at the time of registration or whenever the physician becomes aware thereafter:
    1. any physical, cognitive, mental and/or emotional condition that is negatively impacting your work or is reasonably likely to negatively impact work in the future.
    2. a sexual or inappropriate personal relationship between the physician and the patient.
    3. any voluntary or involuntary loss or restriction of diagnostic or treatment privileges granted by an administrative authority or any resignation in lieu of further administrative or disciplinary action.
  2. A physician must adhere to restrictions imposed by the College, to the satisfaction of the College, or withdraw from medical practice.

Duty to Report a Colleague

  1. A physician must report another physician to the College when the first physician believes, on reasonable grounds, that the conduct of the other physician places patients at risk or is considered unprofessional conduct under the Health Professions Act.
  2. Knowledge of physician conduct that should be reported in subsection (1) includes but is not limited to situations in which a physician:
    1. makes sexual advances to or enters into a sexual relationship with a patient,
    2. suffers from a physical, cognitive, mental or emotional condition that is negatively impacting the work or is reasonably likely to negatively impact the work of the physician,
    3. repeatedly or consistently fails to address his or her behaviour in a manner that interferes with the delivery of care to patients, the ability of other physicians, learners or healthcare workers to provide care to patients, or
    4. is not competent in the care of patients.
  3. Applicability: This broad policy includes all current policies with respect to any physical, cognitive, mental and/or emotional condition that is negatively impacting your work or is reasonably likely to impact your work in the future. This policy includes any disease or illness that may, at any point in the clinical course, have cognitive, physical or psychological aspects.
  4. Process:
    1. Notification of College: health-related concerns which affect practice must be made at the time of annual renewal of the practice permit; these may include physical as well as psychological health concerns. This applies to all physicians in all categories of licensure, as set out in the Standards of Practice on the duty to self-report or to report a colleague.
    2. Evaluation: A colleague treating the physician has a duty to report, as outlined in the Standard of Practice referenced under Point #1. There is protection from the usual confidentiality arrangements as these reports are made in good faith. Once identified on the registration information form, the health concern shall be evaluated by Registrar or designate. This evaluation may include:
      1. verbal review of practice/health condition with the physician
      2. consent to obtain additional medical information and comment on the fitness to practice from the physicians treating physicians may be requested
      3. voluntarily undergoing an independent assessment to determine fitness to practice.
      4. formal assessment of capacity under Section 118 of the Health Professions Act
    3. Determination: Determination of ongoing competency shall be made by Registrar or designate after full evaluation and consultation. Actions may include:
      1. no practice changes
      2. practice limitations as described and notifications under Section 119 of the Health Professions Act
      3. time limited absence from practice
      4. non-time limited absence from practice
      5. practice notification

      Failure to report, when identified, may be referred to the Complaints Director for consideration.


Dr. Jeremy Beach, Assistant Registrar
780-969-4940 or 1-800-561-3899 ext. 4940 (in Canada)

Leanne Minckler, Physician Health Advisor
780-969-4943 or 1-800-561-3899 ext. 4943 (in Canada)