PREAMBLE
This professional standard applies to all individuals currently or previously licensed under the Medical Act, including physicians, postgraduate trainees, medical students, clinical trainees, clinical assistants, and physician assistants. For the purposes of this standard, these individuals are collectively referred to as “registrants.”
Registrants have a professional and ethical responsibility to uphold patient safety, maintain the integrity of the medical profession, and contribute to high-quality care. Self-regulation is a privilege, which depends on registrants consistently meeting high standards of conduct, competence and accountability.
Under the Medical Act and Regulation #9– Professional Misconduct, registrants have the legal obligation to report certain concerns about other registrants regarding conduct, sexual abuse, competence, or fitness-to-practice. Registrants must also self-report adverse actions taken against them.
Reporting a concern about a registrant is not considered filing a formal complaint. The information you provide may prompt the College to begin an investigation. Depending on the nature of the concerns and the outcome of the investigation, this could lead to a Registrar’s complaint. The reporting registrant will not receive updates on the investigation once it has been taken over by the College.
If you report a concern in good faith - without personal or other unjustifiable motives - you are protected from legal consequences.
Failing to report concerns about another registrant or about yourself may be considered professional misconduct and lead to the initiation of a complaint by the Registrar.
This professional standard outlines how to meet your duty to report and supports the profession’s commitment to accountability, transparency, and public trust.
DEFINITIONS
“Capacity”: means that a registrant can practice with competence and without posing a risk to the health or safety of individuals. A registrant has capacity when they do not have a medical, physical, mental, or emotional condition, disorder, or addiction that impairs their ability to carry out their professional responsibilities safely, effectively, and consistently.
“Competence”: means that a registrant possesses and consistently demonstrates the knowledge, skill, judgment, and diligence required to provide safe, effective medical care and deliver medical services in a manner that does not place patients at risk. A competent registrant is able to practice safely without the need for remedial assistance and meets the professional standards expected in the provision of medical care.
REPORTING CONCERNS ABOUT COLLEAGUES
Unprofessional conduct
You must report any information, which if determined to be true, raises concerns about a registrant’s unprofessional conduct and their ability to practice safely and ethically.
Examples of circumstances that trigger the duty to report include, but are not limited to:
- Professional misconduct, as defined under Regulation #9-Professional Misconduct,
- Violations of the Code of Ethics,
- Any form of mental, verbal or physical abuse of a patient,
- Serious conflicts of interest, and
- Serious privacy breaches.
Sexual abuse
You must report to the appropriate regulatory body any reasonable grounds to believe that another health professional has sexually abused a patient or client.
Sexual abuse includes:
- Sexual intercourse or any other form of physical sexual relations between the registrant and the patient,
- Touching, of a sexual nature or in a sexual manner, of the patient by the registrant, and
- Behaviour or remarks of a sexual nature by the registrant towards the patient.
Sexual abuse does not include touching, behaviour or remarks of a clinical nature appropriate to the care or service provided.
Competence
You must report any information, which if determined to be true, raises concerns about a registrant’s competence which could affect their ability to provide safe and effective care. This includes information such as lack of necessary skills or practicing beyond their scope.
Fitness to practice
You must report any information, which if determined to be true, raises concerns about a registrant’s fitness to practice medicine due to a health condition, including substance abuse.
Confidentiality
Identity of a patient
If the concern you are reporting involves a specific patient, you must not include the patient’s name unless the patient - or their legal representative, if the patient is incapable - has provided written consent.
There are exceptions. Disclosure of a patient’s identity is permitted if required by law or if allowed under the Personal Health Information Privacy and Access Act (PHIPAA). PHIPAA permits disclosure when it is reasonably believed to be necessary to:
- prevent or reduce a serious risk to someone’s mental or physical health or safety, and
- prevent or reduce a significant risk to public health or safety, where sharing the information clearly benefits the public.
Identity of the reporting registrant
Whenever possible, the reporting registrant ’s identity will remain confidential as this encourages compliance with the duty to report and helps mitigate potential workplace tensions.
However, absolute confidentiality cannot be guaranteed due to the close-knit nature of the medical community, where identification may be inferred even without explicit disclosure. In addition, confidentiality may not be preserved if a formal hearing is required. In such cases, the reporting registrant may be called as a witness, and disclosure of their identity may be necessary to uphold the principles of procedural fairness.
How to report concerns
You may report your concerns to the College by completing the form available on the College’s website. If you are unable to complete this form, you may send a letter to the Registrar outlining the following information:
- Your name,
- The name of the health professional who is the subject of the report,
- A detailed description of the concerns surrounding professional misconduct, sexual abuse, competence or fitness to practice, and
- The name of the patient or client, if they - or their authorized representative in cases of incapacity - have provided written consent for their name to be included in the report.
When a registrant is required to report information obtained from the registrant’s patient, they shall use their best efforts to advise the patient of their duty to report before filing the report.
The obligation to report remains applicable even when the registrant is your patient. Where it is feasible and safe to do so, the registrant should be informed that a report is being submitted to the College under the duty to report provisions. This reporting requirement supersedes the confidentiality associated with a patient-physician relationship.
Information must also be provided to the patient on how to file a complaint with the College or other relevant health regulatory bodies. You may file a complaint on the patient's behalf, with their permission.
When to report concerns
In cases involving sexual abuse, registrants are required to report their concerns to the governing body of the health professional involved. While the Medical Act requires this report to be made no later than 21 days after the registrant first has reasonable grounds to believe that sexual abuse has occurred, immediate reporting is strongly encouraged as patient safety may be at risk.
For all other concerns, the Medical Act requires that reporting be done without delay.
SELF-REPORTING
What to report
You must report the following to the Registrar without delay:
- You were the subject of a disciplinary process - such as complaint, review, investigation or other proceeding - regarding your conduct or the care you provided, which was carried out by one of the entities listed below:
- a medical regulatory authority,
- a health professional regulatory authority,
- another licensing authority,
- a regional health authority,
- another health authority,
- a hospital,
- a non-hospital surgical facility,
- a university, research or teaching facility,
- a government institution, or
- another entity
- You are currently involved in formal disciplinary proceeding initiated by any of the following entities:
- a medical regulatory authority,
- a health professional regulatory authority,
- another licensing authority,
- a regional health authority,
- another health authority,
- a hospital,
- a non-hospital surgical facility,
- a university, research or teaching facility,
- a government institution, or
- another entity
- Your privileges with a health authority, hospital, non-hospital surgical facility, or other entity have been refused, withdrawn, altered, revoked, suspended, not renewed or restricted.
- Your appointment with an institution where you practice administrative medicine, medical regulation, research or teaching has been refused, withdrawn, altered, revoked, suspended, not renewed or restricted.
- You have been dismissed from employment due to concerns about your care, conduct, competence, capacity or fitness to practice medicine.
- You have resigned from or voluntarily altered your privileges, appointment, or employment through an undertaking or agreement because of concerns about your care, conduct, competence, capacity or fitness to practice medicine.
- A legal action has been commenced against you related to your medical practice or your professional activities.
- A judgment or order has been rendered against you in a legal action, or you have agreed to an out-of-court settlement related to your medical practice or your professional activities.
- You have been arrested, charged, convicted or pleaded guilty or “no contest” to any criminal offence in Canada or elsewhere, including:
- offences under the Criminal Code of Canada,
- offences under the Controlled Drugs and Substances Act,
- offences under the Food and Drugs Act, or
- offences under legislation related to payment for medical services, or
- equivalent laws in all other countries.
- Your right to prescribe controlled substances or any other drug has been restricted, suspended, or removed.
- Your right to bill has been restricted or removed by a billing authority or health care paying agency as a result of an investigation, disciplinary action, undertaking or action.
How to report concerns
You may report your concerns to the Registrar by completing the form available on the College’s website. If you are unable to complete this form, you may send a letter to the Registrar.
Consequences of failure to report
Failure to respect these self-reporting obligations may result in the initiation of a Registrar’s complaint.
APPENDICES
Appendix A: Other reporting requirements
AUTHORITY DOCUMENTS
Medical Act, 1981
Regulation #9: Professional Misconduct
Personal Health Information Privacy and Access Act
ACKNOWLEDGEMENTS
The College acknowledges the assistance of the College of Physicians and Surgeons of Nova Scotia, the College of Physicians and Surgeons of Ontario, the College of Physicians and Surgeons of Alberta, the College of Physicians and Surgeons of Manitoba, the College of physicians and Surgeons of Newfoundland and Labrador, in preparing this document.
APPROVALS
Approved by Council: June 1994
Version: 5
Amendments: September 1999, September 2009, June 2017, and March 23, 2026
REVIEW DATE
December 2030
