The College of Physicians and Surgeons of Ontario: Regulating Medicine in the Public Interest
The College of Physicians and Surgeons of Ontario (CPSO) plays a crucial role in regulating the medical profession in Ontario. All doctors must be members of CPSO in order to practise medicine in Ontario. The college regulates the practice of medicine to protect and serve the public interest. This article delves into the functions, responsibilities, and recent activities of the CPSO, providing a comprehensive overview for a wide audience.
The CPSO's Mandate and Regulatory Power
The CPSO is the self-regulating body for the province's medical profession. The medical profession has been granted a great degree of authority by provincial law, and that authority is exercised through the college. This system of self-regulation is based on the premise that the college must act first and foremost in the interest of the public.
The CPSO holds significant regulatory power. It sets out and enforces professional standards for its members. The CPSO's power is derived from Regulated Health Professions Act (RHPA), Health Professions Procedural Code under RHPA and the Medicine Act. Members of the College are governed by the Medicine Act, 1991, the Health Professionals Procedural Code, the Regulated Health Professions Act, 1991, and by the regulations and by laws of the College.
Governance and Structure
The college is governed by a Board of Directors, formerly known as the College Council. The origins of the College of Physicians and Surgeons of Ontario (CPSO) lie in early 19th-century efforts to regulate medical practice in Upper Canada. In December 2023 the CPSO Council approved a set of governance modernisation initiatives to be effected through by-laws. These included changing the name of the CPSO Council to the Board of Governors. Board members sit on one or more committees of the college. Each committee has specific functions, most of which are governed by provincial legislation. Board meetings are held four times a year, at which time the activities of the college are reviewed and matters of general policy are debated and voted on.
Transparency Initiatives
The College of Physicians and Surgeons of Ontario (CPSO) faced longstanding criticisms for deficiencies in transparency, particularly regarding the disclosure of physician misconduct and medical errors prior to 2013. In response to these concerns, the CPSO initiated its Transparency Project in 2013, aiming to expand public access to physician-specific information to enhance accountability and informed patient choice. The College Council gave its support to a transparency initiative that had four categories. One, an increase in the transparency of the transfer of patient medical records. Two, a proposal that the Notices of Hearing for the college's Discipline Proceedings be posted to a physician's profile on the public register. Third, a proposal that the status of discipline matters as they are proceeding be added to a physician's profile on the public register.
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Handling Complaints and Discipline
The CPSO also handles patient complaints against physicians. A complaint to the CPSO about a physician may be initiated online or by telephone. Details are published on the CPSO "Complaints and Concerns" page. The CPSO mandates investigation of every public complaint against a physician, regardless of apparent merit, under the Regulated Health Professions Act, 1991, contributing to operational strains in its complaints and discipline system. The CPSO will conduct an investigation into the patient’s complaint and will make enquiries into the physician’s practice. The College may determine that disciplinary proceedings as against a physician are warranted.
In recent years the college has struggled to process an increasing volume of complaints about physicians. In 2007 it successfully lobbied the Ontario Ministry of Health to increase the time limit for disposal of complaints from 120 to 150 days, and to give itself increased powers to extend those time limits. These proposals were contained in amendments to the Regulated Health Professions Act 1991 which were passed by the Ontario Legislative Assembly in 2007 and came into force in 2009. A key operational issue is persistent delays in processing, violating the statutory 150-day timeline for complaint disposition. In the discipline phase, operational bottlenecks persist post-investigation referral to the Inquiries, Complaints and Reports Committee (ICRC) or the Ontario Physicians and Surgeons Discipline Tribunal.
A novel solution adopted by the college to the problem of delays in resolving complaints has been to make increasing use of "never reapply" undertakings. A "never reapply" undertaking is an undertaking made by a physician to surrender his or her licence and never reapply for another licence in Ontario or anywhere else in the world. In return, the college promises not to proceed with the complaint, the investigation is terminated and the file closed. These undertakings are probably legally unenforceable both inside and outside Ontario as they would amount to an unreasonable restraint of trade and they are rarely used by other medical regulatory authorities. In the past, such undertakings were only used in the most serious cases, for example sexual abuse of a patient, but they are increasingly being used by the college as a way of disposing of less serious or unspecified complaints.
This data was extracted from the CPSO online public register by a combination of electronic and manual searching. In each case an attempt was made to identify why the undertaking was given, and the undertakings were allocated into four categories. "Sexual" indicates that there was an allegation of sexual misconduct, either proven or unproven, and involving either patients or co-workers. "Explicable" indicates that the reason for the undertaking was non-sexual, but there appeared to be some other good reason why it was appropriate, for example, gross incompetence, a serious criminal conviction, dishonesty, psychiatric incapacity or a repeated failure to remediate. The fourth category, appearing for the first time in 2022, is for COVID-19 related undertakings.
Between 2007 and 2013 the college issued more than 1,000 "cautions" against practising doctors. Cautions are issued to doctors for transgressions that include providing inadequate treatment, poor record-keeping and raising voices in arguments. Between 2004 and 2011 the college prosecuted four physicians for improperly charging block fees to patients. Block fees are annual fees charged by physicians to allow patients to access services.
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Redesigned Physician Register
October 23, 2024, the College of Physicians and Surgeons of Ontario (CPSO) launched its redesigned Physician Register on October 16, 2024. The redesigned register features numerous enhancements, including a better user experience, a more intuitive display of physician information and strengthened cybersecurity. The new register organizes content on a physician’s profile using tabs to reduce the need for users to scroll for information. “We are excited to introduce the redesigned Physician Register, which reflects our commitment to improving access to vital information while ensuring the highest standards of security,” says Nathalie Novak, chief operating officer of CPSO. “The enhancements we’ve made will not only simplify verifying prescription details, but also make it easier for the public to find accurate and up-to-date information about Ontario’s physicians.
CPSO and Medical Assistance in Dying (MAiD)
The College of Physicians and Surgeons of Ontario (CPSO) was at the forefront of policy development as the legislation on medical assistance in dying (MAiD) was coming into force. To receive MAiD, the patient must be found eligible in accordance with criteria in the Criminal Code by two independent clinicians, the patient must consent to MAiD and all of the safeguards set out in the Criminal Code must be met.
The goal of the college’s policy is to respect patients and physicians. Our policy is rooted in the core values of the medical profession, such as service, altruism, trustworthiness and compassion, articulated in our Practice Guide. Our effective referral provision is in place to ensure that objecting physicians do not abandon their patients and that even the most vulnerable members of society have equitable access to our public health care system. Doctors have a fiduciary responsibility to all of their patients no matter where they are in their life cycle, including those who are grievously and irremediably ill and wish to seek assistance in ending their lives. Physicians are not solely responsible for ensuring access to medical assistance in dying. Of note is that an effective referral, in any clinical situation, does not guarantee a specific outcome for a patient.
CPSO's Response to COVID-19
On March 24, 2020, the CPSO Executive Council met to discuss the potential impact of the COVID-19 pandemic on Council business.
Prior to the COVID-19 pandemic, the College of Physicians and Surgeons of Ontario (CPSO) operated under duties imposed by the Health Protection and Promotion Act (HPPA), R.S.O. 1990, c. H.7, with oversight and enforcement through the Regulated Health Professions Act, 1991 (RHPA) under which failure to comply constitutes professional misconduct. Under sections 25(1), 26, 30, and 34(1)-(2) of the HPPA, physicians were required to report to the local medical officer of health as soon as possible upon suspecting or confirming a disease of public health significance (s. 25), carrier status (s. 26), death involving such disease (s. 30), or non-compliance with treatment (s. 34) for such conditions in patients under their care. These reports included details on patient demographics, symptoms, and potential exposures, with diseases specified in the Designation of Diseases regulation, encompassing conditions like tuberculosis, measles, and hepatitis. Physicians also had duties to cooperate with public health investigations and orders under the HPPA, including facilitating contact tracing, isolating patients, and adhering to directives from medical officers of health during outbreaks. For instance, section 22 of the HPPA empowered medical officers to order examinations or treatments, with physicians obligated to comply or face enforcement, while CPSO's oversight ensured such adherence aligned with ethical standards of practice. Additional reporting mandates covered specific scenarios, such as rabies exposures (under HPPA's Communicable Diseases - General Regulation), vaccine reactions within defined timelines (e.g., anaphylaxis within 48 hours), and newborn eye infections within two weeks of birth. Complementing statutory duties, CPSO maintained policies on infection prevention and control (IPAC) for clinical offices, requiring physicians to implement measures like hand hygiene, sterilization, and barrier precautions to mitigate transmission risks during routine and outbreak scenarios. This policy, effective prior to 2020, mandated risk assessments and adherence to Public Health Ontario guidelines, with non-compliance subject to CPSO inspections and potential sanctions. Unlike during COVID-19, pre-pandemic responses lacked a dedicated CPSO policy on broad public health emergencies; instead, frameworks relied on case-specific activations under the HPPA, as seen in prior events like the 2003 SARS outbreak, where public health measures were enforced through existing HPPA mechanisms (with limited documented CPSO disciplinary involvement).
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On April 30, 2021, the CPSO released a statement on “Public Health Misinformation” accusing Ontario doctors of “using social media to spread blatant misinformation and undermine public health measures.” The College of Physicians and Surgeons of Ontario (CPSO) enforced standards requiring physicians to adhere to evidence-based public health guidance in their public communications, viewing deviations as potential misinformation that could undermine trust in health measures. In early 2021, CPSO highlighted concerns over social media posts by physicians that lacked context or contradicted official recommendations on lockdowns, vaccines, and masks, issuing cautions for "irresponsible" or unprofessional statements.
In response, a group of Canadian physicians released a declaration titled the “Declaration of Canadian Physicians for Science and Truth”. The CPSO followed up its “Public Health Misinformation” statement by starting disciplinary action against a number of physicians. As of 16 January 2024, 21 physicians have been disciplined, with sanctions including suspension or revocation of registration, undertaking with restrictions or “never reapply” undertaking.
Since the start of the COVID-19 pandemic, the CPSO has required physicians not to "disseminate false and misleading information" about COVID-19, which may include the physicians' personal opinions about mask wearing, vaccine safety and the effectiveness of certain COVID treatments.
Enforcement actions proliferated from 2021 onward, targeting physicians for public statements, social media activity, and clinical decisions perceived as undermining public health measures. Discipline Tribunal decisions upheld suspensions for non-compliance with masking protocols and dissenting public commentary. In April 2021, an ICRC order suspended a physician's registration for refusing to wear a mask during a patient examination, a ruling affirmed by court review in December 2021 as necessary to protect public safety amid active transmission risks. Cases like CPSO v. Turek (decision released January 19, 2024) resulted in licence suspension for COVID-19-related professional conduct, including misinformation dissemination. Similarly, in CPSO v.
CPSO expanded enforcement by restricting practice privileges for physicians associated with dissenting views, such as barring those accused of promoting anti-vaccination activity from issuing medical exemptions for COVID-19 vaccines or masks. By January 2022, CPSO reported investigating over 40 physicians for disseminating unproven treatments or misinformation related to COVID-19, with actions including license suspensions or revocations for conduct deemed "disgraceful and dishonourable."
During the COVID-19 pandemic, the CPSO faced allegations of overreach in investigating physicians for issuing medical exemptions to vaccine mandates and publicly dissenting from official health guidance, actions claimed to lack explicit statutory basis.
These measures drew criticism for potentially chilling professional dissent, as CPSO's broad interpretation of "misinformation" encompassed views not yet disproven by consensus, such as early skepticism toward vaccine mandates.
Quality Assurance
The College of Physicians and Surgeons of Ontario (CPSO) has implemented quality assurance and improvement programs to promote physician self-reflection and practice enhancement, thereby bolstering public protection through proactive oversight. The College of Physicians and Surgeons of Ontario (CPSO) has implemented the Quality Improvement (QI) Program as a mandatory, proactive framework to enhance physician practice standards and patient safety. Launched to address needs-based quality gaps, the program engages registrants in self-directed learning via an online platform, requiring completion of projects that fulfill regulatory quality obligations for five years.
CPSO's adoption of the College Performance Measurement Framework (CPMF) represents a structured approach to bolstering oversight and accountability across Ontario's health regulatory colleges. This initiative mandates annual reporting on performance standards, including commitments to targeted improvements where gaps exist, thereby fostering transparency and continuous enhancement in regulatory functions.
Expansion of regulatory oversight to physician assistants (PAs), effective April 1, 2025, exemplifies CPSO's efforts to standardize practices in emerging roles. PAs must now meet defined registration criteria and adhere to CPSO standards of practice, ensuring consistent quality and public protection in collaborative care settings.
Under its Strategic Plan (extended to 2027), CPSO has pursued "right-touch" regulation, emphasizing proportionate, evidence-informed policies that modernize standards without undue burden.
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