Duty to Report a Colleague

Standard of Practice

Under Review: NO
Issued by Council: January 1, 2010
Reissued by Council: September 1, 2012; October 1, 2020


A regulated member who is uncertain about legislated reporting requirements not addressed in this standard should refer to the Legislated Reporting & Release of Medical Information Advice to the Profession document or consult with the Canadian Medical Protective Association.

Reporting Requirements

  1. A regulated member must notifyi the Registrar, or the delegate, of the applicable college of the following circumstances as soon as the regulated member has reasonableii grounds to believe a regulated health professional of any collegeiii:
    1. presently has a physical, cognitive, mental and/or emotionaliv conditionv that negatively impacts, or is likely to negatively impactvi, their workvii;
    2. is charged with or convicted of a criminal offenceviii;
    3. is demonstrating a repeated inability to provide patients with what is reasonably considered competent care;
    4. is demonstrating an unwillingness or inability to address behaviour that interferes with patient care or negatively impacts the ability of other regulated members, learners or healthcare workers to provide patient care; or
    5. is behaving in a manner outside of providing patient care that could reasonably be considered unprofessional conduct under the Health Professions Act (HPA)ix.
  2. A regulated member must report another regulated health professional to the relevant college as soon as the regulated member has reasonable grounds to believe the regulated health professional is engaging in behaviour that constitutes sexual abuse or sexual misconduct of a patient, as required by the HPA.
  3. In accordance with the HPA, a report under clause 2 is not required (but may be made)x if information respecting the conduct of another regulated health professional is obtained in the course of the regulated member providing professional services to the other regulated health professional.
  4. When a patient discloses information that leads a regulated member to reasonably believe a regulated health professional has committed sexual abuse or sexual misconduct against a patient, the regulated member must:
    1. provide the patient with information on how to file a complaint with the appropriate regulatory college;
    2. document the account of the sexual boundary violation in the patient’s record; and
    3. advise the patient of the regulated member’s duty to report the incident to the appropriate regulatory college.
  5. Notwithstanding subclause 4(c), while the name of a regulated health professional who is reasonably believed to have engaged in sexual abuse or sexual misconduct against a patient must be reported to the relevant college per the HPA, this can be done without providing the name of the patient.
  6. If a regulated member is unsure if they should report a colleague, regulated health professional or regulated health professional-patient, they must seek appropriate advice (e.g., the Canadian Medical Protective Association or CPSA).Duty of Treating Physicians and Physicians Working in the Context of a Physician Health Program to Report a Regulated Health Professional
  7. A regulated member treating another physician or other regulated health professional, or a regulated member working within a provincial Physician Health Program in a non-treating capacity (e.g., the AMA’s Physician and Family Support Program), must make all reasonable efforts to understand the nature and scope of the regulated health professional-patient’s practice and, with the consent of the regulated health professional-patient, seek information regarding the impact of any medical condition on their practice.
  8. The treating physician, or a regulated member working within a provincial Physician Health Program in a non-treating capacity, must notify the regulated health professional-patient’s regulatory college when the regulated health professional-patient presently has a physical, cognitive mental and/or emotional condition where it is reasonably foreseeable that patients, or others within the context of the regulated health professional-patient’s medical practice, could be seriously harmedxi (physically or psychologically) as a result of the medical conditionxii.
  9. Notwithstanding clause 8, the treating physician must advise the regulated health professional-patient of their duty to self-report to their regulatory college and document this advice in the patient’s record.

[i]“Notify” has been used to signify that contacting CPSA does not automatically result in a formal report, complaint, etc. “Report” is used in clauses specific to the HPA to mirror its language.

[ii] “Reasonable grounds” connotes a belief in a serious possibility based on credible evidence or the point where credibly-based probability replaces suspicion. It is the reasonable belief that an event is not unlikely to occur for reasons that rise above mere suspicion.

[iii] Please refer to Section 127.2(1) of the Health Professions Act (HPA).[iv] Per Recommendation 5 of the Health Law Institute’s “Physicians with Health Conditions: Law and Policy Reform to Protect the Public and Physician-Patients.”

[v] Conditions would include, but not be limited to, the following:

  • blood borne viral infections in those individuals performing exposure-prone procedures
  • conditions affecting primary senses: vision, hearing etc.
  • neurological conditions affecting cognition, motor or sensory function, seizure disorder
  • psychiatric conditions
  • substance use disorder
  • physical disability
  • metabolic conditions

[vi] Negative impact” is defined as harm to patients or others as a result of the practice of medicine. The practice of medicine includes research, education and administration, in addition to the practice associated with patients. (Per Recommendation 3 of the Health Law Institute’s “Physicians with Health Conditions: Law and Policy Reform to Protect the Public and Physician-Patients.”)

[vii] The practice of medicine includes not only patient care, but all activities, such as working with other health care workers, teaching, research and administrative work done in the context of medical practice.

[viii] Please refer to Section 127.1(4) of the HPA.

[ix] Please refer to Section 1(1)(pp) of the HPA.

[x] Please refer to Section 127.2(2) of the HPA.

[xi] Serious harm” is defined as that which is either irreversible or would result in more than minor pain or injury (psychological or physical).

[xii] Section 35(1)(m) of the Health Information Act allows disclosure of medical information without consent if the regulated member believes it will avert or minimize an imminent danger to the health or safety of any person.

About the Standards of Practice

The CPSA Standards of Practice are the minimum standards of professional behaviour and ethical conduct expected of all physicians registered in Alberta. Standards of practice are enforceable under the Health Professions Act and will be referenced in the management of complaints and in discipline hearings.

Questions?

For questions or archived standards, policies and guidelines contact our Standards of Practice Advisor.