Requirements and how the licence works
Type of role
Ontario does not have a clinical assistant or associate physician licence class. The College of Physicians and Surgeons of Ontario (CPSO) does not register, examine, or set entry requirements for clinical assistants. There is no protected title for the role, no public register, and no provincial program through which an internationally trained physician (ITP) applies for the position.
In Ontario, the work that other provinces license as clinical assistant or associate physician is performed by an unregulated worker under delegation of controlled acts. The legal framework is provided by the Regulated Health Professions Act, 1991 (RHPA), section 27(2), and by the CPSO Professional Obligations: Delegation of Controlled Acts policy and its accompanying Guidance for the Profession.
Ontario is one of only two provinces in Canada that does not issue a registered intermediate licence class for physicians who are not eligible for full or provisional registration. The territories also do not issue this class. The clinical assistant role exists in Ontario solely as private employment under delegation. Physician assistant (PA) became a regulated registrant class in Ontario on April 1, 2025, through amendments to Ontario Regulation 865/93 under the Medicine Act, 1991 (O. Reg. 865/93). The PA role is described later in this section.
Legal and policy framework
Under section 27(1) of the RHPA, only authorized regulated health professionals, or properly supervised delegates, may perform a controlled act. Section 27(2) lists 14 controlled acts, including communicating a diagnosis, administering a substance by injection or inhalation, performing procedures below the dermis or below the surface of a mucous membrane, applying a prescribed form of energy, prescribing or dispensing a drug, and managing labour. Any health-related activity not on this list, such as taking a history or performing a physical examination, is in the public domain and may be performed by anyone competent. No delegation is required for public domain activities.
When a clinical assistant performs a controlled act, the supervising licensed physician must comply with the requirements set out in the CPSO Professional Obligations: Delegation of Controlled Acts policy, which include the following:
Clinically assess the patient before delegating, or within two business days of the delegate’s first encounter with the patient, except in specified emergency, public health, and remote-care exceptions
Use a clear and specific direct order, written or verbal, or a written medical directive containing all required elements
Verify that the delegate has the knowledge, skill, and judgment to perform the act safely
Remain physically onsite to supervise, unless an exception applies
Not leave a delegate to manage a practice or patient population independently
Have protocols in place to manage adverse events
Monitor and evaluate the care provided through delegation
Document in the medical record who performed the act
The supervising licensed physician remains fully accountable for every act performed under delegation.
The May 2026 CPSO Guidance for the Profession added two clarifications specific to IMGs working as clinical assistants. First, the supervising licensed physician cannot rely on credentials or licences obtained in other jurisdictions to confirm an ITP’s competence. The physician must directly assess the ITP’s knowledge, skills, and judgment, regardless of training completed abroad. Second, ITPs who are not registered with CPSO cannot use the titles “physician,” “surgeon,” “doctor,” or any variation of those titles, including “M.D.,” in the course of providing health care in Ontario.
Eligibility and application process
There is no centralized application process for the clinical assistant role in Ontario. Eligibility is determined by the hiring licensed physician or institution, not by CPSO or any provincial program. CPSO does not maintain a register of clinical assistants, does not list eligibility criteria for the role, and does not issue a certificate of registration for clinical assistant work.
There is no mandatory examination requirement set by the province. Individual employers may request evidence of a pass result on the Medical Council of Canada Qualifying Examination (MCCQE) or the National Assessment Collaboration (NAC) Examination, but neither is required by law or by CPSO policy to be hired as a clinical assistant.
Employment is established by private contract between the worker and the hiring physician or institution. Most clinical assistant positions in Ontario are in office-based settings. Hospital-based clinical assistant positions exist but are less common than in provinces with a registered clinical assistant or associate physician licence class.
Accountability and recognition of practice
CPSO has jurisdiction over the supervising licensed physician. It does not have jurisdiction over the unregulated clinical assistant. Concerns about a clinical assistant’s conduct are typically addressed through the supervising physician’s CPSO file, through the RHPA’s provincial-offence framework for unauthorized practice or unauthorized title use, through enforcement of the Personal Health Information Protection Act, 2004 (PHIPA) by the Information and Privacy Commissioner of Ontario, or through civil action.
Hours worked as a clinical assistant in Ontario are not recognized as Canadian practice hours by provincial medical regulatory authorities or by Practice Ready Assessment (PRA) programs. Clinical assistant work in Ontario is private employment under delegation. It is not regulated practice and is not documented under any provincial licensing framework.
How the PA role differs from the clinical assistant role in Ontario
Beginning April 1, 2025, the College of Physicians and Surgeons of Ontario (CPSO) regulates physician assistants (PAs) under the Medicine Act, 1991. Physician assistant is a new registrant class established within the existing Medicine Act framework, through amendments to Ontario Regulation 865/93 (O. Reg. 865/93). PA is not a separate profession on Ontario’s list of 27 regulated health professions. The titles “Physician Assistant” and “PA” are protected under the Medicine Act, 1991, and only individuals registered with CPSO may use these titles in Ontario.
The PA role and the clinical assistant role are commonly confused and are sometimes used interchangeably in employment listings, but they are distinct under Ontario law. The differences are summarized below.
| Feature | Physician assistant (PA) | Clinical assistant (CA) |
|---|---|---|
| Regulation | Regulated by CPSO since April 1, 2025 | Unregulated |
| Title | "Physician Assistant" and "PA" are protected titles | No protected title |
| Public register | Yes, maintained by CPSO | None |
| Entry pathway | Graduation from an accredited PA education program plus a certifying examination | Determined by the hiring licensed physician or institution |
| Professional liability insurance | Minimum $10 million, mandatory | Not mandated by any provincial body |
| Continuing professional development | Mandatory; tracked by the certifying body | Not mandated by any provincial body |
| Scope under delegation | Performs controlled acts under delegation from a supervising licensed physician | Performs controlled acts under delegation from a supervising licensed physician |
Both PAs and clinical assistants in Ontario perform controlled acts under delegation. The legal mechanism is the same. The roles differ in regulatory status, title protection, and entry-to-practice pathway.
Internationally trained physicians cannot register as physician assistants in Ontario on the basis of their medical degree. PA registration requires:
Graduation from an accredited Canadian or United States physician assistant education program
Successful completion of a certifying examination administered by the Physician Assistant Certification Council of Canada (PACCC) or the National Commission on Certification of Physician Assistants (NCCPA)
At least $10 million in professional liability insurance issued by a company licensed to carry on business in the province
A medical degree from a foreign jurisdiction does not satisfy the PA education program requirement. The PA program is a distinct educational pathway from medical school.
The CPSO addresses this directly on its Physician Assistant Registration page:
Internationally trained physicians may continue to practise through delegation but may not call themselves a PA. The title “Physician Assistant” or the abbreviation “PA” is protected under the Medicine Act, 1991. Internationally trained physicians will only be able to practise as a PA where they meet the standards and qualifications set out in the Registration regulation (requisite education and certification) and are registered with CPSO.
IMGs may continue to practise in Ontario through delegation of controlled acts under the framework described above. They cannot use the titles “Physician Assistant” or “PA.”
Professional Obligations: Delegation of Controlled Acts | CPSO | May 2026
Guidance for the Profession: Delegation of Controlled Acts | CPSO | May 2026
Physician Assistant Registration | CPSO | 2025
Being a CPSO Registrant | CPSO | 2025
Regulated Health Professions Act, 1991, S.O. 1991, c. 18 | Ontario e-Laws
Medicine Act, 1991, S.O. 1991, c. 30 | Ontario e-Laws
O. Reg. 865/93: Registration (Medicine Act) | Ontario e-Laws
Personal Health Information Protection Act, 2004, S.O. 2004, c. 3, Sched. A | Ontario e-Laws
