Legally Speaking
November 2022
By Sheila Torrance, Legal Counsel, CPSS

Transition to process established in policy “Blood-borne Viruses: Screening, Reporting and Monitoring of Physicians/Medical Students”

As the College previously reported in Doc Talk [see DocTalk 2021, Volume 8, Issue 2:  A Shift in Approach to Screening, Reporting and Monitoring Blood-borne Viruses”] and in Dr. Shaw’s letters to all physicians sent in April and May of 2021, the policy Blood-borne Viruses: Screening, Reporting and Monitoring of Physicians/Medical Students (“BBV policy”) was amended effective March 2021.  While the policy expectations came into force at that time, there were a number of steps required prior to moving the monitoring process from the Registrar’s office to the Physician Health Program (PHP) of the Saskatchewan Medical Association (SMA).  This included the amendment of the health-related renewal questions [see article in DocTalk 2022, Volume 8, Issue 2: Recent Amendments to the Health-related Renewal Questions”]. 

The College is currently in the process of transitioning to the new monitoring processes established in the BBV policy.  Physicians who perform or assist in performing, or who may perform or may assist in performing, exposure-prone procedures (EPPs) and who are seropositive for a blood-borne virus (BBV) [specifically hepatitis B virus (HBV), hepatitis C virus (HCV) or human immunodeficiency virus (HIV)], must report such seropositivity to the Deputy Registrar, Dr. Werner Oberholzer.  After gathering some initial information, Dr. Oberholzer will refer the reporting physician to the PHP committee for management and monitoring.  As set out in the BBV policy, the PHP committee is supported in this work by the College’s Expert Advisory Committee on Blood-borne Communicable Diseases (EAC).

To date, the policy page on the CPSS website has included a notice that the College was still in transition to the new processes established in the policy.  As of October 31, that notice will have been removed and the policy will be fully in force.  While physicians have received several communications drawing their attention to the expectations of the policy, our recent experience in the annual renewal process has highlighted that a number of physicians are still unclear on their obligations.  While physicians are encouraged to read the policy in its entirety to ensure they are compliant, the primary differences with the revised policy can be summarized as follows:

  1. Monitoring - This will be performed on an arm’s length basis by the Physician Health Program (PHP), rather than through the Registrar’s office;
  2. Testing schedule - Instead of the general responsibility that physicians/medical students who perform or assist in performing EPPs know their status, a specific testing schedule has been included: annually for HBV (unless confirmed to be immune), q3 yearly for HCV and HIV;
  3. Reporting - Reporting of seropositive status is only required for physicians/medical students who perform or may perform / assist or may assist in performing EPPs.

Some physicians have also had questions about whether or not their practice includes (or may include) EPPs.  At its most basic, if there is a potential for your blood or body fluid to contaminate a patient’s tissue during an invasive procedure, then it is an EPP.   Can you adequately visualize your hands and fingers throughout the entire procedure, with no risk of injury?  If so, then it is likely not an EPP.  If you cannot, or if there is a potential that you will not be able to, then it is likely an EPP.

The College will continue to work with physicians who have questions about the implementation of the BBV policy, and how it may impact their individual situation.  If you have questions, please contact the Deputy Registrar, Dr. Werner Oberholzer.


  Sheila Torrance is Legal Counsel at the College of Physicians and Surgeons of Saskatchewan.