Cover story: Medico limbo

More than four in every 10 of Australia’s medical doctors were trained overseas but many face registration problems and hundreds are unable to practise. Now a House of Representatives committee is investigating the issue.

Five years ago, a dark cloud of suspicion began to loom over thousands of foreigntrained doctors when Dr Jayant Patel, an Indian-born surgeon at Queensland’s Bundaberg Hospital, was accused of causing the deaths of some of his patients.

Questions had been raised about Dr Patel’s competence soon after the hospital appointed him in 2003, yet it was another seven years before he was tried and sentenced to seven years imprisonment. Dubbed ‘Dr Death’ by the media, Dr Patel was found guilty last July on three counts of manslaughter and one of grievous bodily harm.

The case highlighted the way controls over the employment of foreign doctors, even basic scrutiny of their qualifications, had been ignored for years by health authorities because of a desperate shortage of Australian-trained medical officers.

Dr Mukesh Haikerwal says the shortage arose because the Howard government decided in 1996 to contain spiralling health costs by freezing enrolment increases in university medical schools. In that year, 1,327 medical students graduated while a decade later the figure had risen to only 1,378 – an additional 51 doctors although the population had expanded by nearly 2.5 million people.

To fill the ever-widening gap, Australia became ever-more reliant on importing doctors from overseas. Significant numbers were drawn from developing countries, despite the desperate need for medical help in those countries.

Dr Haikerwal is one of Australia’s best-known foreign-trained doctors. Also born in India but educated in Britain, he is a former president of the Australian Medical Association, chair of the World Medical Association’s finance and planning committee and a professor of medicine at Flinders University in Adelaide – and he still practises in Melbourne’s western suburbs where he first began as a GP in 1991.

“The federal government was forced to start building new medical schools from 2000 on to boost local training and their numbers have jumped from 12 to 20,” Dr Haikerwal says. “But it takes more than 10 years before medical students graduate, complete their internships and other postgraduate training before they go into practice so the demand for foreign doctors has hardly abated.”

In some rural and remote regions, more than half of all doctors are now from other countries and overall they comprise 40 per cent of Australia’s total medical workforce. But the continuing publicity surrounding Dr Patel, his hurried forced departure to America in 2005, the later warrants issued for his arrest and his return to Queensland to be tried last year, raised questions in the public mind about the capabilities of other foreign doctors.

“Overseas trained doctors now face a hostile working environment,” Monash University sociologist Dr Bob Birrell wrote in 2005. “Anecdotal evidence indicates they face a suspicious public [and] any doctor with a foreign name or appearance is likely to be affected... They are likely to be particularly reluctant to take medical employment in regional settings where there is not much social support.”

Until he stepped down last year, Dr Birrell headed the Centre for Population and Urban Research at Monash. In a series of articles beginning in 2004, he and his colleagues reported that quality control of the overseas trained medical workforce was virtually non-existent.

Writing in the centre’s journal People and Place, the researchers revealed that as a result of state and federal government decisions, foreign doctors faced no assessment of their medical knowledge, clinical skills, performance in a supervised hospital setting, or even a check on how well they spoke English.

In a paper in 2005 headed ‘The aftermath of Dr Death: Has anything changed?’, Dr Birrell and Andrew Schwartz, then president of the Australian Doctors Trained Overseas Association, pointed out that despite the findings of a Queensland commission of inquiry into Dr Patel, neither the federal nor state governments had acted to ensure this would not happen again.

The authors noted that state medical boards had decided foreign doctors would have to achieve a score of 7 on the IELTS English proficiency examination as a precondition of registration. But while the Australian Medical Council proposed to implement a medical knowledge test, state and federal health authorities were not committed to enforcing it.

“The [then] Minister for Health and Ageing, Tony Abbott, stated he does not want to be involved – he is content to leave the matter to the states,” Birrell and Schwartz wrote. “In his words, `I’m not going to buy into a quagmire where the federal government has responsibility but no authority’.”

The authors said no state or Commonwealth health department had taken unilateral action to introduce a formal test of medical knowledge, clinical skills or a compulsory period of supervised medical practice, as was obligatory in the United Kingdom, Canada and the United States. Nor had any health authority decided to require a probationary period for foreign doctors employed as specialists in public hospitals that involved strict supervision of their work. “Patel could happen again..,” they warned.

A year later, the Council of Australian Governments (COAG) decided changes would have to be made to the employment process for international medical graduates applying for registration. The aim, the council said, was to “increase the safety and efficacy of the healthcare workforce by assessing the suitability of the applicant for a specific position”.

The council agreed to establish an Australian Health Practitioner Regulation Agency which would assume responsibility for the registration of more than 500,000 health workers in 10 of the main professions. At the time, 85 separate state-run boards were responsible for accrediting doctors, nurses, mid-wives, dentists, pharmacists and other health professionals.

Yet, despite the council’s decision, the state boards continued to perform their roles over the next four years. It was not until last July the regulation agency finally came into being, although almost from the start it has come under attack from healthcare workers who failed to be re-registered and suddenly found themselves unable to do their jobs.

In any event, the entire medical registration system is still disturbingly complex so it is not surprising foreign doctors find it difficult to weave their way through the maze of groups with differing responsibilities. These range from the Australian Medical Council and the special medical colleges to the Medical Board of Australia, which has oversight of the state and territory medical boards. These boards function as committees of the national board and can make decisions about individual practitioners in each jurisdiction.

When strict new accreditation rules were finally implemented across Australia in 2008, however, the regulations appear to have led to a zealousness on the part of some officials charged with assessing foreign doctors.

In some cases their actions seriously affected a significant number of well-qualified professionals.

General practitioners and medical specialists alike, including many who had worked in their communities for a decade or more, suddenly faced having to prove they were competent and some even lost their jobs.

“The current accreditation processes are very arbitrary with rules made on the fly and people changing them when they feel like it,” says Dr Viney Joshi, who succeeded Andrew Schwartz as president of the Australian Doctors Trained Overseas Association.

“They don’t understand that this is ruining the careers of people who have been here for years, working in areas that historically Australian doctors don’t want to go. We are talking about people in their 40s and 50s with no history of problems who have been shafted. Some of what is placed on them is too onerous and more than is required of Australian graduates.”

Indian-born and trained, Dr Joshi is a GP and medical superintendent at the Blackall Hospital in southern Queensland. He quotes the case of an overseas trained gynaecologist who wanted to renew her accreditation with the relevant specialist college but was turned down because she had not performed laparoscopic hysterectomy, a relatively new alternative to the abdominal operation.

“The college now says she must have a certain number of these operations to be accredited but it was not required when she came to Australia years ago,” Dr Joshi says. “She is working in an area where no Australian surgeon wants to go and is on call 28 days out of 30. The doctors in her community will tell you how much she is liked and how much she is needed but now the college says it cannot accredit her because she does not meet the latest criteria.”

In the House of Representatives last October, Bruce Scott (Maranoa, Qld) called for a parliamentary inquiry into the role of the medical colleges in assessing international medical graduate specialists and current accreditation methods, particularly the role of the pre-employment structured interview, known as the ‘PESCI’.

Under the rules set down by the national registration agency, certain medical applicants are required to be interviewed, orally tested in fact, by a group of usually three examiner doctors. The assessment is to establish whether the foreign medical graduate has the knowledge, skills and experience to practise safely in the position for which registration is being sought.

But there have been claims some examiners have exceeded their authority and failed well-qualified applicants who then lost the jobs they had been working in for years.

Mr Scott said the issue of accreditation was causing great distress to a number of doctors in his electorate “and I know across many parts of Australia, particularly in Queensland”.

“There is much concern that the current process to assess the competency of overseas trained doctors is discriminatory and that the process to approve registration for these doctors lacks transparency,” he said.

Seconding the call for an inquiry, Warren Entsch (Leichhardt, Qld) said a strong message had to be sent to the medical colleges that “with the gift of monopoly come serious obligations in the way they treat foreign trained doctors”.

“Regional Australia could not function without the services of these foreign doctors. [Yet] these colleges are nothing but old boys’ clubs. They have been established by those who get major benefits from the current situation. They do not like any competition whatsoever [and] if another doctor comes in and does not play the game, they will attack them relentlessly and they will remove their opportunity or their licence to practise.”

Mr Entsch said he was calling on the Australian Medical Council to start setting accreditation standards and to give the colleges 12 months “to sort out their nonsense, to sort out this mafia that they are involved in and to improve conditions, transparency and accountability”.

“I have absolutely no doubt that we need competent people here but we have foreign doctors training in this country who have no voice and no opportunity to defend themselves or their reputations,” he said.

Responding to these concerns and others from disgruntled medicos and Dr Joshi’s association, Health Minister Nicola Roxon in November asked the House of Representatives Health and Ageing Committee to conduct an inquiry into the registration processes and the support available to overseas trained doctors.

The committee’s terms of reference note the vital role of the specialist colleges “in setting and maintaining high standards for the registration of overseas trained doctors” but state that the committee will:

explore current administrative processes and accountability measures to determine if there are ways OTDs (overseas trained doctors) could better understand colleges’ assessment processes, whether appeal mechanisms could be clarified, and the community better understand and accept registration decisions;
report on the support programs available through the Commonwealth and state and territory governments, professional organisations and colleges to assist OTDs to meet registration requirements and provide suggestions for the enhancement and integration of these programs; and
suggest ways to remove impediments and promote pathways for OTDs to achieve full Australian qualification, particularly in regional areas, without lowering the necessary standards required by colleges and regulatory bodies. 
Dr Joshi welcomed the news. “The treatment of overseas trained doctors is divisive, unfair and discriminatory,” he says. “Once the initial entrance exams to practise in Australia have been passed, where is the rationale for introduction of further layers of examination that are not in existence for our peers?

“Once we have been deemed to be at an Australian graduate level – and many of us are way beyond that upon arrival why is it correct to treat us differently in any way at all? A quite stunning example is the ‘10-year moratorium’ that restricts where OTDs may work for up to 10 years after arrival in Australia.

“It is enshrined in a federally legislated piece of discrimination, never mind that it contravenes the Racial Discrimination Act! That fact has been ignored as OTDs have been used to shore up rural and remote healthcare chasms for the past 13 years. And it hasn’t even worked: regional healthcare is worse now than it ever has been.”

Thousands of overseas trained doctors still waiting to gain accreditation were no doubt also overjoyed to hear of the inquiry. Many have found that Australia’s system of ensuring foreign doctors are qualified to do their work is complex and fragmentary, the bureaucracy disturbingly inefficient and the accreditation processes irregular and lacking clear criteria.

Professor Claire Jackson, however, rejects the claims made in parliament about the medical colleges and the assertions of Dr Joshi and other critics. As president of the Royal Australian College of General Practitioners, and a professor of general practice at the University of Queensland, Dr Jackson also dismisses Warren Entsch’s labelling of the colleges as “old boys’ clubs”.

“Females dominate our profession and the college board,” Dr Jackson says. “We recognise that many international medical graduates are working in rural and remote areas and that they need support as well as help with their education to be able to undertake the studies to gain a fellowship of the college.”

She says there are now flexible routes to fellowship of the college, which enables doctors to gain registration, and that overseas trained doctors do not have to sit an examination: “They can even qualify for fellowship by sending in videotapes of consultations with their patients.”

Dr Jackson says the submission made by her college to the House of Representatives inquiry rejects suggestions the specialist colleges “set standards like an old boys’ club” or that they “change their arrangements as they wish”.

“I absolutely refute that claim as does the college,” she says. “We are accredited by the Australian Medical Council and our examinations, the standards we set and the way we measure those are accredited nationally by the AMC.”

The college is completely transparent and is fully supportive of international medical graduates, Dr Jackson says. On Christmas Eve, the college received a $2 million grant from the federal health department to offer 300 places to overseas trained doctors required to re-register this year.

“They will have personal learning plans prepared for them, lots more support and all our faculties of medicine in the universities have international medical graduate subcommittees, most of whom are IMGs themselves with fellowship of our college,” she says.

“They will be working with these foreign trained doctors, often in remote areas with high workloads, to make sure they get all the support they need to achieve fellowship.”

In its 14-page submission to the inquiry, the college says it has never supported the requirement that overseas trained doctors must serve at least 10 years in an area of need – usually remote or rural – and the policy needs urgent review.

The Australian Medical Association likewise argues in its 12-page submission that the requirement should be scrapped. The association says there could not have been a worse place to send foreign doctors unfamiliar with the Australian culture, its people and their practices.

The AMA says the requirement has exacerbated the doctor shortage and the isolation of country towns has made it harder for foreign doctors to accustom themselves to Australian standards.

Long and winding road

When Dr Susan Douglas arrived in Australia with her husband and two children in 2006, she had no idea it would take years before she could get her qualifications and experience recognised as a long-term Canadian family doctor and academic.

Dr Douglas was an assistant professor at Dalhousie University, a leading research intensive institution in Nova Scotia, with 16 years’ academic and clinical experience. She moved to Canberra after accepting a position at the Australian National University as a senior lecturer in general practice.

As such, she also wanted to practise medicine herself yet it was not until 2008 before she obtained conditional registration to work part-time as a GP in a Canberra medical clinic desperately short of doctors.

Some 3,000 overseas trained doctors each year are granted temporary permits and provisional practising rights, mostly in places where doctors are scarce. In October 2009, after Dr Douglas had applied to become a permanent resident, she learnt that Medicare had withdrawn her provider eligibility, meaning her patients would no longer receive rebates from the health scheme. Under the rules, doctors without full accreditation automatically lose their Medicare rights.

Her plight stemmed from a long-running dispute with the Royal Australian College of General Practitioners over recognition of her Canadian qualifications, even though she later learned other Canadian doctors with the same qualifications had been accepted as fellows of the college.

Dr Douglas was given a year’s extension of her provisional registration and had her Medicare provider number reinstated but she is still trying to obtain accreditation.

Unable to resolve her problems with the college, she has now started the registration process all over again and is following a different registration path. She is hopeful that by next year – six years after first arriving in Australia – she will have put the problems of the past behind her.

“Federal legislation prevents foreign medical graduates working where they want to for up to 10 years unless they practise in a particular area of need,” Dr Douglas says. “My clinic is desperately short but it doesn’t meet the Commonwealth definition as an area of district workforce shortage although it does in the ACT.

“The only reason I have an exemption and have a provider number is because I am an academic. The irony is if I left the university I could no longer work here as a doctor and would no longer have registration or a Medicare provider number.”

Dr Douglas says Australia’s current policies on overseas trained doctors are actively dissuading foreign medical academics and teachers coming to Australia. 

Pathways to practice

In 2008 the Australian Medical Council introduced a nationally consistent assessment process for foreign trained doctors who then had four different ‘pathways’ they could follow to become qualified to work as general practitioners or specialists.

The pathways include obtaining approval to be registered by one of the medical colleges such as the Royal Australian College of General Practitioners, taking the AMC examinations, undergoing workplace-based assessment, or following a specialist assessment pathway.

No doubt aware of the growing concern among foreign doctors and the call for a parliamentary inquiry into their registration, the AMC and the Medical Board of Australia decided in November to review the effectiveness of the pathways.

Chair of the board, Dr Joanna Flynn says the review is not about changing the standards but rather looking at what is working effectively and what could be improved.

“We are making sure these pathways have been implemented as consistently as possible and are as effective as they can be in ensuring IMGs (international medical graduates) have the skills, qualifications and experience to provide safe care to the Australian community,” Dr Flynn says.