Chapter 4 Issues with accreditation and assessment
The Australian Medical Council (AMC) is responsible for the assessment
of international medical graduates (IMGs) qualifications, skills and experience,
leading to various categories of registration provided through the Medical
Board of Australia (MBA).
Accreditation and assessment processes for IMGs can follow a number of
pathways. In broad terms, the AMC administers a range of accreditation
requirements and assessment processes for non-specialist registration. Where Specialist
Registration is sought, the relevant specialist medical college applies its own
model of assessment, though accreditation remains the responsibility of the
This Chapter outlines evidence received from IMGs and from a range of
entities assisting IMGs relating to particular elements of the AMC’s assessment
and accreditation processes. The Committee will also consider elements of the
specialist medical colleges’ models of assessment in this Chapter. Issues
covered include concerns relating to lengthy timeframes and waiting periods
associated with some elements of the assessment and accreditation processes.
Issues relating to the assessments themselves, including concerns regarding the
means and processes for assessing clinical competency of IMGs are also
considered. The Chapter concludes by considering issues associated with
perceptions of assessment and accreditation entities.
AMC accreditation and assessment
In accordance with provisions under the Health Practitioner Regulation
National Law Act 2009 (Qld) (the “National Law”), the AMC is authorised as
the external accreditation entity to carry out the qualification accreditation
function on behalf of the MBA. The AMC is also
responsible for conducting the assessment of non-specialist IMGs leading to
General Registration, as well as liaising with the specialist medical colleges
to facilitate the assessment of IMGs who wish to become specialists.
Further detail in relation to the AMC’s functions and assessment processes may
be found at Chapter 3.
Primary source verification
The first step in the accreditation process for IMGs is verification of
their international qualifications. The AMC is responsible for overseeing
primary source verification, although the primary medical qualifications are
actually verified by the Educational Commission for Foreign Medical Graduates
(ECFMG) International Credentials Services (EICS) of the United States.
Primary source verification is authorised under the National Law, which
The National Board [MBA in the case of medical practitioners]
may ask an entity that issued qualifications that the applicant believes
qualifies the applicant for registration for confirmation that the
qualification was issued to the applicant.
Mr Ian Frank, Chief Executive Officer of the AMC, informed the Committee
of the value of primary source verification observing:
It needs to be understood too that [primary source
verification] is not just purely a barrier. We have had cases, for example, of
people coming out of China where there have been problems with their documents.
Because we have access to the verification services, we were able to pursue it
back into China and get verification from other sources in China that this
person was a legitimate medical practitioner. So it is not just something that
sort of stops people going forward; it can actually be used to verify or
confirm something that might not be readily available to, say, the regulatory
authorities in Australia. So it is a very positive process.
A range of submissions to the Committee, often from IMGs themselves,
outlined concerns relating to primary source verification. Largely, these
relate to the amount of time taken by the AMC to verify documents, the lack of
updates provided to IMGs on the progress of their application, and the lack of
assistance from the AMC in obtaining primary source verification.
There is no published standard to inform IMGs of the length of time
primary source verification may take. However, the AMC’s booklet Quick Guide
to Applying to the Australian Medical Council states:
EICS [ECFMG International Credentials Service] verification
will continue via ECFMG until the candidate's medical school has verified their
medical degree. This process may take several months to several years (this is
largely determined by the medical school responding to the EICS request – the
AMC is unable to contact medical schools to speed this process up).
Dr Elwin Upton submitted to the Committee that 17 months had elapsed
since the date of his applying to the AMC, without primary source verification
being received. As at the date of making a submission to this inquiry (6
December 2010), Dr Upton’s qualifications had still to be verified. Dr Upton
cites an email received from the AMC on 10 February 2010, advising that a
request for verification had been made to the institution and the processing
time for receiving EICS notification would be approximately ‘six to eight
weeks’. However, Dr Upton contacted the overseas tertiary institution directly
and was told there was no record of any request being received from the AMC.
Dr Ponraja Thuryrajah highlighted a similar issue. Dr Thuryrajah
practised medicine in Western Australia from 2004-2007 on Provisional
Registration. In 2008, changes in registration procedures required the AMC to
get primary source verification of Dr Thuryrajah’s qualifications from the
University of Kashmir. Dr Thuryrajah has encountered a number of difficulties
in obtaining verification since that time. After some initial delays
in the process, Dr Thuryrajah told the Committee:
I decided to focus my energies on expediting communication
between the University of Kashmir and the AMC by contacting the University
directly. I did contact the University via telephone, and was informed that the
University had been subjected to an arson attack circa 1983, and all records of
students graduating prior to that year had been destroyed.
The University of Kashmir requested that Dr Thuryrajah post the original
qualification to them so that it could be verified by the institution. However,
Dr Thuryrajah was reluctant to post original documentation due to difficulties
with the postal service. The offer to send a certified true copy was declined
by the institution. Dr Thuryrajah argues that a lack of flexibility associated
with the primary source verification requirement has led to three years passing
without resolution of this issue. He has been unable to practice since that
The AMC advised that of the 6 014 applications received for primary
source verification in 2010, 5 642 sets of qualifications were sent to the
ECFMG but only 2 862 verifications were received.
The AMC reported that:
The most common cause of delays in processing verification is
the failure of the issuing University or institution to respond to the request
for verification. In some instances it appears that additional payments or
inducements are sought by officers of the institutions involved to complete the
The AMC has developed a list of overseas institutions that have not
responded to requests for primary source verification or that have been
particularly slow to respond in the past. On the AMC’s website, IMGs are
encouraged to review the list to identify whether the institution where they
received their qualifications is likely to delay or fail to respond to any
requests to verify their qualifications. The AMC states:
If an IMG is able to identify their overseas medical training
institution in the list provided by the AMC, we recommend that they contact the
institution to confirm that the institution will respond to the EICS
verification request through the agreed processes between the AMC, the ECFMG
and the relevant overseas institution.
The AMC has also attempted to rectify some of the issues with respect to
primary source verification, including assisting IMGs who have successfully
completed all other stages of the registration pathway, excepting the primary
source verification process. The AMC submitted that it has identified a group
of candidates who have met all requirements for the award of the AMC
Certificate but are still waiting for primary source verification. The AMC
stated that at the commencement of 2011, 70 individuals were in this position,
however this number had reduced to 47 individuals from 15 countries following
additional efforts by the ECFMG to expedite the verification the outstanding
Mr Frank expanded further on the AMC’s efforts to rectify delays
occurring in the verification process for candidates who have completed the
assessment process excepting primary source verification, saying:
We have had some discussions at the Medical Board of
Australia to see whether there are ways in which we might be able to deal with
those people without holding them up unnecessarily.
The Committee understands that there is a range of factors that may
prevent the timely processing of applications for primary source verification.
These factors include whether the applicant’s overseas medical school is
recognised by the ECFMC, the completeness of the applicant’s documentation
(including whether correct witnessing requirements have been met) and whether
the issuing institutions themselves respond to requests from the ECFMC.
The Committee notes the AMC’s evidence that much of the delay in primary
source verification may be sourced to the verification processes of the ECFMG.
The Committee acknowledges that the AMC has made substantial efforts to assist
candidates to have their qualifications verified through the ECFMG process. In
particular, the Committee supports the AMC continuing efforts to assist IMGs
who have passed all other components of the registration pathway but have been
unable to achieve primary source verification.
It is evident to the Committee that a large source of frustration for
IMGs is the lack of follow-up or communication from the AMC in relation to the
progress of primary source verification, and their inability to take steps to
rectify any difficulties. The Committee recommends that the AMC and MBA consider
what further assistance might be provided to IMGs seeking to verify their
qualifications, including the provision of regular updates on the progress of primary
source verification, and an anticipated timeframe for the outcome of the
Further, the Committee proposes that the AMC and MBA in consultation
with IMGs take steps to assist IMGs who have encountered obstacles to achieving
verification which are beyond their control, such as circumstances regarding an
institution’s ability or willingness to provide primary source verification.
The Committee recommends that the Australian Medical Council
(AMC), in consultation with the Medical Board of Australia and international
medical graduates (IMGs), take steps to assist IMGs experiencing difficulties
and delays with primary source verification, including but not limited to:
to assist IMGs who have passed all requirements of a pathway towards
registration as a medical practitioner, excepting primary source
with the Educational Commission for Foreign Medical Graduates to ascertain
and address any barriers to achieving timely primary source verification; and
IMGs with up-to-date information relevant to their application, including the
anticipated timeframe for response based on their application, or options on
how they might hasten the process, such as contacting the institution
Competent Authority Pathway
IMGs seeking non-specialist registration who have completed examinations
or accreditation in the UK, Canada, United States, New Zealand or Ireland may
seek General Registration through the Competent Authority Pathway. To be
eligible for this pathway, IMGs are required to have completed all licensing
requirements of the relevant Competent Authority’s accrediting body and a
minimum specified period of post-examination practise in the relevant Competent
Authority country. The AMC submitted to the
The CA (Competent Authority) model recognises that there are
a number of established international screening examinations for the purposes
of medical licensure that represent a ‘competent’ assessment of applied medical
knowledge and basic clinical skills to a standard consistent with that of the
AMC examination for non-specialist registration.
Once recognition under this pathway is granted, IMGs are awarded
‘advanced standing’ towards the AMC Certificate. IMGs with advanced standing
can apply for Provisional or Limited Registration and must undertake a 12
months period of peer reviewed supervision in a designated position prior to
being eligible to apply for General Registration. The AMC told the Committee:
Despite getting some occasional bad press it has probably
been one of the most successful things we have been able to implement in
Australia and it certainly led to us attracting some fairly high quality people
into this country.
The main advantage of the Competent Authority pathway is that it
provides candidates with the ability to expedite their journey towards General
Competent Authority recognition
Evidence provided to the inquiry notes that there are other countries (particularly
those in Western Europe) in addition to those currently deemed to be Competent
Authority countries, which also have very high standards of medical education
The Western NSW Local Health Network told the Committee that consideration
should be given to extending the number of countries deemed to be Competent
Authority countries, saying:
Several European countries, such as Germany and the
Netherlands, appear to produce doctors who are as well-trained as the
recognised competent authority nations, however, they enjoy no preference over
countries whose training systems are viewed less favourably. It may be that
blanket acceptance of medical practitioners from additional countries is not
possible due to differences in the approach to some specialities. It could,
however, be appropriate to recognise those specialities that do have
equivalence to avoid unnecessary assessment and supervision requirements (all
of which consume Health System resources and may deter suitable applicants).
Further, some submissions to the inquiry suggested that the Competent
Authority model is discriminatory. For example, Dr Dennis
The Competent Authority Pathway gave rise to a query of
what[’s] so special about doctors trained in the USA, UK, Canada and NZ? Isn't
[it] that medical knowledge is a universal thing, regardless of language,
colour, country status, the biochemical principles, human anatomical landmarks,
mode of action of medications, types of bacteria and viruses, etc. are all the
same wherever you are on Earth ... Therefore there shouldn't have boundaries in
categorising and assessing competency of an IMG regardless of country of
Dr Johannes Wenzel also submitted:
For decades the medical system has maintained a two-tier
culture where OTDs are treated inferiorly to their Australian trained
counterparts ... This dilemma has not been helped by AMC introducing the
‘competent authority’ pathway, psychologically perceived by majority of OTDs
from the other countries that they are INCOMPETENT!
In contrast to these arguments, the Committee also received evidence
suggesting that increasing the number of Competent Authority countries is
neither feasible nor appropriate. Outlining the reasons for limiting the number
of Competent Authority countries, the AMC noted that the diversity of medical
training conducted around the world has implications on an IMG’s ability to
integrate into the Australian health system:
There is considerable diversity in the format, content and
methodology of medical training across these courses. Equally, there are
significant variations in:
n The clinical context
of medical practice, including the burden of disease, levels of technology and
the delivery of health services.
n Professional ethics,
including non-discriminatory treatment and the rights of all patients.
n The educational
context, including principles, systems and delivery of medical education.
The AMC submitted further:
In the case of the Competent Authority applicants, the fact
that they had already completed formally recognised licensing examinations,
that were rigorous and detailed assessments of medical knowledge and clinical
skills, meant that their entry to the medical workforce in Australia could be
fast-tracked with confidence.
The AMC advised that it is reviewing international examinations and
medical schools and courses that lead to registration for the purpose of
accrediting those that meet set criteria as ‘Competent Authorities’.
The Committee notes the AMC’s comments that any reduction in rigour or
completeness of assessment of IMGs would need to be balanced by a corresponding
increase in the monitoring of IMGs in a clinical setting.
The Committee understands that entry into the Competent Authority list is based
soundly on the similarity between the examination processes of Competent
Authority countries to those in Australia, taking into account relevant factors
such as the assessment of medical knowledge and basic clinical skills. The
Committee is satisfied that the AMC is the appropriate agency to assess whether
it is feasible to extend the list of countries that are deemed to be Competent
The Committee is of the view that the AMC has taken a cautious approach
in limiting the ability of IMGs to ‘fast-track’ the assessment process to those
IMGs who have qualifications from a country whose assessment process is
comparable to Australia. Such caution ensures that IMGs being assessed under
this pathway have the best opportunity possible to integrate into the
Australian health system, while also ensuring that the high standards and
rigour of assessment and registration as a medical practitioner in Australia is
Accordingly, the Committee supports the AMC’s view that the list of
Competent Authority countries should not be extended to include countries which
do not have comparable assessment regime, as this has implications for the
overall safety and standards of the health system in Australia.
Notwithstanding this view, the Committee is also supportive of the AMC
undertaking a review of international examinations and assessment processes to
determine whether any other countries should be added to the list of Competent
Authorities, on the basis of comparability of medical education and assessment
standards. The AMC should be proactive in undertaking visits to enquire into
examination and assessment processes of selected countries in order to expedite
the outcomes of this review.
Standard Pathway (2-part assessment)
IMGs who do not hold qualifications from a Competent Authority country
and who are not seeking registration as a specialist must follow the Standard
Pathway of assessment through the AMC. Assessment under the Standard Pathway
consists of two components – the AMC Multiple Choice Question (AMC MCQ)
examination and the AMC Structured Clinical Examination (SCE). If a candidate
successfully completes both components of this process, the IMG will be awarded
an AMC Certificate which enables the holder to apply for registration through
Part 1 – Multiple Choice Question examination
The AMC advised that there has been a steady increase in demand for the
AMC MCQ examination over the past 5 years, rising from 1,509 candidates in
2005/2006 to 4,466 in 2009/2010. The AMC said of the MCQ
The pattern of passing shows that there is a significant
fall-off in the pass rates after two attempts at the MCQ examination with
66.77% of candidates who pass doing so at their first attempt, 19.69% at their
second attempt, 7.2% at their third attempt and 6.2% at their fourth or
subsequent attempt. The data for 2010, which is consistent with previous years,
shows that the majority of candidates who will pass the MCQ examination (84.54%)
will do so within two attempts and that the pass rates flatten out after two attempts.
Part 2 – Structured Clinical Examination (SCE)
The AMC SCE assesses clinical skills through the use of clinical
stations. Concerns raised throughout this inquiry regarding the SCE include
issues regarding demand for places, how the assessment is administered and
concerns regarding the increasing demand for the examination.
Supply and demand
The AMC submitted to the Committee that the demand for SCE places now
exceeds supply, increasing from 887 candidates in 2005/2006 to 1,258 in
2009/2010. The increased number of
IMGs successfully completing the MCQ has resulted in an increased demand for
the SCE. According to the AMC, the challenge of meeting this increased demand
is affected by the availability of appropriately qualified clinical assessors,
venues and persons to act in either role playing or patient capacities.
Commenting on waiting times to sit the SCE, Dr Wenzel noted:
After passing the AMC MCQ examination, the average wait for a
position in the clinical AMC examination is 18 (!) months which exacerbates
doctors' ‘time out of clinical work’. There are no explanations why some IMGs
have to wait much longer than 18 months!!! It gets worse for OTDs who fail in
their first attempt, they face a wait of about 22 months, in some cases even up
to 3 years! The situation is compounded by the AMC conducing unlimited MCQ
examinations locally and overseas at a time where they cannot provide AMC
clinical examination positions within a reasonable time!
Similarly the Government of Western Australia Department of Health
There is currently an 18-24 month delay for applicants
seeking to sit this exam. There have been steady increases in the number of
exam places and variety of sites these tests are held, but high rates of
failure indicate IMGs are not well supported to pass this exam on the first
attempt. Each attempt requires progressing through the 'wait' period and
additional financial imposts.
The Committee has heard concerns regarding access to the SCE from a
number of IMGs and organisations. These concerns not only
evidence delays in the SCE process, but also the personal consequences
resulting from a failure to complete the process. For example, Dr Chaitanya Kotapati
The current delay for AMC clinical examination is not only
causing delay in the progress of the training of the overseas doctors but also
is contributing to tremendous stress in their personal lives as they are under
constant pressure to meet the requirements of AHPRA (Australia Health
Practitioners Regulatory Agency) in order to maintain conditional registration.
In relation to the AMC’s capacity to address this demand Mr Frank of the
AMC told the Committee:
We know for example that even now with our current clinical
examination we are running 22 series of examinations a year. That is one set of
clinical examinations every two-and-a-half weeks through the year. ... Now
there are up to three venues, three cities, we are running it in. That is
probably the maximum capacity of that system to be able to work.
In terms of addressing wait times for the SCE Mr Frank added:
... one of the things we are looking at is outsourcing part
of the clinical examination to universities to see if we can use their
facilities and their people outside of the weekends, because at the moment we
can only use the weekend facilities because that is when the hospital
facilities are available to us ...
In addition, in an attempt to balance supply and demand, the AMC advised
that it had developed a system which determines a list of priority for SCE
places. The priority list aims to distribute the number of available SCE places
in an equitable way. Under the priority system first-time applicants are
accorded priority over those who have previously attempted the examination.
However, the Committee was advised that one-third of all SCE places are
reserved for repeat candidates, Mr Frank noting that if only first attempt
candidates were selected, repeat candidates would not have the opportunity to
re-attempt the examination.
Mr Frank told the Committee of the current waiting list for the SCE:
Ideally we like to get everybody into an exam within 12
months of qualifying for a clinical examination. In practical terms it is
closer to 18 months, two years now. For repeat-attempt candidates we give
priority to people with fewer attempts over people with more attempts. The
reason for that ... the data shows that they just flatline out and do not get
The AMC also told the Committee about a ‘standby list’ that it has to
ensure that all available SCE places are filled, explaining:
... we also have what is called a standby list and on merit
order the next group of candidates down from the ones that have been
allocated—so if you have got 250 places allocated—we take another 100 places
and we contact the people and say, ‘Do you wish to be placed on a standby list
in the event that somebody declines one of the places that has been allocated?’
If they say yes, we put them on that list and we treat them in merit order. So
if a vacancy becomes available—often at the last minute—then we contact those
people and say, ‘There is a place available. Do you wish to take it?’
However, Dr Paramban Rateesh made the following observation of his
experience of being called from the standby list to take the SCE:
... all the times I have failed [the SCE] I have been called
from the [standby] list when I was already told no because the last person has
dropped out and they wanted that money to come back to them. I am getting a
phone call on a Friday saying ... ‘Are you ready to take up the exam for the
coming Saturday?’ The condition is that if I said no then I would go to the
bottom of list, then I would have to climb a mountain to get back up.
The Committee notes statistics provided by the AMC show that a high
percentage of candidates pass the AMC MCQ examination within two attempts,
while candidates who attempt the examination on more than two occasions find it
extremely difficult to pass. As the AMC MCQ is a computer based assessment, the
Committee understands that it can be readily accessed by IMGs, and can be taken
by applicants who are not based in Australia. The Committee understands that
the AMC MCQ is an important screening tool, providing an initial assessment of
IMGs clinical knowledge prior to successful applicants progressing to the next
stage of the AMC assessment, the SCE.
In contrast, the Committee perceives that there is a need to increase
the availability of places for the SCE. However, it also understands that the
resources available to increase the capacity of the SCE are finite. In this
circumstance, the Committee is pleased that the AMC is undertaking a number of
initiatives to deal more effectively with the demand by establishing
prioritisation mechanisms, including prioritisation and standby lists, to
maximise the equitable allocation of places and ensure that the available
capacity is utilised.
In addition, the Committee encourages the AMC to continue exploring the
full range of options available to increase the availability of SCE places, such
as outsourcing to universities. To this end, the Committee recommends that the
AMC examine options for increasing the availability of the AMC SCE for the
benefit of IMGs.
Amid concerns that many IMGs are required to wait for up to two years
for the opportunity to undertake the AMC SCE, the Committee believes that additional
examination places must ensure that IMGs can undertake examination within a
reasonable timeframe. The Committee appreciates the AMC’s contention that an
ideal scenario for IMGs attempting the AMC SCE for the first time should be
accommodated within 12 months. However, the Committee considers that a six month
period would be more appropriate. As foreshadowed in Chapter 1, the Committee
intends to review progress made in relation to the report’s recommendations at
a later date. The adequacy and feasibility of this timeframe will be considered
in consultation with the AMC and IMGs at that time.
The Committee recommends that the Australian Medical Council
take action to increase the availability of the Australian Medical Council
Structured Clinical Examination (SCE) so that those making a first attempt at
the examination be accommodated within six months of their initial
It is evident to the Committee that the scheduling priorities and the
standby list used to allocate places for the SCE are not well understood by
IMGs, and as such causes confusion and frustration. This is particularly the
case for IMGs who are repeat candidates with lower priority, who are likely
therefore to experience even longer waiting times. The Committee is of the view
that the AMC should alleviate this by publishing detailed information on its
website in relation to the allocation of places, and the current anticipated
waiting times for undertaking the SCE.
The Committee recommends that the Australian Medical Council
publish detailed information on its website outlining the processes for
determining the allocation of places for the Structured Clinical Examination
(SCE). The information should explain prioritisation, the purpose and
operation of the standby list and provide up-to-date information on waiting
times for undertaking the SCE.
The Committee notes that the AMC is prioritising first-time candidates
who attempt the SCE over those who are repeat candidates. The Committee is of
the view that a further step towards reducing the demand for the SCE would be
to identify the difficulties that repeat candidates have encountered and
consider whether further support might be offered to those candidates. This
issue is considered in more detail below.
Provision of feedback
Another concern raised in evidence relates to feedback received in
relation to the SCE. IMGs in particular have expressed their frustration to the
Committee about the lack of feedback provided to them once they have been
advised that they have failed a component or components of the SCE.
The AMC’s website advises that the overall result for each of the 16
marked ‘stations’ of the SCE are recorded as a pass or fail mark only.
Candidates are graded as a clear pass, marginal performance or clear fail.
In his submission to the inquiry, Dr Wenzel criticised the lack of SCE
The AMC clinical examination does not entail constructive
feedback for candidates who fail a station. No other university or college
restricts examination results to a simple pass/fail and provides feedback in
[the] form of a global tick box approach which does not relate to individual
Having failed on three occasions to pass the SCE, Dr Rateesh noted that
in the absence of constructive and specific feedback he was not able to
determine precisely why he had failed and seek to improve on any deficiencies.
The Committee is concerned that feedback for candidates attempting the
SCE is limited to whether the candidate passed or failed a particular station.
This leaves candidates unaware of any shortcomings in their knowledge and unable
to take steps to rectify these shortcomings. As the provision of constructive
feedback is crucial to assisting IMGs to advance to registration the Committee
believes this situation should be rectified.
The Committee recommends that the Australian Medical Council
provides a detailed level of constructive written feedback for candidates who
have undertaken the Australian Medical Council’s Structured Clinical
Targeted level of AMC examinations
The Committee has heard that some IMGs are dissatisfied with the
competence level targeted by the AMC through the MCQ and SCE examinations. The AMC’s website states:
The examinations are set at the level of attainment of medical
knowledge, clinical skills and attitudes required of newly qualified graduates
of Australian medical schools who are about to begin intern training.
Dr Michael Cleary, giving evidence to the Committee on behalf of
Queensland Health, compared the AMC examinations to the final examinations
provided to medical students in Australia, saying:
The AMC exam is in two parts: a clinical component and a
multi-choice component. In lay terms, the examinations are meant to be
equivalent to a sixth-year medical student, so someone who has graduated from
university in Australia who has the knowledge, skills and abilities to be able
to practise medicine as a junior doctor.
Dr Cleary also told the Committee:
The clinical examination requires you to have an
understanding of the healthcare system as well as an understanding of medical
practice. It is very difficult—I would say it would be extraordinarily
difficult—to pass that exam from overseas without having practised in
Australia, so generally people come and practise in Australia.
Dr Susan Douglas, representing the Australian Doctors Trained Overseas
Association (ADTOA), told the Committee:
The nature of that test is that it actually is a proxy for
someone who is just getting out of medical school. The evidence clearly shows
that the type of knowledge an experienced clinician has, like an IMG, is very different from an AMC entry test ...
Similarly, Dr Viney Joshi also representing ADTOA, told the Committee:
The AMC exam is by no means a test of an individual’s ability
to safely practise medicine. We are looking at people in their 40s ... It is
well known among people who are involved in adult education that when people in
their 40s or 50s have been in a particular stream of a profession for 15 or 20
years, they lose the academic ability. I think the assessments should be more
pointed towards their safety in their chosen field of expertise. For example,
for an ophthalmologist, there should be a peer review process to see whether he
is safe as an ophthalmologist—not that he is asked to go and sit the AMC exam,
which has directed questions on obstetrics and gynaecology, which this man may
have studied 22 or 25 years ago. He will never pass that exam.
The Committee understands that the AMC examinations are targeted at the
level of an Australian medical graduate and is aimed at testing an IMG’s basic
medical knowledge and knowledge of the Australian medical system. As the
examinations do not seek to assess knowledge beyond that which is required of a
new medical graduate, the Committee is of the view that the examination
achieves its desired outcome and places IMGs seeking employment in Australia on
an equal playing-field as Australian-trained graduates.
The Committee understands that there are a number of IMGs, particularly
those who completed their basic medical education some time ago, who feel
disadvantaged by this assessment mechanism. The alternative assessment process
offered through workplace-based assessment (discussed below) should alleviate
these concerns for some IMGs. The Committee considers, however, that the
examinations should be retained in their current format, as the assessment
appropriately establishes the foundation of medical knowledge which is expected
of all practitioners seeking employment in Australia.
Standard Pathway (Workplace-based assessment)
IMGs choosing the Standard Pathway of assessment may choose an
alternative to the SCE, this being the workplace-based assessment model (WBA).
A candidate for WBA must pass the AMC MCQ and must also comply with a number of
other conditions regarding their English language proficiency and employment.
Although the WBA alternative pathway was included in the 2007 COAG IMG
Assessment Initiative proposals, it was not endorsed by
all Australian jurisdictions and is therefore limited to four sites nationally,
n Hunter New England
Area Health Service (New South Wales);
n Rural and Outer
Metropolitan United Alliance (Victoria);
n Launceston General
n Western Australia
Private Hospital and Joondalup Health Campus.
The Committee has received evidence regarding the effectiveness of this
program, as well as evidence advocating for this pathway to be expanded and
made available on a national scale for the benefit of all IMGs.
Effectiveness of the workplace-based assessment model
Mr Frank, representing the AMC, told the Committee that the SCE is a
valid form of testing as it provides a three-hour snapshot of an IMG’s clinical
performance across a range of disciplines. However, Mr Frank noted
that assessing somebody in a workplace setting over a longer period of time is
the ideal, stating:
... being able to assess somebody over a period of time in a
workplace setting ... is a far more effective way of testing people, and that is
one of the reasons why the AMC was a strong advocate for getting workplace
based assessment implemented.
The AMC submission includes the following observations on WBA:
This model offers a number of advantages over the AMC
clinical examination pathway:
n The assessments are
undertaken over time, providing a much more reliable and accurate evaluation of
the clinical skills of the IMG.
n The IMG is assessed
in terms of his or her 'performance' rather than 'competence' alone. In other
words, they are assessed in relation to how they actually perform in a clinical
setting rather than measuring their capabilities in an artificial examination
n The assessment
includes feedback on performance which assists in addressing performance
problems and issues, a function that is not available in the AMC clinical
examination, unless these can be linked to bridging programs.
n The IMGs are employed
and are better able to offset the cost of their assessments.
Other evidence to the inquiry was generally supportive of WBA as a
credible alternative assessment to the AMC SCE.
Ms Marita Cowie, Chief Executive Officer of the Australian College of Rural and
Remote Medicine (ACRRM), told the Committee that ACRRM has received seed
funding from the Australian Government Department of Health and Ageing (DoHA)
to trial a new WBA program which will also provide an alternative to the AMC
SCE for IMGs. Ms Cowie told the Committee that ACRRM is hoping that the WBA
program will allow candidates working in general practice roles to obtain General
Registration more efficiently than the current clinical examination system.
Concerns expressed in evidence primarily related to the limited
availability of WBA places, issues associated with ensuring the quality and
independence of WBA review, and the resource implications associated with
implementing and participating in WBA.
Based on evidence to the inquiry the Committee understands that WBA
model provides a useful and effective method of clinical assessment. As such it
offers a credible alternative assessment pathway to the AMC SCE. The Committee
is encouraged by the positive feedback in relation to WBA provided during the
inquiry by representatives from a number of host sites that are currently
offering this model of assessment. The Committee was impressed by the success
of the award winning WBA program run by Hunter New England Health,
noting that in a little over 12 months 49 IMGs had successfully progressed
through the assessment and another 19 were expected to complete the program in
the near future. Similarly high rates of
success were reported for IMGs undertaking WBA through Launceston General
Hospital. The Committee considers
that these programs provide good examples of WBA program best practice and is
encouraged to note that with support from DoHA, ACRRM is in the process of
implementing a pilot WBA to operate in general practice settings.
In view of the AMC’s advocacy of WBA, and the positive feedback on the
model from those sites currently supporting this type of assessment, it is
unclear to the Committee why this model it is not offered more widely around
Australia. In Chapter 3 the Committee has already noted information provided by
the AMC indicating that although WBA was included in the original 2007 COAG IMG
Assessment Initiative proposals, this form of assessment was not endorsed and
signed off by all Australian jurisdictions at that time. According to the AMC
this resulted in delays in implementing WBA at a national level.
The Committee concludes that the limited endorsement of WBA by
jurisdictions as part of the 2007 COAG IMG Assessment Initiative proposals,
combined with other constraints such as the availability of financial, human
and administrative resources needed to support WBA may have contributed to the relatively
small number of sites available to host this assessment pathway. Although
understandable, concerns regarding the resource implications of hosting WBA may
need to be balanced with consideration of the benefits deriving from the
additional clinical services offered by the IMGs who are undertaking WBA.
Given the evident success of WBA and widespread support for this form of
assessment, the Committee believes that action should be taken to increase
access to WBA for IMGs seeking registration through the Standard Pathway. To
achieve this aim, the Committee recommends that COAG’s health workforce agenda
include consideration of WBA to increase jurisdictional endorsement of this
pathway and increase availability nationally.
The Committee recommends that the Council of Australian
Governments include workplace-based assessment (WBA) pathway for
international medical graduates on its health workforce agenda in order to
extend endorsement from state and territory governments and increase the
availability of host sites nationally.
Also, to gauge whether improvements could be made to the current WBA
model, the Committee recommends that the AMC commission an independent
evaluation of WBA. The evaluation should include a cost-benefit analysis of WBA
and encompass the views of all stakeholders including IMGs, clinical assessors
and host institution administrators. The outcomes of the evaluation should be
The Committee recommends that the Medical Board of Australia
in conjunction with the Australian Medical Council, commission an independent
evaluation of the workplace-based assessment (WBA) model. The evaluation
should incorporate a cost benefit analysis of WBA, and encompass the views of
all stakeholders, including international medical graduates, clinical
assessors and host institution administrators. The outcomes of the evaluation
should be made public.
Specialist medical college processes
IMGs who are deemed to be specialists or who have trained as a
specialist in their country of origin may pursue one of the pathways towards
registration as a specialist medical practitioner in Australia. The AMC and
specialist colleges are required to liaise in order to coordinate the
assessment and accreditation processes for IMGs seeking specialist recognition.
Assessing level of comparability
Assessment of an IMG’s claims for Specialist Registration is conducted
by one of Australia’s sixteen specialist medical colleges, and leads to a
determination of the IMG’s level of comparability as ‘substantially
comparable’, ‘partially comparable’ or ‘not comparable’. The outcome of this
assessment will impact on the length of time an IMG is required to undergo
supervised practise under peer review, and whether there are additional
requirements to be met (e.g. college examinations).
Although the specifics of specialist medical college assessments vary,
evidence concerning these processes identified common issues of general
concern. These issues relate primarily to the transparency and fairness of
specialist medical college assessment processes.
An overview of the specialist medical college assessment processes is
provided in Chapter 3 of the report. In brief however, assessing the level of
comparability usually involves the relevant college in the first instance
reviewing documents as verified by the AMC which detail qualifications, skills
and experience gained by overseas trained specialists.
Applicants are also required to submit an application for assessment to
the relevant specialist college. Further assessment usually involves interview
with applicants to determine an IMG’s level of comparability to the standard
expected of an Australian-trained medical specialist. Assessors for this
process are generally chosen from the Fellowship of the relevant college.
The Royal Australian and New Zealand College of Radiologists (RANZCR) explained
in its submission that:
The interview is a structured and thorough process that
provides an opportunity for the panel to:
n explain the
n clarify the
applicant’s training and experience;
n determine the
applicant's suitability for practice in Australia.
It is an opportunity for the applicant to:
n detail and explain
previous training and working experience.
n ask any questions of
the panel about the assessment process.
Distinctions between levels of comparability
The Committee has heard evidence suggesting that there is some confusion
regarding the classification of IMGs level of comparability. Specifically, some
members of the IMG community are unsure of the weight accorded to individual
aspects of an IMG’s prior skills, experience and training.
In highlighting this issue, the NSW Department of Health suggested that
the specialist colleges should develop clear, evidence based criteria by which
comparability of training programs can be assessed.
In this regard the Department noted:
The majority of specialist Colleges do not provide a list of
qualifications, or guidance on evidence of experience, that they consider to be
substantially comparable to Australian qualifications for the benefit of applicants
and their potential employers ... This lack of clear information on the
criteria to be met makes it difficult for an employer or applicant to easily
determine if they will be assessed as partially or substantially comparable at
the early stage in an assessment process.
Alecto Australia Medical Recruitment also noted that it is unclear what
overseas qualifications are likely to be considered substantially comparable or
otherwise, and submitted:
It would be helpful to provide a listing of the qualifications
that are generally deemed to be ‘substantially comparable’.
The submission from Queensland Health also raised concerns regarding
criteria for determining comparability, noting:
The definitions of comparability are recognised by all
colleges; however each college stipulates extra requirements beyond the
comparability definition without clear explanation of the reasons.
The Western NSW Local Health Network raised the issue of consistency of
college assessments within, and between colleges, saying:
The approaches to assessment also vary between colleges and some
consistency would be useful. Greater transparency would improve the whole
assessment system. It would allow health services to better understand college
processes and improve recruitment decisions.
The AMC noted that the Joint Standing Committee on Overseas Trained
Specialists (JSCOTS), formed by the AMC and Committee of Presidents of Medical
Colleges, had examined the issue of assessment comparability with input and
support from the colleges. While progress had been made toward achieving a
common definitions and understandings of the different comparability levels,
the AMC added:
... it appears that there are still some problems with the
application of the terminology, including outcome reports of a 'substantially
comparable' assessment, but with an additional 24 months oversight (the
terminology for 'substantially comparable' makes it very clear that the maximum
oversight is 12 months). Some outcome
reports have confirmed 'substantially comparable' but with workplace based
assessment (of summative nature). Again this is inconsistent with the agreed
assessment outcomes. These examples illustrate the need to ensure that
processes are monitored and continually updated and confirmed to ensure consistency.
This has been a key role for JSCOTS.
Recognition of prior training and experience
Some evidence to the inquiry suggests that not enough weight is afforded
to previous medical training and experience that IMGs have gained in their home
country when applications for specialist recognition are assessed.
The Committee has been told that where an IMG’s prior experience is not
given adequate recognition, an IMG can spend significantly longer under peer
reviewed supervision, and may be required to demonstrate basic skills and
experience which they would argue they have previously gained in their home
country. Drs David Wood and David Levitt submitted:
When an OTD has significant experience in a speciality and is
actively and successfully progressing towards appropriate registration in that
speciality they are required to do a requisite amount of general training at an
intern level. This shows a lack of understanding of:
n The experience level
of the OTD in this speciality; and
n The experience that
this OTD will have had in the basic specialties by exposure in current training
at a higher level.
Dr Paramban Rateesh told the Committee that the Royal Australian College
of General Practitioners (RACGP) requires that IMGs have a minimum of four
years experience before sitting the RACGP exams:
For the Royal Australian College of General Practitioners, I
need to be a general practitioner for a minimum of four years, but my 30 years
of experience has been counted only as one year and nine months.
IMGs who are deemed to be ‘substantially’ or ‘partially’ comparable to
an Australian-trained specialist may also be required to undertake a period of supervision
under peer review, before they are eligible to apply for Fellowship with the
relevant specialist medical college. The Royal Australasian College of
Physicians (RACP) provided the following evidence in relation to the peer
The purpose of the period of peer review is two-fold.
Firstly, it allows the overseas trained doctors the opportunity to be
orientated to the Australian health care system and his/her workplace. It also
allows practising specialists to interact with the overseas trained doctors in
a clinical context to determine if he/she is performing at an appropriate level
and to identify any areas of practice that might require improvement prior to
fulfilling the requirements for specialist recognition.
IMGs assessed as substantially comparable may be required to undertake a
period of peer review of up to 12 months, or up to two years for IMGs assessed
as partially comparable. However the periods vary for individual IMGs as this
is determined on a case-by-case basis. In the document Assessment of
Overseas Trained Specialists Guidance for Colleges, prepared by the JSCOTS,
the peer review process for an IMG assessed as substantially comparable is
discussed as follows:
The applicant is eligible for registration as a recognised specialist
and may apply for fellowship without further examination, but may be required
to undertake a period of up to 12 months oversight or practice under peer
review by a reviewer appointed through the college assessment unit. This is to
ensure that the level of performance is similar to that of an Australian trained
specialist, and to assist with their transition to the Australian health
system, provide professional support and help them to access continuing
professional development. The length of peer review and nature of assessment is
up to the individual college to determine on a case-by-case basis.
For IMGs assessed as partially comparable the same document provides the
following guidance on the period of peer review:
In order for a partially comparable applicant to be considered
substantially comparable the applicant will be required to undertake a period of
up to 24 months of training and assessment' under a supervisor appointed
through the college assessment unit, to ensure that the level of performance
reaches that of an Australian trained specialist, and to assist with their
transition to the Australian health system, provide professional support and
help them to access continuing professional development.
The Western NSW Local Health Network submitted to the Committee that the
‘probationary’ period imposed on some IMGs seeking specialisation accreditation
should be tailored to each individual to ensure the period is focussed on that
individual’s knowledge, experience and skills, stating:
Although there is a careful assessment of the qualifications
and experience of overseas trained specialists, there appears to be a blanket
approach to the question of probation. In many cases, two years is clearly
unnecessary and has led to situations in rural areas where ‘probationary’
specialists have been leaders in teaching and advising their colleagues.
The NSW Department of Health also noted that it is unclear what
implications a period of peer review would have on an IMG’s registration
Currently there is confusion for both employers and
registrants on whether an overseas trained specialist, who is assessed as being
substantially comparable but requiring 12 months peer review/ supervision, is
eligible for specialist registration or only limited registration.
The Committee understands that college assessment interviews and peer
review are vital elements of the assessment of an IMG’s qualifications, skills
and experience gained overseas for those seeking specialist recognition.
However, the evidence provided during the course of the inquiry suggests that
there are a number of elements which could be clarified and improved.
The Committee has observed that among IMGs there is confusion about the
classification of comparability levels and how they are determined in the
context of past skills and experience. To avoid this confusion the Committee
encourages the specialist medical colleges to keep IMGs well informed on the definitions
for each level of comparability. Specifically, guidelines outlining how
particular qualifications might ordinarily be considered by a college
determining comparability would be a helpful indicator for IMGs to digest prior
to making their application for assessment. For ease of access the Committee
recommends that the AMC and specialist medical colleges ensure that the
clarified definitions and guidelines are made available on their websites.
The Committee notes the role of the Joint Standing Committee on Overseas
Trained Specialists (JSCOTS), as outlined by the Australian Medical Council,
in clarifying the definitions of each level of comparability. The Committee
supports the continued role of JSCOTS, seeing this as is an important step in
ensuring consistency and transparency between colleges.
Another prevalent issue relates to the period of time an IMG is required
to spend in supervised practice under peer review following an assessment as
‘substantially’ or ‘partially’ comparable. The Committee acknowledges that peer
review by individual colleges is an integral component of the pathway towards
specialisation. While noting that the period is determined on a case-by-case,
it is apparent to the Committee that IMGs are frustrated by the lack of objective
guidelines explaining how an individual’s qualifications, skills and past
experience are used to determine the duration of peer review. The current
system of informing IMGs that the period of peer review is ‘up to’ one or two
years is unhelpful and could be further detailed for clarity. The Committee is
of the view that the colleges should seek to rectify this situation.
The Committee recommends that the Australian Government Department
of Health and Ageing and Australian Medical Council, in consultation with the
Joint Standing Committee on Overseas Trained Specialists and the specialist
agreed definitions of levels of comparability on their websites, for the
information of international medical graduates (IMGs) applying for specialist
and publish objective guidelines clarifying how overseas qualifications,
skills and experience are used to determine level of comparability;
and publish objective guidelines clarifying how overseas qualifications,
skills and experience are taken into account when determining the length of
time an IMG needs to spend under peer review; and
and maintain a public dataset detailing the country of origin of specialist pathway
IMGs’ professional qualifications and rates of success.
Specialist medical college examinations
In addition to interview and peer review, some specialist colleges may
require an IMG to undertake the relevant college examinations for their chosen
specialisation. Evidence to the
Committee has highlighted a range of issues regarding the requirement for IMGs
to sit college examinations which require further investigation.
Competence level of college examinations
Evidence to the Committee suggests that college examinations generally
assess IMGs at the level of competence expected of an Australian-trained
medical graduate entering the relevant specialist medical college training
program. Specifically, IMGs who have acquired significant specialist experience
in their home countries have been frustrated by the target level of the college
Some IMGs have informed the Committee that they have been required to
re-learn skills and basic specialist knowledge which they have not utilised in
practise since their early training as a specialist overseas. These IMGs have
argued that such examinations are inappropriate for overseas trained
specialists with years of experience, and do not accurately reflect their level
of competence as a specialist in their chosen field.
In a joint submission to the inquiry, Associate Professors Michael Steyn
and Kersi Taraporewalla, told the Committee:
The level of expertise examined is that of a trainee
completing the training program rather than at someone with experience beyond
Associate Professor Steyn expanded on this point during a public
My insight to answering a question for an exam was that of a
registrar—a trainee. When I answered it is like a trainee, I passed; when I
answered it like a specialist, I failed.
Dr Christoph Ahrens told the Committee that a specialist’s knowledge of
a chosen field evolves and deepens over time. He noted that during this period,
general knowledge which is not directly applicable to the specialist’s practice
may not be retained. He added:
I am supposed to sit the orthopaedic registrar’s examination.
This may seem fair at first sight, as all Australian Orthopaedic Surgeons have
to sit this exam at the end of their training. It is however an inappropriate
assessment tool to assess a senior surgeon. The exam is designed for the
purpose to test the knowledge of trainees before they are allowed to work
independently. It is unable to test surgical skills or ability of clinical
judgement including the very vital judgement of surgeons owns limits.
A South African trained ophthalmologist with over 20 years specialist
experience overseas, seeking Specialist Registration in Australia after several
years working in an Area of Need (AoN) position, observed:
The college assessment is inappropriate for the age of the
specialist: - no other Australian ophthalmologist at my age (50 years old)
is required to write the exam, nor are they likely to pass if they did without
The South Australian Government Department of Health also noted:
In some cases, highly qualified specialists from overseas
have failed to gain specialist qualifications because of college requirements
that they sit a fellowship exam, despite the fact that they work within a
specific sub-speciality and will not realistically practice within the full
scope of the fellowship.
The Committee understands why many specialist IMGs feel frustrated when
they find they are required to complete a graduate-level assessment,
particularly when they are practising a sub-specialty within their chosen
field, sometimes for many years. The Committee is of the view that specialist
medical colleges should consider taking a more targeted approach to the
assessment of IMGs who have been deemed substantially or partially comparable
to an Australian-trained specialist with an increased focus on WBA and reduced
reliance on college examinations.
A more targeted approach should include the ability for IMGs with
substantial experience in particular sub-specialities to be assessed on the
basis of the skills and experience required for that sub-speciality rather than
on facets of the speciality which the IMG is unlikely to utilise during the
practise in their chosen sub-speciality. Consideration should be given to an
IMG’s qualifications, level of experience and skills accumulated during their
overseas practise. In particular, it would appear that this type of assessment
would be appropriate for IMGs who have attained significant specialist
experience in niche sub-specialities.
The Committee recommends that specialist medical colleges
adopt the practise of using workplace-based assessment (WBA) during the
period of peer review to assess the clinical competence of specialist international
medical graduates (IMGs) in cases where applicants can demonstrate that they
have accumulated substantial prior specialist experience overseas. As part of
the WBA process the specialist medical colleges should make available the
criteria used to select WBA assessors.
Specialist medical college examinations should only be used
as an assessment tool where specialist IMGs are recent graduates, or where
deficiencies or concerns have been identified during WBA.
The Committee also understands that the Australian Health Workforce
Advisory Council (AHWAC) has been commissioned by the Australian Health
Workforce Ministerial Council (AHMC) to inquire into and report on the
assessment requirements for Fellowship of each of the medical specialist
colleges in relation to the recognition of qualifications and management of
assessment processes for overseas trained doctors.
The Committee anticipates that this review will include further recommendations
for improving specialist college assessment processes for overseas trained
specialists seeking Specialist Registration in Australia.
Reconsideration, review and appeal of college decisions
An IMG seeking recourse following a specialist medical college’s
decision regarding their application is required to follow the review mechanisms
stipulated by that college. From evidence provided to the Committee, it appears
that a number of colleges employ a three stage process for appeals.
In the first instance, an IMG may seek review from the original decision
makers, usually an internal committee or board of the college.
Where a decision is upheld, an IMG may then seek review from a higher-level
committee of the college. Where such a review is
upheld, many specialist medical colleges have the ability to convene a formal
Generally, an Appeals Committee may only be convened through a decision
by the college’s Chief Executive Officer, if an IMG has exhausted all other
avenues of review. An Appeals Committee is
usually convened with a majority of non-college members.
With the agreement of the Appeals Committee, an IMG may be entitled to have
legal representation present during the appeal.
The Committee’s inquiry has taken evidence which highlights a negative
perception of the clinical dispute resolution mechanisms available to IMGs
seeking specialist accreditation. Dr Chaitanya Kotapati, submitting in a
private capacity, told the Committee that there is an urgent need to regulate
the appeal processes of the AMC, MBA and specialist medical colleges to improve
accountability and transparency.
Dr Anatole Kotlovsky told the Committee that based on unverified
information, adverse findings were made by a specialist medical college in
relation to his application and he was not aware of any right of appeal:
No opportunity to present my perspective regarding the
subsequent adverse decisions against my professional recognition or advice of
my right to appeal these decisions was ever provided to me.
Another IMG, who wished to remain anonymous, stated:
I submitted an appeal to RANZCO which was supposed to be
heard within 3 months and surprisingly was allowed to be re- employed and re-
registered until the date of the expiry of the appeal. Shortly afterwards
RANZCO requested that the appeal should be held in abeyance whilst RANZCO re-
assess my clinical, surgical and academic abilities over a further year. I had
no choice but to accept this additional assessment, as my registration which
had been coupled to the appeal period was about to expire. If registration
expired I would have 28 days to leave the country.
Some contributors to the inquiry expressed concerns with the independence
of the appeals process, with the Committee receiving evidence calling for a
process entirely independent of college structures to conduct final
determinations. For example, Dr Viney
Joshi told the Committee:
I feel it is time that the government stepped in and created
some sort of an ombudsman which sat above the colleges and the regulatory
bodies—that is, AHPRA, the medical board and all these organisations—where at
least people could go and get a fair deal.
Dr Christopher Hughes from RANZCOG expressed some reservations about
such a process:
... if it was for an external independent body to be making
those decisions, I am not sure that the intimate professional expertise and
knowledge to reverse or come up with an alternative decision is necessarily
there, if it is going to involve people outside the specialty area. I guess you
can take them from the specialty area but outside the college process.
Dr Jennie Kendrick, Fellow and Censor-in-Chief of Royal Australian College
of General Practitioners (RACGP) told the Committee that determining whether an
IMG has reached the appropriate clinical standard should be assessed by
appropriate clinical experts.
It is apparent that the nature of many specialist medical college assessment
grievances could be deemed as subjective, as often it is one clinician
assessing another in a supervisory capacity. An example of this might be an IMG
not receiving a favourable report during the peer review period. Despite a
large number of submissions being received with respect to appeals, the
Committee has received evidence that the number of reviews subject to a
formalised appeals process by an Appeals Committee is relatively small.
The Committee understands that specialist medical college Appeals
Committees fulfil the function of providing a final process for the
determination of decisions made by colleges. However, that there are aspects of
college Appeals Committees which could be improved in the interests of
transparency. The first of these is the discretion of the Chief Executive
Officer of a relevant college to determine whether an Appeals Committee should
be convened. The Committee is of the view that following the completion of the
second-stage of appeal regarding a decision of a college, IMGs should have
automatic grounds to appeal to the college’s Appeals Committee. The Committee
is also of the view that IMGs should have the option to retain an advocate to
represent them in an appeal to the relevant specialist medical college’s
The final aspect the Committee has considered in relation to the
specialist medical colleges Appeals Committee is its membership. The Committee
understands that Appeal’s Committee’s constitute a majority of independent
members. However, the Committee is concerned about the perception of many IMGs
who have made submissions to this Committee regarding their belief that the
appeals processes of the specialist medical colleges are not independent,
impartial or transparent.
The Committee is of the view that the colleges should provide clear and
detailed information on the Appeals Committee and its membership on its
website, including profile information on each member of the Committee to
inform IMGs of each member’s impartiality. The Committee also recommends that
the Appeals Committee of each college should also comprise of an additional
member who is an IMG and member of the college’s international medical graduate
The Committee recommends that all specialist medical
colleges consult with the Australian Medical Council to ensure each college
undertakes a consistent three-stage appeals process, incorporating the
automatic right for an international medical graduate (IMG) to undertake the
next stage of appeal, following completion of each preceding appeal;
option for the IMG to retain an advocate for the duration of any appeal
process to an Appeals Committee, including permission for that advocate to
appear on the IMG’s behalf at the appeal itself; and
capacity to expand membership of the Appeals Committee to include an IMG who
holds full membership of the relevant specialist college, but has no
involvement with the decision under review.
The Committee is also concerned about submissions to the inquiry from
IMGs who advised that were not informed regarding the relevant college’s
appeals process and therefore did not avail themselves of the process. To
rectify this issue, the Committee suggests that the colleges provide a
two-pronged approach to ensure IMGs are informed about their right to appeal a
decision made by the college, during their assessment process:
n by providing clear
and detailed information on the relevant college website regarding the appeals
process, including timeframes for lodging an appeal, the stages of appeal and
how the appeals operate; and
n by providing relevant
information on the next stage of appeal, including deadlines for submitting an
appeal, in writing to all IMGs, in the same document advising the IMG of the
decision the college has made in respect of their application for
The Committee recommends that the specialist medical
colleges undertake the following steps to ensure international medical
graduates (IMGs) are aware of their right of appeal regarding their
application for specialisation:
n publish information regarding their appeals process in a prominent
place on their website, including information regarding each stage of the
appeals process, timelines for lodging appeals and the composition of Appeals
Committee membership; and
that IMGs are informed of their right to appeal when any decision is made
regarding their application, with information regarding their right to appeal
a particular decision provided in writing on the same document advising the
IMG of the decision made regarding their application.
During the inquiry, the Committee also canvassed the concept of
developing an overarching independent appeals mechanism with respect to
decisions of clinical competence made by specialist medical colleges. Although
independent appeals processes are available for administrative decisions made
by the MBA/AHPRA (through the National Health Practitioner Ombudsman as outlined
in Chapter 6), where matters of clinical judgement arise no independent
mechanism exists beyond the Appeals Committee process discussed above. The
Committee believes that such a mechanism, discharging its functions
independently, is paramount to providing reassurance in relation to the
integrity of clinical competence assessments.
While evidence to the Committee was in general terms supportive of an
overarching independent appeals mechanism to review decisions relating to
clinical competence, there was a paucity of detail on the composition and
functioning of an independent review mechanism. However, the Committee proposes
that an overarching independent appeals mechanism for the review of clinical competence
decision should comprise an appropriately selected panel. Composition of the
panel will need to allow for the necessary perception of independence, in
particular independence from the specialist college subject to review.
Importantly, composition of the panel also needs to preserve the integrity clinical
decision making through the involvement of medical practitioners with the
requisite knowledge and expertise to review college decisions relating to
clinical competence. While not wishing to impose a structure, the Committee proposes
that necessary balance between independence and clinical expertise could be
achieved by a panel comprising:
n an independent Chair
familiar with either administrative or clinical matters (eg National Health
Practitioner Ombudsman or Commonwealth Medical Officer or their independent
n medical practitioners
familiar with the particular speciality, with an equal representation of
nominees made by the IMG and by specialist medical college subject to review;
n medical practitioners
from specialist medical colleges other than that subject to the review, with
familiarity in clinical assessment. It might be that these panellists could be
drawn from a pool of nominations made by specialist medical colleges, selected
at the discretion of the independent Chair.
The Committee recommends that the Australian Health
Ministers Advisory Council, in conjunction with the Australian Government Department
of Health and Ageing and the National Health Practitioner Ombudsman, develop and institute an overarching,
independent appeals mechanism to review decisions relating to the assessment
of clinical competence to be constituted following an unsuccessful appeal by
an international medical graduate to the Appeals Committee of a specialist
In making its recommendations to improve the transparency and
independence of appeals processes relating to assessments of clinical
competence, the Committee recognises the need for colleges to ensure that
specialist IMGs are appropriately qualified, skilled and experienced. Ensuring
that the community continues to receive health care that is safe and high
quality remains paramount.
Perceptions of assessment and accreditation authorities
Evidence has been provided to the Committee suggesting that specialist
medical colleges are often not held accountable for their decisions, with a
perception that some specialist colleges are ‘boys clubs’ with a ‘closed shop’
mentality which discriminate against IMGs. Dr Joshi told the Committee of his
concern regarding the specialist medical colleges, saying:
I am going to make a very controversial statement here, but
colleges are degenerating into old boys’ clubs sadly enough. Instead of
becoming centres of quality education they are becoming bastions of power and
absolutely like an exclusive club, whether you are part of that club or not.
Even when you become a part of the club through getting your fellowship whether
you can pervade into the inner sanctum sanctorum depends on how good your
manipulative skills are. If you are not slick enough then you get left out.
Dr Michael Galak submitted to the Committee:
The registering bodies or a body now, are not answerable to
anyone with the political clout to change their decisions. The hypothetical
possibility of going to the Administrative Appeals Tribunal or Human Rights
Commission is useless because these organisations, having tackled Medical Boards
before, learned the awesome power of the legal protection these registering
bodies enjoy. Who would wish to squander the limited resources on a hopeless
quest? In the end OTDs are left unprotected.
Dr Jonathan Levy of the Australian Doctors Trained Overseas Association (ADTOA)
told the Committee that many IMGs were scared to contribute to the Committee’s
inquiry as a result of their perceptions:
... they are all scared of the taskmaster on the ground and
will not raise their heads above the parapet ... If everybody who wanted to put
a submission in had put a submission in, you would have had two, three, four or
five times the number that you received.
The Royal Australian and New Zealand College of Ophthalmologists (RANZCO)
submitted to the Committee that it should be made clear that registration
decisions are the responsibility of the Medical Board of Australia on advice
from the AMC, and not by the College itself. RANZCO noted that there was a
tendency to demonise the College and accuse them of restricting entry of
doctors to their speciality. RANZCO also stated in
this regard that:
The College takes pride in the fairness and transparency of
its decisions made in good faith, and feels that the MBA and the AMC should be
public in defending such processes undertaken at their request.
Chair of the MBA, Dr Joanna Flynn responding to a question about whether
the accreditation processes were susceptible to being manipulated to
deliberately restrict IMG entry, observed:
The way that it is dealt with structurally is to make sure
that the standards that the colleges are using to assess are published, that
they are clear, that there are appropriate reports written of the basis on
which decisions were made and that there are appropriate appeals processes. I
also believe that most people working as a doctor, which I do, recognise that
there is a significant workforce shortage across the whole medical workforce—
that there is more than enough work for everyone. So whereas 20 years ago the
issue was about, ‘Don’t stay on my patch; there’s not enough work for both of
us,’ I really do not believe there is anyone who believes that now.
The Committee has heard evidence, particularly from IMGs themselves,
suggesting that the AMC and specialist medical colleges lack transparency and
fairness when performing their roles of assessing and accrediting IMGs
qualifications, prior skills and experience for the purposes of registration.
The Committee is particularly concerned that some IMGs assert that these
entities have acted with a degree of bias and/or discrimination. The Committee
trusts that the AMC and specialist medical colleges aim to carry out their
functions in an impartial, fair and transparent way, as affirmed by their
representatives who gave evidence before the Committee during the course of
With regard to the specialist medical colleges, the Committee has
already referred to the outcomes of the 2004-5 Review of Australian specialist
medical colleges conducted by the Australian Competition and Consumer
Commission (ACCC) in conjunction with the Australian Health Workforce Officials
Committee (AHWOC). The review focused on four principles - transparency,
accountability, stakeholder participation and procedural fairness – making 20
recommendations to improve college assessment and accreditation process. The
Committee understands that since 2005 the colleges have made considerable
progress in implementing many of the recommendations.
Nevertheless, noting continuing concerns raised and perceptions held by
IMGs and associated health stakeholders throughout Australia, the Committee
encourages the AMC and specialist medical colleges to continue to take further
steps towards achieving a high level of transparency and accountability in its
dealings with IMG candidates seeking accreditation and/or registration as
specialists in Australia.
As recommended by the Committee earlier in this Chapter, transparency
should include the dissemination of clear and concise information regarding
assessment processes, including explanatory information on how assessment
processes are undertaken and the criteria used to determine levels of
IMGs should also be afforded access to appropriate independent and
efficient appeals processes when they object to a decision made regarding the assessment
their clinical competence. The Committee notes that there is further discussion
on MBA/AHPRA appeals processes in Chapter 6 which deals with IMG registration