AUSTRALIA: Overseas doctors fill large gaps

When Dr Susan Douglas (pictured) arrived in Australia with her husband and two children in 2006, she never realised it would take years before she could get her qualifications and experience recognised as a long-term Canadian family doctor and academic. Had she known, Douglas says she would never have migrated here with her family.

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

She naturally also wanted to practise medicine herself yet it was not until 2008 that she obtained conditional registration to work part-time as a GP in a Canberra medical clinic desperately short of doctors. She is now hopeful that full registration may finally be approved next year.

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 Douglas had applied to become a permanent resident, she learnt that Australia's government medical insurer, Medicare, had withdrawn her provider eligibility, meaning her patients would no longer receive rebates from the health scheme.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. Yet, as is the case with GPs from Britain, New Zealand and the US, Canadian doctors mostly have no problems gaining accreditation and membership of the college.

Unable to resolve the problems, Douglas started the registration process all over again and is following a different path. She hopes that by next year - seven years after first arriving in Australia - she will have put the problems of the past behind her.

She says Australia's current policies on registration of overseas-trained doctors are actively dissuading foreign medical academics and teachers from coming to Australia. Had it not been for her children having been at school in Canberra for the past four years, she says she and her husband would have returned to Canada.

Douglas is not alone because thousands of other overseas-trained doctors have experienced problems gaining the necessary authority to practise and some have been working as unskilled labourers or as taxi drivers for years. How they failed to gain registration is not clear given that controls over the employment of foreign doctors, even basic scrutiny of their qualifications, had been ignored for years by health authorities.

The former conservative government of John Howard 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 in the medical workforce, Australia became ever-more reliant on importing doctors from overseas and significant numbers were drawn from developing countries whose need for medical help was even more desperate.

But growing community concern about the uncertain abilities and command of English of doctors from Africa and Asia, and India in particular, forced the government to act: in 2000, new medical schools started to be built and over the next decade the number of schools grew from 12 to 20.

As critics pointed out, however, 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 and even now in some rural and remote regions, more than half of all doctors are from other countries.

Across Australia, these immigrants comprise 40% of Australia's total medical workforce yet in most cases they were taught and trained in non-English countries with different cultures and approaches to medical practice quite unlike the traditional British style that Australia follows.

Typically, Australians training to be doctors undertake six or seven years of undergraduate education and then another two years' internship in a hospital before they qualify as a general practitioner. If they want to become a specialist they may have to study and train for another four to seven years.

Dormant public suspicions about the abilities of foreign doctors was heightened when an Indian-born surgeon at Queensland's Bundaberg Hospital, Dr Jayant Patel, was accused of causing the deaths of some of his patients. Questions had been raised about Patel's competence soon after the hospital appointed him in 2003 yet it was another seven years before he was he was found guilty last July on three counts of manslaughter and one of grievous bodily harm and sentenced to seven years imprisonment.

The publicity surrounding Patel - dubbed 'Dr Death' by the media - had been continuous since his hurried departure to America in 2005 to escape prosecution and later when warrants were issued for his arrest that resulted in his return to Queensland to be tried last year

"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, Birrell headed the Centre for Population and Urban Research at Monash. In a series of articles beginning in 2004, he and 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?, 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 Patel, neither the federal nor state governments had acted to ensure this would not happen again.

Although state medical boards had decided foreign doctors would have to achieve a score of seven on the IELTS English proficiency examination as a precondition of registration, and even though the Australian Medical Council had proposed implementing a medical knowledge test, state and federal health authorities failed to adopt these provisions.

Birrell and Schwartz noted that no state or federal 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 UK, Canada and US.

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.

It was another year before the Council of Australian Governments decided changes would have to be made to the employment process for international medical graduates applying for registration. The aim, the council belatedly admitted, 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 this unanimous decision by the heads of the state and federal governments, the state medical boards continued to perform their roles over the next four years. It was not until last July that the regulation agency finally came into being.

Unfortunately, the task the new body had been set up to perform and the size of its responsibilities were too great and, almost from the start, it has come under attack from health care workers who failed to be re-registered and suddenly found themselves unable to do their jobs.

In any event, Australia's 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 specialist 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.

Responding to calls from federal politicians and disgruntled medicos, the Labor government organised an inquiry into the registration processes and the support available to overseas-trained doctors. The committee has been taking submissions and holding public meetings across Australia. It is expected to report with recommendations later this year.

All articles in the Special Report: The Internationalisation of Medical Education

GLOBAL: Internationalisation and medical education
ASIA: World-class medicine pursuit drives collaboration
MIDDLE EAST: Medical cities seek foreign academics
INDIA: Medical education gets international flavour
CARIBBEAN: Medical schools battle to retain US access
SOUTH AFRICA: Cuba helps to train rural doctors
AUSTRALIA: Overseas doctors fill large gaps
FRANCE: Medical reform aims to fight 'human wastage'

Comment:
Thank you for this article. The Australian government has banned the media from publishing anything that would even remotely expose deeply criminal registration policies and processes - CRIMINAL is the most correct word because registration policies are based on the lies and greed of existing power brokers.

While all Australian universities have 50%-55% as a minimum mark to pass any exam at medical and dental schools, the Australian Dental Council demands 65% as a minimum.

The ADC demands that overseas dentists who have already gained Australian citizenship and passed one or two of the three registration exams and who have been working in the health industry for at least a decade as bottomline servants - care givers and orderlies - sit the English test again!

These people already work in Australia in mediocre jobs for years, speak, read and write English, and have passed the English test and the preclinical test already. But the parasitic body of the ADC had to reinvent ways to roll in big bucks while doing nothing. How better than to set up new English tests at a level higher than that for linguists, and toughen other exams so that as many can fail and go back to resitting them over and over again.

This is something that International Court should investigate - not the Australian government. Government officials will NEVER truly investigate as they already know what is going on and condone it.

Andreas Stubbs