Spike, Neil A. MB, BS, FRACGP
Health care is an ever increasing global problem, and there is a world-wide shortage of doctors.1,2 Australia is no different, experiencing chronic shortages of Australian-trained doctors available for work in hospitals, in regional general practices, and in some speciality areas (like emergency).3
Australia has a federal system of government, and health funding is provided by both the central government and the eight state and territory governments. The Australian and state and territory governments jointly fund the state-run public hospital system to provide free hospital care. The Australian government funds the universal health insurance system (Medicare Benefits Scheme), which provides subsidies for medical service expenses incurred outside the public hospitals.
The Australian government also is responsible for funding basic medical education for universities with either undergraduate or postgraduate entry programs. All Australian medical school programs require accreditation by the Australian Medical Council (AMC). The AMC is a government-funded national standards body for medical education and training.
Given the decrease in doctors’ weekly work hours and the ever-increasing demand for medical services, the Australian Government has introduced five new medical school programs since 2000, adding to the existing ten medical school programs.4 This initiative provided a 30% increase in publicly funded positions for medical students in Australian medical schools, though no specific numbers are available from the government yet. Three additional schools will be introduced by 2008. It is anticipated that the number of students completing university medical programs in Australia will increase from 1,300 in 2005 to 2,100 soon after 2010.
The actual impact of these strategies will not be seen in the short-term, as it takes up to 13 years for doctors to become fully educated and trained,5 so there is an increasing reliance on the imported workforce of international medical graduates (IMGs), previously called overseas trained doctors, to meet the medical workforce needs.
In Australia, more than 7,000 IMGs comprise 20% of the current total medical workforce (IMGs comprise 35% of current rural general practitioners), and the Medicare Plus Scheme from the federal government includes plans to recruit 1,200 more.6 This raises significant challenges for a system already struggling to maintain the quality of medical care provided at all levels of the health care system.
Under the current federal system of government in Australia, the states and territories are responsible for the licensing of medical practitioners. This process is administered by the State and Territory Medical Boards using the individual Medical (Practitioners) Acts. Although in 1991 all states and territories agreed to a national standard of nonspecialist registration for IMGs (the AMC examination followed by 12 months of supervised practice), each state and territory has discretionary powers under its relevant legislation to register individual practitioners who do not meet the agreed national standard where it is in the public interest to do so. This provision is commonly used for what is called the “area of need” category. This category does not qualify an applicant for full registration and usually carries with it a time limitation, a geographic limitation, or some limitation on the scope of practice.
To give some indication of the scale involved, in 2004, a total of 876 IMG candidates presented for the AMC clinical examination. Of these, 519 met the performance criteria and passed the AMC examination to qualify for registration. However, 317 (61%) of those who passed already had some form of conditional registration and would be exempt from the national standard requiring an additional 12 months of supervised practice. Only the remaining 202 (39%) candidates would be expected to complete an additional 12 months of supervised practice.
Current IMG Pathways
Some of the IMGs wishing to enter practice in Australia have specialist qualifications and have been practicing as specialists in their own countries. These doctors may be eligible for an assessment of their specialist qualifications through the AMC and the relevant Australian specialty college. For the majority of IMGs there are two pathways to enter the Australian medical workforce. These pathways depend predominantly on whether the IMG has permanent residency status or temporary resident status. Current data on principal source countries is only available on the permanent residency doctors who present for the AMC examination. No specific data is available on temporary resident doctors, as this group does not pass through the AMC examination. However, a survey undertaken by the AMC in 2004 indicates that the source countries between the two groups may be similar (Table 1), and finds India and Egypt the commonest source countries.
IMGs with permanent residency status
IMGs may be granted permanent residency status predominantly by entering Australia as a New Zealand citizen (most of whom were third-country entrants according to Birrell7), as a spouse sponsored by an Australian citizen, or as an accompanying spouse of a migrant. However, these doctors possess medical qualifications from an overseas university that are not recognized by the AMC.
From the 2004 Australian Medical Workforce Advisory Committee (AMWAC) report, the numbers of IMGs entering Australia with permanent residency status have been increasing (Figure 1).5 Given the continuing workforce shortages in particular areas, it is expected that these numbers will continue to escalate in the foreseeable future, or at least until more recent local graduate strategies take effect.
For full general registration as a permanent resident doctor, there is a defined assessment process. In addition to immigration requirements, demonstration of English language proficiency, and certificates of good health and good character, candidates must pass a formal staged examination. The standard that AMC examinees must achieve is defined as “the level of attainment of medical knowledge, clinical skills and attitudes required of newly qualified graduates of Australian medical schools who are about to enter intern training.”8
The AMC examination process is two-staged and begins with a Multiple Choice Question (MCQ) examination. According to the AMC Examination Specifications, the MCQ examination is designed to test the principles and practice of medicine in the fields of internal medicine, pediatrics, psychiatry, surgery, and obstetrics and gynecology. The questions are designed to reflect common clinical conditions that would be encountered in the Australian community.
Current figures from the AMC indicate that between January 1, 1999, and December 31, 2004, a total of 5,333 candidates had sat for the MCQ examination, 2,975 (55.8%) of whom passed—2,065 (69.41%) passed on their first attempt, 512 (17.21%) on their second attempt, 191 (6.42%) on their third attempt, and 207 (6.96%) on their fourth or subsequent attempt.
The AMC is currently trialing a MCQ examination developed in cooperation with Medical Council of Canada (MCC), which will be administered by computer in secure examination locations around the world, prior to the applicants receiving visas to enter Australia. This will ensure a level of medical knowledge before the applicant arrives in Australia, sits for the AMC examination, and begins working under supervision. It does not ensure that IMGs recruited directly to prearranged positions on temporary visas meet this requirement.
The second stage of the AMC examination is a clinical skills assessment. On successful completion of the MCQ component of the AMC examination, candidates may enroll in the Structured Clinical Assessment. The AMC Examination Specifications state the objective of this clinical examination is to evaluate the clinical competence and performance of the candidate in terms of his or her medical knowledge, clinical skills, and professional attitudes for the safe and effective clinical practice of medicine in the Australian community.
For the period January 1, 1999, to December 31, 2004, the AMC reports that 2,063 of 3,569 (57.8%) candidates have been successful in the clinical examination—1,275 (61.80%) passed at the first attempt, 519 (25.16%) passed on the second attempt, 183 (8.87%) passed on the third attempt, and 86 (4.17%) passed on the fourth or subsequent attempt. Changes to the clinical examination format were introduced in 2004 to reduce the “backlog” of candidates who had completed the MCQ test but were awaiting a position to complete the clinical examination.
Following the successful completion of both the MCQ and clinical AMC examination requirements, a supervised hospital experience may be required prior to full registration. However, as discussed earlier, there has been a trend for IMGs with permanent resident status to be given “conditional status” by State Medical Boards and placed in medical employment before they have completed their AMC requirements, or after they have already failed to obtain AMC accreditation. This occurs predominantly because of workforce demands and practitioner shortages in rural and provincial regions.
In addition, concerns were raised in one Australian state (Victoria) that doctors who had not completed their AMC assessments were working in the public hospital system. As a result, a series of new measures to evaluate and certify IMGs were announced9:
* A new standardized preregistration assessment of medical skills and clinical knowledge, and cross-cultural and communications skills;
* A communication and cultural training program;
* A comprehensive preemployment orientation to the Australian and Victorian health systems; and
* More rigorous and monitored supervision and ongoing assessment of these doctors employed in the public hospital system.
However, such approaches have not been implemented nationally and still occur on an ad hoc local basis, often in response to media pressure. With this unregulated approach, larger national issues will remain unresolved.
IMGs with temporary residency status
A second group of IMGs are temporary resident doctors who can be recruited directly into “districts of workforce shortage” or “areas of need.” These IMGs encounter no formal assessment process once their visa applications have been sponsored by the recruiting bodies. “Districts of workforce shortage” and “areas of need” are predominantly in rural and remote areas and refer to those communities that have less access to medical services than the general Australian community, or to those communities that have specific medical practitioner needs. “Districts of workforce shortage” are classified by the Australian Department of Health and Ageing, whereas an “area of need” is determined by the state or territory health departments. An “area of need” is usually associated with a specific medical specialty, whereas a “district of workforce shortage” refers to a geographic area with reduced access to services.
In the last decade there has been an escalation in the recruitment of IMGs holding temporary resident visas with previously arranged work contracts (Figure 2). At present, to obtain registration from a state or territory medical board, IMGs are only required to provide evidence of qualifications. These doctors are often sent to the most desperate areas of need where support, both educational and cultural, is minimal. The result is that the most underserviced regions of the country continue to be underserviced by less qualified doctors for reasons of political expediency.
In 2005 a doctor from this pathway was the focus of a formal government inquiry (Royal Commission) following his alleged involvement in more than 80 deaths in a provincial hospital. The unfortunate example of “Doctor Death,” as he has been labelled in the media, is evidence that the qualifications of IMGs with temporary residency status are not accurately checked, as it appears this doctor had previously had his license withdrawn in the United States. Such sensational headlines unfortunately reflect poorly on the IMG workforce, which is unwarranted. However, concerns about the quality of medical care can only be addressed by a more open, national standardized system of registration.
Studies from a number of sources10–12 have identified a range of issues that must be considered as part of a national strategy on resolving the IMG workforce concerns:
* With multiple recruiting agencies and a two-tiered system that depends on visa status, there is no single point source of reliable information for IMGs;
* Evidence from multiple sources suggests that the current Occupational English Test is insufficient. As a result, communication issues with IMGs are regularly reported;
* There is significant variability in the medical knowledge, clinical skills, and professional attitudes of IMGs;
* IMGs receive insufficient orientation to the Australian health care system and Australian culture;
* There is a lack of professional and personal support for IMGs and their families;
* IMGs experience many stresses in their personal lives—separation from family, inadequate employment opportunities for a spouse, and cultural isolation;
* Workforce demands are such that IMGs are employed in positions of medical need, but these needs are inadequately matched to their clinical skills and previous experience;
* Because of service demands, there is often limited supervision for IMGs, and they receive little or no feedback on their clinical performance; and
* IMGs are often required to meet heavy workforce demands as well as complete training and certification demands of employers or professional bodies.
Recommendations from recent studies10–12 have highlighted a number of key requirements in order for the above issues to be addressed:
* A national approach involving all stakeholders and legislators;
* A national source of relevant and current information for IMGs to access on available positions, prerequisites, and procedures;
* A national registration system for all IMGs, regardless of visa status, to avoid exploitation and discrimination;
* A national uniform standard of English language assessment;
* A national comprehensive assessment process that requires demonstration of appropriate communication skills, medical knowledge, and clinical skills to a level of fitness for safe practice;
* A national standard for orientation programs for IMGs that address the Australian health care system at the macro and micro levels, as well as cultural awareness;
* National accreditation of education and training support programs for IMGs that are flexible and accessible; and
* National accreditation and funding of training for medical educators involved in the supervision and training of IMGs.
A steering committee that includes relevant professional bodies and the medical boards has recently been established. The committee implemented a new uniform standard for English tests in each of four categories (reading, writing, listening, and speaking). This is considered an initial step in the right direction. Many more complex issues identified above are still to be resolved, but the quality of medical care for the Australian community depends on a willingness and commitment from governments (federal, state, and territory), immigration officials, educators, accreditation organizations, health care providers, and professional bodies to reform the current system.
A Complex Issue
The continued reliance on IMGs in the Australian health care setting is well documented, and the problems of the existing system become more and more evident as time passes. The IMGs are an essential component of our medical workforce, and a national strategy that is cognizant of past mistakes and has a clear focus of quality health care should be implemented to better integrate these doctors into the Australian community.
There is a separate debate that cannot be considered in appropriate depth in this article—the ethics of internationally recruiting doctors from countries that can ill afford to lose their precious medical resources. There is a moral issue here that has been lost in the debates about registration, educational, and assessment standards. In the words of Bundred and Levitt,
The migration of physicians from less-developed countries to more developed countries is not a new phenomenon, but the ethics of national policies, which allow countries to recruit en-masse the most qualified physicians, at no cost or penalty to themselves, should now be challenged.13
Countries involved in the active recruitment of doctors from the developing world often need to place these doctors in areas where local graduates will not usually work. Such recruitment policies, by a range of providers with vested interests, offer a relatively inexpensive and quick solution to inadequate resource planning at a local and national level.
There are many complex issues around the registration and assessment of IMGs in Australia. This may be partly explained by the division of health responsibilities between the federal and state and territory governments, with each state and territory establishing its own medical board under its state’s legislation, leading to a fragmented process with varied requirements for registration. Even with all the publicity and hysteria over the “Doctor Death” case, this tragic situation has not led federal officials to accept the need for change in the national system of certifying IMGs. Indeed, federal Health Minister Tony Abbott was quoted as saying that doctor registration and assessment is a matter for state and territory registration boards. “I’m not going to buy into a quagmire where the federal government has responsibility but no authority.”14
IMGs provide not only a necessary and invaluable service in the Australian health care system, but they also add to the richness of our multicultural society at a medical and community level. They and the communities they serve deserve better.