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From: Rescuing Medical Education Conference
Stamford Sydney Airport
O'Riordan St (cnr Robey St), Mascot
18 February 2005
Professor Bob Birrell
Centre for Population & Urban Research, Monash University
CHAIRMAN: Now to hear from Professor Bob Birrell, who is the Director of the Centre for Population & Urban Research at Monash University in Melbourne
PROFESSOR BIRRELL: Thank you very much. My contribution is going to be somewhat different from those that preceded it, since I’m going to be talking about the registration issues associated with overseas trained doctors in Australia. Nonetheless the topic is obviously relevant to the question of medical standards that you’ve been addressing here.
The bottom line is that there are currently several thousand overseas trained doctors practising in the front line of medicine in Australia who have not been formally assessed as to their qualifications, and who are increasingly coming from non western medical schools where it’s very uncertain about the standards and even the content of the curriculum that they have studied.
Now, I was a little bit concerned that perhaps you were all aware of this situation and that my information wouldn’t be of any great value, but there are many young students here who may not be familiar with this situation. I had an experience on the way up here in the plane this which has confirmed my judgment that maybe it wasn’t a waste of time. There was a young man sitting next to me, and as I spied on what it was that he was reading, the letterhead was the College of Physicians. So – although I hate to admit it in this company – I am a sociologist – I thereupon interrogated him, or interviewed him perhaps, and I learned quite a bit about the situation. He was an advanced trainee as a physician. So I asked him a number of questions about that. Then after we’d finished, he then turned and asked me what I was doing. I told him that I was coming to address this meeting. What was my message? Well, just the one I just put to you. And he said to me, “What, you mean people are practising in Australia without being properly assessed?” Now, here’s a young man who’s been through the medical system who could state that. And yet as I said, there’s at least 3,000 in that circumstance.
I want to provide you with some of the information and some of the background on how this came about. My personal interest in this has largely come from concern about opportunities for young Australians. The situation in the early 1990’s was that the Australian Government --- in the early 90’s the Australian Government decided that there were too many doctors in Australia, and that the numbers were growing too rapidly, and this was a real threat to the Australian budget. Every additional doctor added another $250,000 by virtue of their capacity to bill for that many services. That was the notion.
And at that time, although the number of starting grads was only about 1,200, it had been around 1,400 a decade earlier in the early 80’s. The concern about too many doctors largely arose from the fact that there were very large numbers of overseas trained doctors coming into Australia and the Government was having real difficulty in managing this inflow. People were coming in via the family reunion programme, via New Zealand, and so on – I’ll give you a little bit more detail on this shortly. But once here, they were demanding the right to practice, complaining bitterly about the Australian Medical Council examination – an attempt to control the numbers – going on hunger strikes, and so on.
Perhaps the bottom point, the nadir of this process, was in 1995 when the then Labour Government decided that it would deal with the problem by reducing the number of starting Australian medical school students from 2,000 to 1,000. It couldn’t control overseas doctors so it would attack the intake of local doctors. As it turned out that was never implemented because the universities resisted and – as you will no doubt remember – in March 1996 the Coalition was elected with a landslide.
Once the Coalition got in power it acted resolutely on this issue, and its main action was to stipulate that persons who passed the AMC, and who registered for the process after 1996, would not be permitted to bill on the Medicare system until ten years after registration. In addition, they changed the rules on access to general practice by enforcing a requirement that Australian doctors, and AMC graduates if necessary, were not permitted to bill on the Medicare system unless they had passed the post graduate family medicine programme then run by the Royal Australian College of General Practitioners.
That was a radical intervention which significantly reduced the flow of Australian doctors into the medical workforce. At the time there were already shortages of GP’s in regional Australia and we predicted confidently that they would worsen because, prior to this 400 quota on the number who were allowed to start the family medicine programme, there was in the order of 700 or so Australian doctors moving into general practice after they’d finished their intern years.
At the time the Australian Medical Workforce Advisory Council, which had just recently been established, took the view that there was no shortage of Australian doctors, rather there was a mal-distribution, and so it embraced the Government’s line. As it turned out, that diagnosis was simply incorrect. The shortage of doctors was much more fundamental.
Just one or two examples of this. In Victoria, the Victorian Government has to fill the at junior doctor level, round about 550 to 600 places in the second year junior doctor level. That’s how much funding they have, that’s how many junior doctors the public hospitals in Victoria need. But there were only about 330 graduates from Monash and Melbourne each year. They’ve got a fundamental structural problem here. How do they deal with it? Well, they employed overseas trained doctors, most of whom had not passed through the Australian medical examination systems.
Another example which I owe Morton Rawley(?), who was just telling me that one instance of this more general structural problem is that we don’t have enough graduates at the moment to fill all the vocational training programmes that we have. That’s now showing up in applicants for the family medicine programme. Last year they only got some 580 applicants but there were 600 places in the quota.
So we’ve got some serious structural problems in Australia, and they produced – by the early years of this century – a fundamental medical crisis in terms of the supply of doctors.
The result has been an escalation in the employment of overseas trained doctors. They now, as you well know, form a second tier workforce in the sense that they are filling positions that other Australian trained doctors either don’t wish to, or there’s simply not enough to provide that workforce. We have a serious problem with standards as a consequence because of the uncertainty about their medical training.
I first encountered this situation in the late 90’s when we were surveying candidates for the AMC scheme, interviewing them, discussing their situation. We found then that, in fact, a very significant proportion of them were actually working. The response was, oh, hang on, how can that be, don’t we have an accreditation system in Australia that requires persons to be fully assessed before they actually go out and practice. Well, we do in principle, but in reality – because of the supply crisis – these were permanent residents I’m talking about now – they were actually being employed because there were no others to do the job.
Subsequently we did a study of those employed in the Victorian public hospital system, and we found by 2001 there were some 280 overseas trained doctors doing this junior second year medical officer task, and none of them had completed the AMC process. Most came from Asia and the Middle East – very non western type medical schools of which there is some concern about the standards. All were registered on a conditional basis by the Victorian Medical Board.
Since that time, as I said, the numbers employed of temporary resident overseas doctors have escalated, and as part of strengthening Medicare, the Government has added to this process by removing red tape, by subsidising the recruitment process.
I’ll just give you a little bit of information on the scale of this. There are several categories – a very complex situation – several categories of OTD’s. This is the first one. These are category 422. These are called temporary resident doctors. They come here sponsored by employers. They now visit for four years and they can renew. These are the nominations by the various State health departments, and they give us an indication of the scale of utilisation of this particular visa category. They are mainly recruited to area of need positions. You can see that in Western Australia in 2003 there were 597 such sponsorships. You can see they are quite heavily used also in Victoria, and particularly so in Queensland where the system is very heavily dependent.
Most of these people actually come from Britain so in a sense there hasn’t been too much of a worry here because at least they’ve done a Western style medical course. Many of them are recent grads who like the idea of coming out to Australia for an initial furlough and then they go home. But there has been a move towards non western medical schools here. I haven’t got the details in this particular slide, but there has been.
This is the second category, these are occupational trainees. They are coming out on roughly the same scale now as the temporary resident doctors. To get a visa as an occupation trainee, the employer has to submit a training programme. Medicine is an important area but they could be coming out here to study karate and have a training programme in that as well. As far as the Government is concerned, or DIMIA, immigration, as long as they have a training programme and the relevant registration board is prepared to take them on, or register them, they will issue a visa.
Just to give you an idea of scale, about mid last year there were about 1,200 registered by the New South Wales Medical Board – 1,200. Most of them were doing junior medical doctor work in the public hospital systems. There may be a little bit of difficulty reading these figures but the key point I want to make from this table is that you can see that back in 97, 98, those coming from the UK and Ireland constituted nearly half of the inflow, but over the past five or six years you can see that that source has declined and increasingly we are taking occupational trainees from non western medical schools. That then raises the question about standards.
A third source of overseas trained doctors are the permanent residents who’ve come to Australia one way or another, many of whom are seeking to enter the medical workforce. Now, I again apologise for the complexity of this table, but if you just look at the bottom left hand corner you will see there was some 4,670. These are people who just came in the five years 1996 to 2001, and were here in 2001. This is census data. So you can see the scale of it. It’s enormous relative to the annual number of graduates from our medical schools.
Fifty-three percent of them were actually being employed by 2001 as medical practitioners. Some of them were British temporary resident doctors who had come here on four year visas. Many of the others were people who were employed who had not yet completed their AMC examination.
It is important to note here that our Government is not recruiting these people. It was suggested this morning that, you know, it’s immoral for us to be recruiting overseas trained doctors from third world countries. We aren’t recruiting these. They came under their own volition. Some four or five hundred or so are coming each year. A couple of hundred or so are coming via the third country route of New Zealand. That is they come to New Zealand, get New Zealand citizenship, and then under the CER rules they then can move across to Australia. Another hundred to two hundred are coming under the family reunion programme with spouses. Some others are coming under the humanitarian programme.
We are not recruiting them. Nonetheless, they are coming in large numbers. There is a substantial stock out there hungry for entry into the medical system, and there is a case for helping them, given our supply crisis, to get up to speed, to pass the AMC examination. Much less of a case, I think, to employ them before they’ve finished that examination process.
The situation then is that we’ve got a supply driven utilisation of overseas trained doctors. The orientation of the Federal and State Health Departments is that really any doctor is better than no doctor. The assessment levels are minimal. Mainly they are determined by the employer. If the employer makes a judgment that he or she would like to employ this person, then the medical boards will register them on a temporary basis.
The solution to this situation is, in a sense, quite simple. We can simply do what the American Educational Council for Foreign Medical Graduates do, that is require an English language test and an examination system, similar to the AMC system. In America they also require a three year accredited residency and then they can practice independently.
I’m coming to the end. I have often wondered how could this situation have arisen in Australia. We allegedly have a very powerful medical profession. We certainly have a profession that is very proud of its standards, as this morning’s seminar indicates. How could it be then, that we’ve allowed to get ourselves in a situation like this, even worse than in America, Canada or Britain, which all have assessment systems.
I think it is an indication of the loss of real power on the part of organised medicine in Australia, particularly in general practice. So far the specialist colleges have held the line more effectively. They are at least maintaining their right to accredit at the specialist level. I am very fearful, and echo some of the thoughts already indicated on the panel this morning, about the views of the ACCC. Allan Fells was a shocker. He wanted to let the market rip. He had absolutely no respect for the traditions of professional altruism, responsibility for standards that were embodied in the rules, or in the conventions, whereby Australian specialists work at very very low rates in the public hospital system, when they could be employed in the private hospital system at multiple fee levels.
I do agree that it is urgent that this message get out to the public. I was involved in a consultancy with RACS a couple of years ago, and although I never shared the Fells view – or many of the people who provided evidence for his enquiry – that the specialists were all about feathering their own nests and their standards were just a cloak to control numbers – although I never agreed with that – I had some suspicions – it was only when I got out and talked to quite a number of surgeons that I realised the extent of commitment to the patterns I’ve just described. But I don’t think yet that the public is fully aware of this.
So the situation we have at the moment then is that, notwithstanding all your concerns about improving medical standards, there are thousands of overseas trained doctors, many from non western medical schools whose standards are uncertain, and what they’ve learned – the relevance of what they’ve learned – may or may not be relevant to Australian patient needs. There is a real problem still to be addressed about this predicament.
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