In the 1880s, the head of the statistics unit of the Registrar-General’s office in London noted that the shortage of medical practitioners in England was such that there was “imminent danger” that qualified medical care might become “quite inaccessible to vast numbers of people”.1 This shortage was a direct outcome of the Medical Act of 1853, which prescribed strict criteria for the education and registration of medical practitioners. Its effect was to reduce recruitment into the profession because of more formidable courses while concomitantly phasing out unqualified practitioners.1 Now, at the beginning of a new century, we find that the predicament of Victorian England has become a global problem. There is a shortage of doctors worldwide, and Australia is no exception.2-4

A number of factors have contributed to our doctor shortage. Prominent among these is federal government policy in the 1990s, which limited the number of medical school places in Australia, as all the while the Australian Medical Workforce Advisory Council maintained there was no shortage of doctors.5

Having miscalled policy, the federal government is now rapidly seeking to remedy its gaffe. Five new medical schools have recently been established6 and the number of bonded medical places (requiring graduates to work for a minimum period in districts of workforce shortage) in our existing medical schools has been increased by 234.7

The projected outcome of these initiatives is that the number of Australian medical graduates will increase from about 1200 in 2004 to about 2200 in 2014 (Warwick Hough, Director of Workplace Policy, Australian Medical Association, Canberra, personal communication). Whether this number will meet society’s demands a decade from now is anyone’s guess, but one thing is certain: Australia’s healthcare will be dependent on overseas-trained doctors (OTDs) for some time to come.

Our increased dependence on OTDs is reflected by recent bureaucratic activity attending the government’s announced Strengthening Medicare package, with its additional 725 OTDs working in Australia by 2007.8 One consequence has been the generation of a report on OTDs submitted to the Medical Training Review Panel of the Australian Department of Health and Ageing in February 2004. It outlines a bewildering array of Australian policies and guidelines, and differing surveillance and stewardship of OTD programs.

The report identifies:

• enormous inconsistencies in terminology;

• lack of national coordination in collection of data on OTDs;

• inadequacy of data held by different agencies and departments;

• differing entry points of OTDs controlled by different jurisdictions (eg, through the state and territory Areas of Need program or the federal Districts of Workforce Shortage program);

• a multitude of stakeholders, all focusing on their individual programs, with poor communication among themselves;

• doubts about the adequacy of assessment and supervision of OTDs entering Australian medical practice by medical boards and about the adequacy of the Australian Medical Council (AMC) examination.

Finally, the report on OTDs found there were inadequate resources for orientation, ongoing training and supervision of OTDs, and suboptimal support for their families.

Some progress has been made, such as the recruitment of OTDs through contracted recruitment agencies, reduced “red tape” in the assessment and recognition of OTDs, some flexibility in immigration arrangements to allow OTDs to stay longer,8 and fast-tracking of selected applicants to provisional registration and assessment by the AMC.

However, the reality is challenging. The data on birthplaces of OTDs in the article by Birrell in this issue of the Journal () reflect the reality of the global village we now live in.9 Yet, while the backgrounds, knowledge and skills of OTDs are diverse, evaluations of competence may be bypassed when employing OTDs in Australia, and formal assessments of communication skills (as distinct from linguistic proficiency) and cultural awareness are not included in current assessments.10 This has the potential to compromise patient care.

To facilitate an orderly integration of OTDs into the Australian healthcare system, McGrath () calls for a national body to establish uniform standards in licensure, to review and, where needed, to boost training resources and capacity. He argues that these are the minimum requirements to meet our duty of care to both the public and OTDs.11 We would also argue that recommendations by this body and coherent, relevant OTD data should be regular agenda items for the Australian Health Ministers’ Conference.

Focusing on OTDs as the primary short-term solution to our doctor shortage has serious ethical and global implications. The “brain drain” of healthcare professionals from many developing countries compromises their healthcare systems and demoralises their healthcare workforces already struggling to cope with major public health problems such as HIV and malaria. It constitutes a major loss in financial as well as human capital — particularly as any remittances sent back by emigrants (estimated at US$72.3 billion in 2001 and the second-largest source of external funds for developing countries) are not necessarily reinvested in healthcare.12 Unless recruiting countries like Australia adopt policy options such as creative employment contracts that also subsidise the country of origin, it is likely that “borrowing” OTDs will continue to broaden the gulf between developed and underdeveloped countries.

OTDs must not be seen as a long-term solution to our doctor shortage. The Australian Health Ministers’ Conference’s recent National Health Workforce Strategic Framework states: “Australia should focus on achieving, at a minimum, national self sufficiency in health workforce supply, whilst acknowledging it is part of a global market.”13

In the meantime, OTDs make a valued and essential contribution to our society and to the provision of healthcare to Australians. We should respect their contribution with the attention and care it deserves.