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Australian policy on overseas-trained doctors

Robert J Birrell
Med J Aust 2004; 181 (11): 635-639.
Published online: 6 December 2004

Abstract

  • Since the late 1990s Australian employers have recruited an increasing number of overseas-trained doctors (OTDs) to hospital and “area of need” general practice positions.

  • While assessment standards vary by state and field of medicine, most OTDs are appointed without a formal assessment of their medical knowledge and clinical skills, with registration to practice being conditional only on their working in hospitals and “areas of need”. By comparison, formal assessment is required before an OTD can practise medicine in the United States, the United Kingdom and Canada.

  • Most of these doctors hold temporary resident visas, but a minority are permanent residents who have not completed their Australian Medical Council accreditation examinations.

  • In 1997–98, most OTDs arriving under temporary resident visas were from the United Kingdom and Ireland, and by 2002–03 this had dropped to under 50%; OTDs now come from a greater diversity of countries.

The rapid increase in use of overseas-trained doctors (OTDs) in Australia’s medical workforce is a consequence of a government decision in the early 1980s to cap the number of entrants to Australian medical schools. This decision flowed from projections of the medical workforce which indicated that, as a consequence of previous rises in medical training levels and continued high migration of OTDs to Australia, the doctor-to-population ratio in Australia was too high.1 Until recently,2 there have been no increases in medical students, despite a rapid increase in the nation’s population and the growth in per-capita demand for medical services.

There was a decline in the doctor-to-population ratio (from 485:1 to 413:1) over the decade 1986 to 1996.3 This, with the increased costs of Medicare, contributed to the stance of the Australian Medical Workforce Advisory Council (AMWAC) by the mid-1990s that any gaps in the supply of doctors in Australia were due to maldistribution of the medical workforce rather than an underlying shortage.4 This perception underpinned the government’s 1996 legislation requiring all future medical graduates who wished to practise as general practitioners to complete a postgraduate family medicine course first. The annual number of training places allocated for those wishing to enter the program was initially limited to 400.5

Emerging evidence of a workforce shortage

The restriction on entry to general practice sharply cut the number of new entrants to the general practice field and contributed to a widening shortage in the supply of GPs, making it harder for regional areas to attract locally trained GPs. Shortages were also evident at the junior hospital doctor level, in part because there were not enough second-year interns to fill these positions in the public hospital system.

One outcome, which first led me to question AMWAC’s “maldistribution” thesis, was the finding that hundreds of permanent-resident OTDs, who were yet to complete or had failed the Australian Medical Council (AMC) examinations, were being employed in these junior public hospital positions in Victoria and other states.6 Furthermore, by the end of the 1990s there were not enough fully registered junior doctors to fill all the training places available in the various specialty programs. This, with federal government limits (based on AMWAC advice) on the number of training places being financed, resulted in some specialties having too few trainees to provide routine hospital-based services (eg, surgery) and insufficient fully trained fellows to meet patient demands.

These shortages have prompted increasing recourse to the recruitment of OTDs. The main pathways by which they have entered Australian medical practice are as temporary resident OTDs, occupational trainees or permanent resident OTDs. The conditions for these designations are described in Box 1.

Accrediting OTDs to practise: how Australia compares with other countries

By 2004 there were some 2000 visa category 422 OTDs and a further 1500–2000 visa category 442 OTDs working in medical positions in Australia (estimates based on unpublished Department of Immigration and Multicultural and Indigenous Affairs [DIMIA] stock counts for visa subclass 422 and numbers of occupational trainees registered with state medical boards). These numbers are likely to increase as a consequence of the federal government’s Strengthening Medicare initiatives to encourage recruitment of OTDs9 and pre-election promises of more doctors and nurses, including expansion of medical training in Australia. However, as the benefits from these training initiatives will not be experienced for another 8 to 10 years, it follows that dependence on OTDs will increase.

There is no national standard for the appointment of OTDs in Australia. By contrast, in Canada, the United States and the United Kingdom an OTD must pass a test of English, medical knowledge and clinical skills before being allowed to practise. In Canada and the United States, OTDs are also required to serve in a probationary hospital residency position.

In Australia, each state medical board has developed its own set of rules. In the case of occupational trainees, these vary according to whether the OTD is appointed to a training program within a medical specialty or to a general hospital position. In some specialties the relevant college assesses the applicants’ credentials. In others, this involvement is less evident. In the case of general hospital positions, the employing hospital makes the assessment, which is then accepted without further evaluation of the OTD’s skills by the relevant state medical board.

As regards “area-of-need” positions, the employer makes the final decision, although usually after an assessment by a professional recruiting intermediary. These generally base their judgements on a review of prospective candidates’ curricula vitae, sometimes accompanied by an international telephone interview. Only in a few cases is there any systematic evaluation of the medical knowledge and clinical skills of the appointees. Again, the state medical boards usually accept the judgement of employers without any direct involvement in assessment of the candidates. New South Wales is an exception. There are relatively few “area-of-need” appointments in NSW, but, where they are made, the NSW Medical Board assesses candidates by means of a face-to-face interview covering clinical skills and conducted by clinicians familiar with the relevant area of practice. The main task of medical boards is to check that the medical qualifications and experience of the appointees are as claimed. Until recently, most of the medical boards did not require OTDs to pass an English test. However, most now have instituted such a test, or will do so in the near future.

Trends in OTD use
Temporary resident OTDs (visa subclass 422)

The numbers of OTDs granted subclass 422 visas increased from 670 in 1993–94 to 1419 in 1999–2000, and 2249 in 2003–04. By September 2003, according to DIMIA stock counts, there were 1950 OTDs in Australia who were holders of a subclass 422 visa (unpublished data from DIMIA).

Box 2 details the number of OTDs nominated by each state health authority in this visa category. Though not all of those nominated subsequently sought a visa,Box 2 shows that the greatest use of subclass 422 visas was in Queensland, Western Australia and Victoria, where OTDs have been recruited to fill “area-of-need” vacancies, primarily in regional general practice positions, but also in locum services and in some junior hospital positions. These doctors are currently being encouraged to stay permanently in Australia; one route to achieving this is successful completion of the Royal Australian College of General Practitioners’ Fellowship examinations.10

Recruitment under this visa subclass is increasing, partly because of regulatory changes from the federal government’s Strengthening Medicare package. These visas are now being issued for 4 years (previously 2 years) with the option of renewal. In addition, the Commonwealth agreed to pay the recruitment expenses ($10 000 to $25 000 each) for OTDs employed in family medicine who have been engaged by designated private sector recruiters.11

Box 3 shows the birthplaces of OTDs arriving in Australia. A decade or so ago the great majority of OTDs were drawn from the UK. However, in recent years, as the numbers recruited have grown, so has the diversity of countries of origin. By 1997–98, the UK and Ireland were still the dominant source, accounting for 70% of the arrivals in that year. However, by 2002–03, this share had fallen to 43%.

Occupational trainees (visa subclass 442)

There are no accurate statistics for this category of OTDs, as DIMIA does not differentiate visas allocated to doctors in this category from those issued to other occupation groups. The scale of their use has to be deduced from various sources, such as arrivals in Australia under visa subclass 442 who list their occupation as doctor, and the counts of registrations by state medical boards. Most occupational trainees are employed in NSW and Victoria. As of 29 June 2004, 1202 were registered in NSW and 712 in Victoria.

Occupational trainees come from a much wider range of source countries than has been the case for OTDs with subclass 422 visas.Box 4 shows the arrivals who were doctors under this visa by birthplace. By 2002–03 most of these doctors were being drawn from non-Western countries.

Permanent resident OTDs

There is a large number of OTDs who arrived in Australia recently and who hold permanent residence, mainly on the basis of entry as a New Zealand citizen, spouses sponsored by an Australian citizen, or as accompanying spouses of migrants. As Box 5 indicates, some 500 or more have arrived each year. Most of those coming as New Zealand citizens were third-country entrants who first migrated to New Zealand, subsequently obtained New Zealand citizenship, and thereby the right to move to Australia on a permanent basis. Hardly any of those shown in Box 5 would have held medical positions on arrival, because doctors were not permitted permanent visas as principal applicants under Australia’s skilled migration categories from 1996 to 2001 (inclusive). The spike in arrivals of OTDs from New Zealand for the year ended June 2001 reflects changes in the rules governing movement of people between Australia and New Zealand. Since mid-2001 New Zealand citizens are no longer eligible for most Australian welfare benefits unless they meet the standards required of people eligible for Australia’s skilled migration program.

Box 6 indicates the labour-force status of people with a degree in medical studies resident in Australia in 2001 and who had arrived between 1 January 1996 and 7 August 2001 (inclusive). Most of those born in the UK and Ireland would have arrived on temporary resident medical visas (subclasses 422 and 442). This is why 83% were employed as doctors. Aside from those born in New Zealand and South Africa, most of the others (who were born in non-English-speaking-background [NESB] countries) would have arrived in the permanent resident categories detailed in Box 5. As Box 6 shows, many were not employed as doctors; most of these would have been seeking to pass or had failed the AMC examinations, providing much of the supply from which provisionally registered permanent resident OTDs are drawn. There are currently several hundred permanent resident OTDs who have not completed the AMC examinations and who are working as junior hospital doctors or in areas of need (unpublished data from the Medical Practitioners Board of Victoria).

Some 200–300 OTDs have completed the AMC exams successfully since mid-1990.Box 7 shows the pass rates by major country of training at the examinations held in 2002.

Conclusion

The number of OTDs employed in Australia’s medical workforce has increased sharply since the mid-1990s. This dependence will grow in the near future as a consequence of recent measures to facilitate the recruitment of OTDs. Until the mid-1990s, most OTDs came from the UK and Ireland. However, most now come from a diversity of backgrounds.

There is no national standard in Australia for assessing OTDs before they are permitted to practise. Assessment standards vary by state and area of medical practice. With a few exceptions, OTDs are permitted to practise without having to pass a test of medical knowledge and clinical skills like that required in the UK, Canada and the USA.

This is an unsatisfactory situation for standards of patient care in Australia, as a growing share of OTDs is being drawn from non-Western training backgrounds, where the standards and relevance of knowledge and skills to Australian patient need are uncertain.

1 Main designations for entry to Australian medical practice for overseas-trained doctors

Designation

Visa subclass

Limit of term

Conditions


Temporary residents

422

4 years (with option of renewal)

Require a sponsoring employer who must demonstrate that the position is in an identified “area of need” and that they have been unable to recruit an Australian resident to fill the position.7

Occupational trainees

442

2 years (with option of renewal)

Appointed as junior doctors and as trainee specialists in hospitals. Requirement for a visa to be issued is that the Department of Immigration and Multicultural and Indigenous Affairs receives a letter from the relevant medical college stating that a training program has been prepared and a letter signed by the medical director and training director attesting that the overseas-trained doctor will be trained in the hospital. Occupational trainees do not have to work in an “area of need”.

Permanent residents

Enter medical practice either through successful completion of the Australian Medical Council examinations, or through employment as provisionally registered junior hospital doctors, or as GPs in “area-of-need” locations.

2 Number of visa subclass 422 nominations, by state, 2000–01 to 2002–03

State

2000–01

2001–02

2002–03


Western Australia

456

472

597

Victoria

406

508

581

New South Wales

58

89

176

Tasmania

94

82

89

South Australia

60

68

133

Australian Capital Territory

7

12

50

Northern Territory

84

98

97

Queensland

899

716

1016

Total

2062

2045

2739


Source: Birrell and Hawthorne, based on unpublished data provided by the Department of Immigration and Multicultural and Indigenous Affairs.10

3 Medical professionals arriving under visa subclass 422 (principal applicants, by country of birth)*

Country of birth

1997–98

1998–99

1999–00

2000–01

2001–02

2002–03


United Kingdom and Ireland

572

634

463

552

538

476

India

32

31

37

49

67

123

South Africa

71

72

154

126

121

95

United States of America

89

6

10

18

30

43

Germany

6

10

10

10

29

32

Netherlands

2

14

9

52

23

27

Pakistan

3

3

17

27

21

26

Sri Lanka

3

4

4

17

33

25

Malaysia

4

8

2

6

16

23

Canada

3

21

8

2

18

17

Philippines

2

2

1

7

9

17

Bangladesh

0

0

3

11

12

13

Other

35

41

133

113

132

184

Total

822

846

851

990

1049

1101


Source: Department of Immigration and Multicultural and Indigenous Affairs overseas arrivals and departures (unpublished). * Includes long-term (visits of 12 months or more) and short-term (visits of less than 12 months) arrivals.

4 Medical professionals arriving as occupational trainees on subclass 442 visas (principal applicants, by country of birth)*

Country of birth

1997–98

1998–99

1999–00

2000–01

2001–02

2002–03


United Kingdom and Ireland

444

173

321

338

221

251

India

49

77

78

62

78

89

China

36

30

11

67

57

63

Malaysia

28

23

46

37

45

62

Sri Lanka

15

21

16

43

40

40

Thailand

3

15

25

18

11

25

Philippines

6

6

11

17

14

19

Singapore

13

7

6

7

11

19

Hong Kong

57

17

3

1

13

16

Germany

13

15

13

32

13

16

Japan

11

9

14

12

18

16

United States of America

10

10

6

18

14

12

South Africa

4

7

11

5

10

9

Canada

4

19

5

5

13

5

Other

123

128

167

133

106

140

Total

816

557

733

795

664

782


Source: Department of Immigration and Multicultural and Indigenous Affairs overseas arrivals and departures (unpublished). * Includes long-term (visits of 12 months or more) and short-term (visits of less than 12 months) arrivals.

5 Permanent resident medical practitioner settlers: New Zealand citizens by birthplace; principal applicants of other nationalities by migration category; and family accompanying principal applicants, 1997–98 to 2002–03

Nationality

1997–98

1998–99

1999–00

2000–01

2001–02

2002–03


New Zealand citizens

Birthplace (of New Zealand citizens)

New Zealand

33

48

49

77

42

37

UK, Ireland, USA, Canada, South Africa

9

19

17

30

21

16

Southern Asia

13

12

114

210

29

15

Middle East and North Africa

2

4

10

51

9

6

Other birthplace

11

28

62

121

30

22

Total New Zealand citizens

68

111

252

489

131

96

Other nationalities

Migration category (of other nationalities)

Principal applicants

Spouse, prospective marriage

128

135

123

153

175

194

Other family

24

22

8

17

10

10

Skilled

39

38

48

38

28

34

Other (including humanitarian)

7

9

4

4

11

6

Total principal applicants of other nationalities

198

204

183

212

224

244

Family accompanying principal applicants (mainly spouses)

92

93

109

103

104

141

Total medical practitioner settlers

358

408

544

804

459

481


Source: Department of Immigration and Multicultural and Indigenous Affairs, overseas arrivals and departures, year ending 30 June (unpublished). UK = United Kingdom; USA = United States of America.

6 All persons aged 15–64 years with a degree in medical studies who arrived in Australia between 1 January 1996  and 7 August 2001, by birthplace, labour force status and occupation in 2001

Labour force status and occupation (%)


Birthplace

Total

Manager, administrator

Medical practitioner

Other professional

Other employment

Unemployed

Not in labour force


UK and Ireland

857

2

83

7

2

1

5

Southern Central Asia

516

0

39

2

14

11

32

China

489

2

5

19

27

8

39

India

430

1

66

5

4

10

13

Middle East and North Africa

411

3

36

5

9

18

29

South Africa

363

2

81

3

5

1

8

Eastern and South Eastern Europe

325

0

29

6

17

12

36

New Zealand

286

1

84

5

3

2

5

Other Europe

206

1

52

19

6

1

19

Malaysia, Hong Kong and Singapore

140

0

59

4

6

2

29

USA and Canada

104

3

53

9

9

6

18

Philippines

81

0

33

7

14

7

38

Other

470

1

42

7

11

8

31

Total

4678

1

53

7

10

7

22

7 Australian Medical Council examination outcomes, by major country of training, 2002

Country of training

No. of candidates

% Passing MCQ (1st or repeat try)

No. of candidates

% Passing Clinical (1st or repeat try)


India

133

47

49

63

Bangladesh

81

80

63

48

China

69

51

35

57

Iraq

54

87

65

66

Egypt

48

46

30

73

United Kingdom

38

74

34

88

Pakistan

36

75

19

53

Sri Lanka

34

82

34

65

Philippines

33

33

23

39

South Africa

17

88

23

91

Other

328

45

184

59

Total candidates

871

56

559

62


Source: Derived from Australian Medical Council Annual Report, 2002.12 MCQ = multiple-choice questions.

  • Robert J Birrell

  • Monash University, Melbourne, VIC.

Correspondence: 

Acknowledgements: 

I thank the Monash Institute for the Study of Global Movements for financial assistance for this research. The research was conducted as an independent enquiry and the author was not accountable to any funding agency for the results.

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