Australian healthcare is greatly enriched by its overseas-trained doctors (OTDs).
There is no national approach to support the integration of OTDs into the workforce.
The problem areas are well defined — the need for better information access; better orientation to our healthcare systems and the workplace; improving communication with patients and healthcare workers; standardised assessment of knowledge and skills; and education and training support —so, let’s get on with it.
Australia has an enviable international reputation for the quality of its medical services. Our overseas-trained doctors (OTDs) are valued members of our profession and enrich our multicultural society. However, the failure of past medical workforce policies, particularly to accommodate public hospital and rural medical workforce needs, has led to Australia becoming increasingly reliant on OTDs to sustain our medical workforce. Our obligatory dependence on OTDs also reflects the internationalisation of the medical workforce, and integration of OTDs into the national workforce is a common problem shared by countries with similar healthcare systems — the United States,1 the United Kingdom,2 Canada3 and New Zealand.4
Over the past 5 years there has been increasing strain on the Australian healthcare system as a result of the rapidly growing numbers of OTDs. This strain is seen particularly in outer metropolitan and rural hospitals and general practices, where workforce shortages result in significant numbers of OTDs whose background training, communication skills, clinical skills and orientation to the Australian healthcare system can vary markedly. Furthermore, there are real concerns that, for temporary resident OTDs and many permanent resident OTDs, conditional registration to practise in so-called “area of need” positions and geographic “districts of workforce shortage” does not encompass standardised assessment processes, and may compromise patient safety. In contrast, permanent resident OTDs wishing to attain general registration to practise unconditionally are required to pass the Australian Medical Council (AMC) examination, set at the standard of a final-year medical school examination. The AMC is an independent national standards body for primary medical training which advises on the accreditation of medical schools in Australia and New Zealand, and, more recently, the accreditation of specialist colleges.
Difficulties in relying on recruitment of OTDs as a solution for our medical workforce shortage are repeatedly reflected in reports stretching back to 2000 by state postgraduate medical councils (which oversee accreditation and prevocational training of hospital medical officers),5 the Confederation of Postgraduate Medical Education Councils (CPMEC)6,7 and the Medical Training and Review Panel Overseas Trained Doctors Subcommittee.8
The consistency of findings across different past reviews is impressive. The Confederation of Postgraduate Medical Education Councils’ National Scoping Study, commissioned by the Australian Department of Health and Ageing, reported on international practices, and undertook a comprehensive survey of existing resources within Australia in consultation with key stakeholders. The report concluded that the issues can be broadly categorised into six key domains: (i) international perspective, (ii) information access, (iii) orientation, (iv) communication, (v) assessment, and (vi) education and training support for OTDs.7 The 2001 study by the Postgraduate Medical Council of Victoria, which encompassed a broad range of stakeholders, including 283 Australian Medical Council candidates employed in public hospitals, medical registrars, nurse unit managers and Hospital Medical Officer managers, also identified similar key issues (see Box 1).5
While moves have been made to address a few of these issues in various states, Australia lacks a national coordinated approach.
In response to some of these reviews, in August 2003 the former federal Minister for Health and Ageing, Kay Patterson, set up a departmental Overseas Trained Doctors taskforce. On 18 November 2003, the government announced its Strengthening Medicare package, which contained a number of initiatives relating to OTDs. These included international recruitment strategies, changes to immigration arrangements, additional training support programs, reduced “red tape” in approval processes, assistance for employers and OTDs in arranging placements, and the formation of a Medical Specialist Training Taskforce.9 Yet these initiatives focus primarily on recruiting an additional 725 OTDs to work in Australia.9 There has been no agreed standardisation of orientation, communication, education and training programs, or indeed of assessment processes, for these doctors. Moreover, the cohort will add to the 900 OTDs taking the Australian Medical Council (AMC) examinations every year and the 4000 OTDs who have temporary registration. The problems associated with this emerging crisis have been highlighted in this issue of the Journal (page 635)10 and elsewhere.11-14
In the United States and Canada, supervision of early postgraduate training of OTDs occurs under the auspices of university medical schools. In the US, the Educational Council for Foreign Medical Graduates is responsible for evaluating the qualifications of OTDs entering into graduate medical education. A graduate of a medical school located outside the US or Canada must be certified by the Educational Council, and this involves a comprehensive three-step assessment process, including a clinical skills examination in the United States Medical Licensing Examination. In Canada, a national taskforce recently released its recommendations on the strategy for integrating OTDs into supplying doctors for Canada (Box 2).3 Members of the taskforce included representatives of medical licensing authorities, physicians, medical schools, OTDs and federal and provincial government officials. In the UK, a well-developed postgraduate deanery is responsible for managing all prevocational training (including that for OTDs) in the National Health Service. The UK is facing an additional pressure on its medical workforce crisis as a consequence of reduced working hours of European doctors. This may also influence the recruitment of doctors to Australia, as well as attracting many of our young graduates to work in the UK.
Assessment for safe practice conforming with Australian standards is a complex process. Australian-trained doctors undergo a long period of supervised clinical skills training and continuous assessment that includes prevocational training in accredited positions as an intern and postgraduate Year 2 trainee, followed by supervised vocational training. OTDs are a very diverse group, with variable needs for training and upskilling.5,7 To ensure all OTDs meet safe practice standards, a standardised, comprehensive pre-employment assessment, followed by a year of supervision, oversight of practice and/or mentorship, are recom-mendations of the Medical Training Review Panel Overseas Trained Doctors Subcommittee.8 The CPMEC believes that average training costs for an OTD would be at least equivalent to the costs of training an intern. Yet, current Australian government funding is largely directed towards recruitment agencies for doctors to be employed in the previously mentioned “area of need” positions, or “districts of workforce shortage”, predominantly in general practice. There is virtually no funding for pre-employment assessment, support, training and supervision of OTDs in hospital posts where most are employed.5
It is difficult to determine which existing professional body would be the most appropriate to take on the responsibilities of assessing and training OTDs. While the AMC is responsible for the assessment of permanent resident OTDs, most OTDs entering the Australian workforce do not require AMC accreditation as temporary resident or “area of need” or “area of workforce shortage” doctors. In each of the eight jurisdictions, the medical boards are independent statutory authorities established under state Medical Practice Acts and register practitioners without AMC contact. Yet, the medical boards have no capacity to undertake assessment examinations. Australian universities are not responsible for prevocational training; nor are our postgraduate training organisations funded to manage the training needs of OTDs in our public hospitals. The medical colleges are responsible for assessing specialist training and for overseeing practice for a period determined by the state or territory medical board on advice from the relevant college. However, for the colleges to be responsible for evaluation or training presents difficulties in terms of consistency of process, particularly as supervisors in most colleges are unfunded.
The postgraduate medical councils in each state have good credentials for accrediting hospital training posts, and a national group (CPMEC) is ideally positioned to oversee this process. In response to a report on AMC candidates in Victorian hospitals, the state government funded a pilot assessment for safe practice process, comprising standardised interview, online written test and clinical skills assessment. In response to this pilot, the Victorian Department of Human Services has commissioned the Postgraduate Medical Education Council of Victoria to further develop these assessment tools for trial by hospitals seeking to employ OTDs.
Ensuring adequate capacity and funding for assessment and training was the first recommendation of the Canadian Taskforce to address very similar issues (Box 2). Yet, in Australia, no critical review exists of either the capacity or the needs of our medical education facilities or assessment bodies to accommodate the requirements of OTDs. It is surely time for such a critical appraisal, which would also need to take into account the additional planned rapid increase in medical schools and Australian medical graduates.
The fragmentation of assessment, training and education of OTDs in Australia is problematic, and not made any more cohesive as a result of Strengthening Medicare initiatives. Nothing short of a coordinated, national strategy will suffice, and much can be learned from programs established in countries with similar healthcare systems. The key elements that need to be included in a national strategy are summarised in Box 3. There are signs that Australian authorities are paying heed to the clamour of voices and that progress is being made towards these broad objectives. There is a plan for the Australian Department of Health and Ageing to establish a web-based national information and referral service for OTDs and stakeholders; the AMC is streamlining its assessment processes to include an online multiple-choice examination which will be delivered offshore; and the Australian government has engaged the Royal Australian College of General Practitioners to identify, assess and counsel those permanent resident OTDs not currently in the medical workforce. The Australian Medical Association (AMA) has recently released a position paper on overseas-trained doctors.15 The AMA has adopted a policy on OTDs based on 12 principles, including one that states that responsibilities of recruiting agencies, employers and medical boards need to be explicit in relation to ensuring assessment, supervision, training, mentorship and support of OTDs.
Australia needs the immediate establishment of a national body, similar to the US Educational Council for Foreign Medical Graduates or the Canadian Taskforce, to address licensure and minimum- standards issues, to examine training capacity and support mechanisms, and to facilitate effective integration of OTDs into our medical workforce. On arrival in Australia their training and skills development needs are very variable: some can move very quickly into specialist practice; for others it will be a long, hard road. For others still, alternative career pathways must be sought. In continuing to recruit OTDs to hospital posts or “area of need” positions, there must be a duty of care to the public and to our overseas-trained colleagues.
1 Summary of key issues relating to Australian Medical Council candidates employed in Victorian hospitals5
No single point source of information for overseas-trained doctors (OTDs).
Significant variability in medical knowledge and clinical skills of OTDs.
Insufficient orientation to the Australian healthcare system and culture.
OTDs employed in positions where there was almost no matching to previous experience.
Limited supervision and feedback processes.
Additional workloads for hospital medical staff to accommodate the training needs of OTDs.
2 Recommendations of the Canadian Taskforce on Licensure of International Medical Graduates3
1. Ensure adequate capacity and funding for assessment and training of overseas-trained doctors (OTDs).
2. Work towards standardising the evaluation process for OTDs applying for licensure in Canada.
3. Expand or develop supports/programs to assist OTDs with the requirements and process for medical licensure in Canada.
4. Develop an orientation program to support medical faculty and physicians working with OTDs.
5. Develop capacity to track and recruit OTDs through the creation of a national database.
6. Establish a research agenda that would evaluate the OTD licensure recommendations and the impact of the strategy on Canada's physician supply.
3 Key issues to be considered in an Australian national strategy for OTDs
Immigration, education and healthcare bodies must work together to achieve the necessary reforms, which would provide:
Access to national, consistent, authoritative and up-to-date information relevant to OTDs;
A national registration system for OTDs;
A uniform minimum standard of English language assessment;
An accredited national comprehensive process of assessment comprising communication skills, medical knowledge and clinical skills, up to and including fitness for safe practice;
Standardised and accredited orientation programs;
Funded, flexible, customised, accessible and accredited education and training support programs for OTDs; and
Accreditation, training and funding support for medical educators supervising OTDs.
- 1. Fiscella K, Frankel R. Overcoming cultural barriers: international medical graduates in the United States. JAMA 2000; 283: 1751.
- 2. Advisory Group on Medical and Dental Education, Training and Staffing. Report of the Working Group on Refugee Doctors and Dentists. 2000. Available at: www.dh.gov.uk/PublicationsAndStatistics/Publications/PublicationsPolicyAndGuidance/PublicationsPolicyAndGuidanceArticle/fs/en?CONTENT_ID=4005329&chk=Lrapxo (accessed Nov 2004).
- 3. Report of the Canadian IMG Task Force. Paving the way to licensing more international medical graduates. Available at: www.hc-sc.gc.ca/english/media/releases/2004/2004_08bk1.htm (accessed Nov 2004).
- 4. Health Workforce Advisory Committee. The New Zealand health workforce. Future directions — recommendations to the Minister of Health, 2003. Available at: www.hwac.govt.nz/publications/HWACfuturedirections03.pdf (accessed Nov 2004).
- 5. Postgraduate Medical Council of Victoria. AMC candidates in the Victorian public hospital system, 2002. Available at: www.dhs.vic.gov.au/pdpd (accessed Nov 2004).
- 6. Confederation of Postgraduate Medical Education Councils of Australia and Medical Education Council of New Zealand. Report of the Workshop for Permanent Resident Overseas Trained Doctors. 2003. Available at: www.cpmec.org.au (accessed Nov 2004).
- 7. Confederation of Postgraduate Medical Councils (CPMEC). Information and resources relating to education and training available to overseas trained doctors in Australia. A National Scoping Study. Canberra: Australian Government Department of Health and Ageing. 2004.
- 8. Medical Training Review Panel, Department of Health and Aging. Overseas trained doctors subcommittee report: report submitted to the Medical Training Review Panel, February 2004. Canberra: MTRP, 2004.
- 9. Australian Government. Strengthening Medicare. 2003. Available at: www.health.gov.au/internet/wcms/publishing.nsf/Content/health-medicare-health_pro-otd-moreinfo.htm (accessed Nov 2004).
- 10. Birrell RJ. Australian policy on overseas-trained medical doctors. Med J Aust 2004; 181: 635-639.<eMJA full text>
- 11. Hawthorne L, Birrell B. Doctor shortages and their impact on the quality of medical care in Australia. People and Place 2002; 10(3): 61-63.
- 12. Barton D, Hawthorne L, Singh B, Little J. Victoria’s dependence on overseas trained doctors in psychiatry. People and Place 2003; 11(1): 54-64.
- 13. Birrell B, Hawthorne L. Medicare Plus and overseas-trained medical doctors. People and Place 2004; 12(2): 84-100.
- 14. Birrell B. The regulation of medical practice in Australia, Canada, United States and Britain. People and Place 2004; 12(3): 40-51.
- 15. Australian Medical Association Position Statement. Overseas trained doctors. 2004.
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