The need for consistency in assessing international medical graduates for work in Australia led the Council of Australian Governments, in 2006, to direct health ministers to implement a nationally consistent approach.
An Implementation Committee was established in late 2006 to oversee the development of the new assessment process; the first steps were completed by July 2007 and further development will occur over the next 12 months.
The pre-existing Australian Medical Council (AMC) examination pathway will continue to be available, and there will be two additional pathways for non-specialists. The pre-existing pathway for specialists is being revised.
Elements that are being introduced include:
standardised pre-employment assessment, including an off-shore screening examination;
assessment of competence against a standardised position description and, if necessary, a structured clinical interview by an AMC-accredited provider before obtaining limited registration;
orientation to the job, the Australian health care system and to communication and cultural issues;
standardised supervision and supervisory reporting;
a requirement for compulsory continuing professional development for reregistration;
assessment by an AMC-accredited provider before gaining full registration; and
consistency of assessment for specialists by specialist colleges.
Some elements have been operating in some jurisdictions from July 2007, and there is a commitment to full implementation in participating jurisdictions by July 2008.
Australia, like many developed countries, relies on international medical graduates (IMGs) to supplement its locally trained workforce. In response to the growing realisation that the number of medical graduates being trained in Australia would have been inadequate to meet demand into the future, the previous federal government increased the number of places at Australian medical schools significantly, and established a number of new medical schools.1 However, the time between commencement at medical school and full and independent participation in the workforce ranges between 8 and 13 years, so Australia is likely to rely on IMGs to fill gaps for at least the next 10 years.
IMGs fill the spectrum from recently graduated doctors who come to Australia to take hospital or other positions for short periods, through to senior specialists working in metropolitan hospitals or academic institutions for the long haul. Although many come from countries in which English is the first or second language, many come from other countries, and an increasing number have undergone training in China and Eastern Europe (Ian Frank, Chief Executive Officer, Australian Medical Council, personal communication).
Assessment processes for IMGs have varied depending on the location and the nature of the positions for which they have applied. There are medical registration requirements set by the state or territory medical board, training and experience requirements set by the relevant college, and suitability requirements for the specific position set by the employing authority. Each body that sets requirements relies on some information or assessment by the other bodies. For IMGs who intend to practise privately, there is further assessment by the Australian Government Department of Health and Ageing for the purposes of obtaining a Medicare provider number so that their patients can access Medicare benefits for treatment. Although the Australian Medical Council (AMC) has had a defined role in assessing IMGs for a number of years, and has developed well regarded multiple choice question (MCQ) and clinical examinations that must be passed before unconditional or general registration, most IMGs currently registered to practise in Australia have not completed the AMC examinations.2 Their registration is conditional and they practise in areas of unmet workforce need.
Recent data indicate that around 31% of general practitioners in Australia are IMGs, although the proportion is greater in rural and remote areas (37%) than in urban areas (28%).3
The lack of a mandatory nationally consistent assessment process and local workforce requirements have, in some cases, led to unintended consequences; in the most notable case — that of Doctor Jayant Patel in Queensland — there have been adverse effects on patient outcomes.4
In their December 2005 research report, Australia’s health workforce,5 the Productivity Commission noted widespread support for national standards for assessing IMGs, while noting the concerns about the impact of any changes that might reduce the flexibility of current arrangements.
At its meeting in February 2006, the Council of Australian Governments (COAG) agreed “to a national assessment process for overseas qualified doctors to ensure appropriate standards in qualifications and training as well as increase the efficiency of the assessment process”.6 It was agreed in July 2006 that “health ministers will implement initiatives to establish by December 2006 a national process for the assessment of overseas-trained doctors”.7
As a general principle, the screening, assessment and supervision requirements for IMGs wishing to work in Australia should be based on the risk associated with the position for which they are seeking registration, and on the qualifications and experience of the IMG. The pre-existing AMC examination path leading to the AMC certificate will continue to be accessible, but the new approach to assessment provides a variety of pathways to registration depending on IMGs’ previous training and assessment, knowledge base, clinical skills, and the suitability of their skills and experience for the position for which they are applying.
An overview of the process, using the new standard pathway as an example, is given in Box 1. This shows how non-specialists with a range of training and experience can be matched against the intrinsic risk of the positions they are applying for, and how the assessments and supervision can be tailored appropriately. Similar matrices have been developed for specialists. The concept of this matrix was largely developed by Dr Alison Reid of the Medical Board of New South Wales and Deputy Chair of the AMC Expert Panel.
The term “competent authority” is used broadly in the area of international relations whereby countries mutually recognise the certification of goods or qualifications provided by agencies in other countries to facilitate free trade. The competent authority pathway allows IMGs who have completed prescribed examinations or accredited training in countries that have both a similar health care system, and similar training, assessment and registration systems to those in Australia to receive advanced standing towards the AMC certificate. This means they are not required to undertake the AMC examination, although they will need to undertake workplace-based performance assessment. Currently, registration by the competent authority pathway is possible for IMGs from the United Kingdom, Ireland, Canada, the United States and New Zealand, although other countries may be considered in the future.
In addition to the pre-existing AMC examination pathway (comprising MCQ and clinical examinations),8 which will continue to be available, a new standard pathway and a new competent authority pathway will be available for both non-specialists (including those who are applying for hospital non-specialist positions and those applying for general practice positions who are not trained and recognised as GPs in their country of origin) and specialists (including those who trained and are recognised as GPs in their country of origin).
Under the new national assessment process, all IMGs will be assessed against standardised position descriptions to ensure that their training and skills are appropriate to the position for which they are applying. This also provides assurance that the supervision and support provided will be adequate for the skill level of the IMG.
As the first step in the assessment process, it is essential that there is assurance about applicants’ basic competence. Non-specialists’ basic competence can be established by their successful completion of the AMC MCQ examination offshore. For applicants with advanced standing granted on the competent authority pathway, basic competence is assumed. For specialists, basic competence is established by individual college assessment of the applicant’s training and experience.
An applicant’s suitability for employment must be assessed by the employer by matching their curriculum vitae and application with the position description. If the employer believes further information is required, a recruitment interview or a structured clinical interview may be undertaken, and this will be done by an appropriate provider. The AMC has been given the task of developing a method of accrediting providers, although this has not yet occurred. Not all applicants require a structured clinical interview, particularly if they are applying for a highly supervised or low-risk position.
IMGs come from a variety of backgrounds and cultures. Workplace, cultural and health system orientation can help to ease each IMG into the Australian professional and cultural environment. This will be the responsibility of each employer, and should be provided within 3 months of employment.
It is expected that an orientation plan will be provided as part of the supervision and assessment plan submitted with the initial registration application. Evidence of completion of a satisfactory orientation program must be submitted to the relevant medical board with a supervisory report. While the AMC does not intend to accredit individual orientation programs, general guidelines on orientation for integrating IMGs into the medical workforce in Australia will be endorsed.
All applicants will undertake a period of supervision to ensure that they are performing at a suitable standard. Initially, this supervision is to monitor and support IMGs during their introductory period of working within the Australian health care setting. The supervision period introduces and sets in place a culture of continuous learning and professional development.
New requirements regarding the qualifications of the supervisor, the frequency and nature of interaction between supervisor and IMG, and the form and content of the supervisory report have been standardised.
The level and frequency of supervision will be part of the conditions of registration granted to IMGs to work in the health care system. Supervision requirements for IMGs registering to work in Australia will be based on the risks associated with the position for which they are seeking registration, and the qualifications and experience of the IMG. In this way, responsibilities and resources can be appropriately allocated and managed.
In addition to the supervisory requirements that will extend throughout the period that the IMG occupies the position, further assessment will be undertaken as necessary. This will be in the form of either a workplace-based performance assessment by an appropriate provider, leading to the issue of the AMC certificate, or of an assessment by the appropriate specialist college, leading to award of college fellowship. The AMC has been given the task of accrediting providers and, to date, interim accreditation has been granted to entities in all states (generally, applications have been submitted from health departments and medical boards jointly), and final applications are pending in both territories.
A range of workplace-based assessment methods, including the Mini-CEX (mini clinical evaluation exercise),9 are currently being trialled by the state and territory health departments to determine their applicability in this environment, supported by an AMC reference group.
Those who have undertaken non-general practice specialist training in a country designated a competent authority may be eligible for further assessment on both specialist and competent authority pathways if they wish.
Most of the specific developments relating to assessment of overseas-trained specialists (in this context, the term specialist excludes those who have undertaken general practice training) were undertaken by the AMC Joint Standing Committee on Overseas Trained Specialists. A recognised pathway for assessment of overseas-trained specialists existed previously, but there was variability in its application between colleges and between jurisdictions.
While many of the new processes for non-specialists will also apply to specialists, there are a number that are unique to specialists — some existed for some specialist colleges previously, but under the new arrangements there is a move towards a common approach for all colleges.
classifying overseas-trained specialists (in comparison with Australian-trained specialists) as “substantially comparable”, “partially comparable” or “not comparable” (previously, colleges had used different terminology);
allowing those who are considered “substantially comparable” to gain fellowship without the need for further examination (some colleges previously required examination, even for substantially comparable specialists, but now most do not, and the remainder are moving in this direction); and
allowing assessment of suitability for an area-of-need position and of additional requirements to gain college fellowship to occur simultaneously (previously, this would have required two similar assessments at different times, but now a single assessment can be done at the beginning of the process and any additional requirements highlighted).
Box 2 summarises important milestones, past and future, in the process of implementing nationally consistent procedures for assessing IMGs. As the implementation is a work in progress, some of the information in this article may have been superseded by the time of publication. Information will be made available publicly as it becomes available, and the AMC and jurisdictional websites will be regularly updated. Relevant websites are shown in Box 3.
2 Implementation of nationally consistent assessment
First 6 months of 2007 — monthly meetings were held by the Implementation Committee (with much of the detailed work performed by external agencies such as medical boards and their registrars, and the Australian Medical Council [AMC], including a specially convened AMC Expert Panel and the AMC Joint Standing Committee on Overseas Trained Specialists)
End June 2007 — detailed features of the new assessment model were agreed on and reported to the Health Workforce Principal Committee. The Implementation Committee was disbanded and a Technical Committee* was formed to oversee further work to allow full implementation over the next 12 months
July 2007 — a “competent authority” pathway was implemented in Queensland, and is being progressively implemented in other participating jurisdictions (this will be independently evaluated by an external consultant within the next year)
* Members of the Implementation Committee and Technical Committee are shown in Box 4.
3 Where to find more details
ACT Department of Health: http://www.health.act.gov.au
NSW Health: http://www.health.nsw.gov.au
Northern Territory Department of Health and Community Services: http://www.nt.gov.au/health/
Queensland Health: http://www.health.qld.gov.au
South Australian Department of Health: http://www.health.sa.gov.au
Tasmanian Department of Health and Human Services: http://www.dhhs.tas.gov.au
Victorian Department of Human Services: http://www.dhs.vic.gov.au
Western Australian Department of Health: http://www.health.wa.gov.au
4 Implementation Committee and Technical Committee members*
ACT = Australian Capital Territory. NSW = New South Wales. * All are members of both committees unless indicated otherwise. † Members of the Implementation Committee alone. ‡ Members of the Technical Committee alone.
- 1. Australian Government Department of Health and Ageing. Medical Schools — more places. Fact sheet. Canberra: The Department, 2005. http://www.health.gov.au/internet/wcms/publishing.nsf/Content/factsheet-medical_schools.htm (accessed Feb 2008).
- 2. Joint Standing Committee on Migration. Negotiating the maze: review of arrangements for overseas skills recognition, upgrading and licensing. Canberra: Commonwealth of Australia, 2006. (Parliamentary Paper No. 187/2006.) http://www.aph.gov.au/house/committee/mig/recognition/report.htm (accessed Feb 2008).
- 3. Australian Government Department of Health and Ageing. General practice statistics. General practitioner types and place of qualification. Canberra: The Department, 2007. http://www.health.gov.au/internet/wcms/publishing.nsf/Content/health-pcd-statistics-gpquals.htm (accessed Feb 2008).
- 4. Davies G. Queensland Public Hospitals Commission of Inquiry. Final report. Brisbane, QPHCI, 2005. http://www.qphci.qld.gov.au/ (accessed Feb 2008).
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- 6. Council of Australian Governments’ Meeting 10 February 2006. Canberra: COAG, 2006. http://www.coag.gov.au/meetings/100206/index.htm (accessed Feb 2008).
- 7. Council of Australian Governments’ Meeting 14 July 2006. Canberra: COAG, 2007. http://www.coag.gov.au/meetings/140706/index.htm (accessed Feb 2008).
- 8. Australian Medical Council. Nationally consistent assessment for international medical graduates. Canberra: AMC, 2006. http://www.amc.org.au/COAGIMGAssessment.pdf (accessed Feb 2008).
- 9. Jolly BC. The new curriculum framework and assessment practices: current challenges for postgraduate years 1 and 2. Med J Aust 2007; 186 (7 Suppl): S33-S36. <MJA full text>