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Impeding the supply of expertise in Australian health care: actions of the Australian and New Zealand College of Anaesthetists

Soren Sondergaard
Med J Aust 2008; 189 (8): 460-462.
Published online: 20 October 2008

After working for many years in Scandinavian countries, I have had the opportunity to spend 2 years’ sabbatical leave in Australia working in the Department of Anaesthesia and Intensive Care and the Hyperbaric Medicine Unit at Royal Adelaide Hospital (RAH). Professionally, it has been enriching to observe an approach to administering anaesthesia that is so different — yet still effective — from my Scandinavian experience. Both systems have their advantages and drawbacks, and it’s a privilege to be conversant with both.

On a personal level, it has been a happy excursion as well, venturing into the magnificent landscapes of the Australian continent and delving into the Australian lifestyle and attitude to life in matters large and small. It has been a fascinating endeavour to engage in its emergent culture and unique history, which still exerts an enormous influence on politics, policies, administration and social patterns.

My experience of working here and the attraction of the country itself eventually flowed into an application for recognition of my Scandinavian specialist status by way of an upgrade from “limited registration” status with the Medical Board of South Australia (MBSA) to “full registration” status with the Australian Medical Council (AMC).

This, however, turned into an exercise in paper hurdles and, in my opinion, overzealous scrutiny, an experience I wish to share and discuss with the medical community of Australia.

As an overseas-trained specialist (OTS), the path to specialist recognition entails an assessment by the AMC and the OTS Committee of the Australian and New Zealand College of Anaesthetists (ANZCA). To my unsuspecting mind, my chances of passing appeared to be good: 22 years’ experience in the field, including 13 years at Sahlgrenska University Hospital (which includes all specialties and is the largest university hospital in northern Europe); an extensive and solid training in general anaesthesia and subspecialties; experience as a specialist in anaesthetics and intensive care in Denmark and Sweden; and specialist recognition in anaesthetics in the United Kingdom. During the last 6 years of that period I was a Senior Consultant and Vice Head of the Department of Anaesthesia and General Surgery at Sahlgrenska University Hospital. I worked independently for a year at RAH and initiated two studies at RAH and Flinders Medical Centre, resulting in one article and a letter accepted for publication.1,2 Add to the clinical work a research portfolio of a dissertation, co-authorship of 20 peer-reviewed articles on clinical studies, tutoring PhD students, and 50 or so presentations at congresses and scientific meetings.

Yet, according to ANZCA, my qualifications and experience were not equivalent to Australian standards. The OTS Committee could only establish that I could not safely be left to work independently (despite having done so for the previous year at RAH). To be accorded full registration status, I was required to pass certain sections of the ANZCA Fellowship examinations. This decision was upheld by ANZCA’s reconsideration and review committees, causing some bewilderment and perplexity among my colleagues at RAH. Appeals to ANZCA on my behalf by a former Assistant Minister of Health and Ageing and by the Chief Executive Officer (CEO) of the MBSA were politely turned down.

In all modesty, from my conversations with other OTSs seeking registration, I’m not the only one finding this state of affairs unsatisfactory and unfavourable to health care provision in Australia, and it may be worth raising the discussion in the wider medical community. But first one has to know a few facts.

ANZCA is a self-proclaimed professional body representing the anaesthetic community. The AMC and state medical boards rely on its judgement in applications for specialist recognition, although they are free to act without obtaining the opinion of the ANZCA OTS Committee. A recent incident of malpractice by a surgeon registered by the Medical Board of Queensland has made authorities extremely cautious and restrictive in exercising this power (Joe Hooper, CEO, MBSA, personal communication).3

ANZCA is self-governing and its policies, initiatives and actions are not regulated by any federal legislation. The Minister for Health and Ageing does not exert any authority over ANZCA (Nicola Roxon MP, Australian Government Minister for Health and Ageing, personal communication), and although the AMC (Box 1) and the Australian Competition and Consumer Commission (ACCC) (Box 2) have repeatedly suggested that ANZCA change its criteria for granting specialist recognition to OTSs, this has had no discernible impact on ANZCA regulations.

Holding a position as professor at a recognised university (Box 3) exempts you from sitting the exam, but in my opinion, this can only be characterised as unequivocal snobbery. A variation of an “assisted passage” is granted to Fellows of the UK Royal College of Anaesthetists.7,8

Thus, while hospitals Australia-wide are in urgent need of specialist anaesthetists, while medical boards are granting special conditions to OTSs working in areas of need, and while local initiative at the hospital level is introducing physician assistants to circumvent the College’s regulations on the supply of specialists, ANZCA is still able to unilaterally impede those wanting to register from doing so — and neither the federal government nor the AMC nor the ACCC have a say in this.

Apart from implicitly declaring Scandinavian anaesthetic training and practice inferior to that of Australia, the College’s motives were expressed in a number of arguments, as outlined below. The issued raised by these arguments need to be seriously contemplated and discussed (quotes are from members of ANZCA’s OTS Committee, as expressed to me and other applicants).

Argument A: “The College cannot discriminate between applicants coming from different countries — all should be treated equally.” This argument may stem from Australia’s highly praised egalitarian principle (in Australian lingo, “a fair go”), which in essence states that whoever is empowered can decide whether an applicant or immigrant is really equal to an Australian ideal — that is, implicitly, a person of British descent. Hirst, explaining the meaning of Australian “newspeak”,9 names this “egalitarianism tempered by checks on respectability”. To paraphrase Orwell’s famous words, “All are equal, but some more equal than others”.10 Recall the dictation test (1902–1958) (a test used to assess intending immigrants, with the purpose of excluding non-Europeans) and the “White Australia” policy (1901–1966).11 In this context, treating all applicants “equally” amounts to regarding the standard of anaesthetic practice in Central Africa as equal to the standard in Scandinavia — and both as inferior to the Australian standard. Discrimination (in the sense of distinguishing) is recognising qualities and differences and making choices accordingly. This type of discrimination is legal and is exercised every day. It is only if a Sudanese applicant is rejected in favour of a Swedish applicant — or vice versa — simply because of nationality that it becomes a criminal act. It would seem that the College, instead of discriminating (ie, distinguishing), is still suffering from a rebound from the peculiar Australian version of discriminatory practice. To me, it appears that the OTS Committee of ANZCA simply abandons the effort of separating the wheat from the chaff, whatever its provenance, and demands that everyone pass through the needle’s eye.

Argument B: Another argument ran like this: “You seem to be quite good at it. You wouldn’t have a problem passing the exam.” But why waste time, money, and effort on something unnecessary? — unless perhaps there is an unwritten rule that all immigrants to Australia should be subjected to some hardship. (Recall the manpowering of the Snowy Mountains Hydroelectric Scheme and the cane fields of Far North Queensland,11 or read Romulus, my father.12) “We are jumping through hoop after pointless hoop”, as one colleague phrased it.

Argument C: A member of the OTS Committee declared that “even a Nobel Prize laureate would have to sit the exam”. This is a light commitment: the only anaesthesiologist who ever came close to winning the Nobel Prize was Topchibashev, a surgeon from Azerbaijan, in 1978, for his work on analgesia. He died in 1981. The comment, however, is revealing of the utter lack of appreciation of whatever instillation of ideas and experience a Nobel laureate (sans comparaisons) might bring to the College.

Argument D: The last rebuttal from the review committee came with a reference to the assessment procedure being designed “to uphold the reputation of the profession”, which, of course, is the usual institutional gambit. The “reputation” antic was effectively laid to rest by High Court Judge Michael McHugh when commenting on opposition to the elevation of Margaret Cunneen to Senior Counsel (Box 4).

Argument E: One applicant was told that, unfortunately, the members of the OTS Committee are unable to assess applicants as they think fit because, in their words, “our hands are tied”. Given the self-governing nature of the College, one can only wonder — by whom? This was a “discussion stopper”, and I think it fair to question why the interview was derailed in this fashion.

My entanglement in Aussie red tape, however frustrating, is nothing compared with the “troubled trek of foreign medical graduates” described by Srivastava.14 She describes the plight of overseas-trained doctors, mostly from non-Western countries, who apply, year after year, to sit an examination that will qualify them to practise in Australia. At least I have a civilised, highly developed society to return to. I’m not in Australia to survive, I’m here to contribute to the development of her health care system.

All in all, working and living in Australia can be a wonderful experience. However, applying for recognition will require you to pass a specialist exam, even after decades of working as a specialist. On a personal level, you are left wondering why it’s necessary and whether there is any justification for having to undergo this ordeal after more than 20 years in the profession. Personally, I don’t think so, and I haven’t met any peers willing to accept the conditions — other things being equal. On a national level, you may wonder whether the Australian community is reasonably and fairly served by the ANZCA assessment procedure.

1 Quotes from the Australian Medical Council relating to assessment of overseas-trained anaesthetists

“The [Australian and New Zealand College of Anaesthetists (ANZCA)] expects nearly all overseas-trained anaesthetists to undertake the Final Fellowship Examination with the exception that they are exempted from the MCQ. Otherwise, they are handled with the local trainees. Although this may be appropriate for those relatively early in their careers, it is a difficult requirement for those in more advanced stages in their career and not something that is expected of Australian or New Zealand anaesthetists at this stage in their career. The Team considers that it is necessary for the College to consider more flexible methods of recognising overseas-trained anaesthetists, taking into account the stage of their career, the nature of their practice and methods of in-service assessment of competence rather than relying in all cases on an examination. Whilst a program which has flexibility is more difficult to implement in a fair and even-handed way, it does allow more appropriate evaluation of standards for anaesthetists at different stages of their career.”

“In recent years, the College has responded to concerns about discrimination between overseas-trained anaesthetists from different countries and has moved to require all overseas-trained anaesthetists to undertake the performance assessment and the clinical practice assessment. It has made a small number of exceptions for people in high academic posts or in director positions in hospitals.

While acknowledging the concerns about discrimination against people from countries where the training program is less familiar to the College, the Team considers that the College should develop more flexible methods of assessing individuals according to their training and experience and area of practice. For example, requiring nearly all anaesthetists, no matter what phase of their career and no matter how specialised their practice, to undertake the Final Examination (with the exception of the MCQ) with a pass standard set at that of trainees currently undertaking ANZCA’s anaesthetic training program might be seen as inappropriate for someone relatively advanced in their career with a specialist form of practice. Such an assessment is not required of Australian anaesthetists at comparable stages of their career. Moreover, in many cases it will be possible to be confident that the standards of training and practice undertaken by a given individual are comparable to those of an anaesthetist at a similar phase of their career trained in Australia. It might be more appropriate in such situations to rely on referees’ views or to undertake in-service assessment.

It is suggested that the College familiarise itself with the training programs overseas and design flexible, individualised mechanisms for assessment of overseas-trained anaesthetists, taking into account their previous training and assessment, their stage of career, their pattern of practice and the range of assessment methods available.”4


MCQ = multiple choice questions.

2 Quote from the Australian Competition and Consumer Commission regarding assessment of overseas-trained specialists

“[The] process [of undergoing a period of supervision] relates to the assessment for registration. There may be additional requirements to be met if an overseas trained specialist with comparable skills and training seeks fellowship of a medical college. The review notes that standards for overseas trained specialists appear to be inconsistently applied when compared to Australian fellows.

The review notes that it appears difficult to obtain recognition of comparability across most colleges, in part reflecting the high standards of the Australian specialist workforce. One college’s policies specifically state that overseas trained specialists could not be judged to be comparable without first completing the college assessment process. The issue is complex and jurisdictions are currently engaged in activities designed to simplify the process without compromising standards of service delivery.”5

3 Australian and New Zealand College of Anaesthetists’ regulation 6.3 relating to admission to Fellowship of the College

Regulation 6.3: Admission to Fellowship by election

“The Council of the College may consider applications from the following medical practitioners who are permanent residents in Australia or New Zealand for election to Fellowship of the College without examination:

6.3.1 (a) A Chair or full Professor of Anaesthesia employed full-time by a recognised University, or a full-time Head or Director of a Department of Anaesthesia of a hospital or clinical school that normally has university-appointed academics on its staff and is recognised by Council as a major teaching institution, provided that the applicant holds a qualification in anaesthesia acceptable to Council and is a practising clinical anaesthetist. The criteria for considering such applications shall be determined by Council.”6

4 Quote from former High Court Judge Michael McHugh on cartels

“Whenever the continued existence of a cartel is challenged, its defenders invariably point to the quality of the goods or services that it produces to argue that the public interest has been and will be best served by maintenance of the cartel or the anti-competitive practice under challenge . . . It is an argument that the professions — whether it be law, medicine, pharmacy or architecture — regularly employ to defend their practices.”13

  • Soren Sondergaard

  • Anaesthesia and Intensive Care, Sahlgrenska University Hospital, Gothenburg, Sweden.


Competing interests:

None identified.

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