International medical graduates in Australia: a historical perspective (1930–1950s)

International medical graduates (IMGs) are an important part of Australia’s health workforce, accounting for about 23.5% (n = 16 186) of all doctors in Australia today.1 The recruitment and placement of IMGs in rural areas is particularly vital to the provision of health services in rural Australia, where there has been a shortage of health professionals for some time.1-6 Over one-quarter of Australia’s population are born overseas, and the arrival of refugee doctors has been observed as providing one of the “most poignant chapters of Australia’s great immigration experiment”,7 yet it is not well documented. We have drawn on historical archives and media articles to outline key issues associated with the arrival of refugee doctors, highlight improvements in the IMG experience and describe the key issues that continue to influence the experience of Australian IMGs.

Before 1938, few refugees came to Australia. During World War II (WWII), the Australian Government authorised the increased entry of refugees from Europe. A small number of these were Jewish doctors seeking asylum from the war,8 and in Rutland’s account of Jewish medical practitioners in Australia (1933–1956), she argues that they fought to recreate themselves as medical practitioners “in the face of not only financial and physical hardship but of suspicion and resentment on the part of the Australian medical profession”.8 At this time, the Australian branch of the British Medical Association (BMA) (the forerunner of the Australian Medical Association) was strongly opposed to allowing refugee doctors without “British” training (trained outside the United Kingdom, New Zealand or Australia) to practise in Australia.8-10 Kunz7 highlighted the concern that the BMA had with the uncertainty of the professional standards of non-British-trained doctors, and the increased competition that would occur if they were allowed to practise.

For IMGs arriving in Australia before WWII, the ability to practise was far from straightforward. Generally, those without British training had to requalify by attending one of four Australian universities,7,8,10 but German and Austrian doctors were ineligible to practise, due to the War Precautions Act 1914–1918 (Cwlth). This was legislated at the time of World War I to restrict and intern people of German and Austrian birth in Australia, and continued until the New South Wales Medical Practitioners Act 1938 allowed doctors of any nationality to register. The change in legislation resulted in doctors who were non-British-trained and with “outstanding qualifications” being registered without retraining. However, registrations of this kind were limited to eight IMGs per year for NSW.8,10

In 1939, 40 non-British-trained refugee doctors with outstanding qualifications, many of whom were Jewish, applied for registration, but only three were accepted.8 Other similar refugee doctors at the time sought legal advice about registration and many continued to practise unregistered.11 Most of these unregistered medical practitioners later attended the University of Sydney to complete their requalification.8 In late 1939, the NSW Medical Practitioners Act was amended to allow “regional registration”.8 Much like the compulsory schemes of today, this allowed non-British-trained refugee doctors to practise anywhere in NSW after completing a compulsory 5-year regional placement.8

The refugee doctors unable to complete their university training would continue to work under this scheme. Those who could not reregister often went to Commonwealth-controlled territories, such as Papua New Guinea, Antarctica and Macquarie Island, to work with other non-British-trained refugee doctors who had arrived after the war.7,8,10 Refugee doctors were only able to practise in Antarctica and Macquarie Island for a year at a time, and many repeatedly took this opportunity.7,8,10

After WWII, the migration of skilled refugees into Australia occurred at an unprecedented rate. This included an estimated 300 male and 70 female doctors arriving between 1947 and 1951.7,10 These doctors were from across Europe, with many arriving from Hungary, Yugoslavia, Italy, Austria and various eastern European countries. It has been documented that many of these doctors were specifically recruited to come to Australia while living in refugee camps.7 The recruitment has since been described as misleading, as these doctors were unable to register as medical practitioners once they arrived in Australia.7 Ineligibility for registration was largely attributed to the claims that their standards of education were “dissimilar” to that of British and Australian universities.7 Medicine studied and practised elsewhere in Europe was described by the BMA at the time as being “little better than witchcraft”.7 Such claims started what authors described as a long debate about the educational and professional merits of foreign or “alien” doctors in Australia.7,9

At this time, the Commonwealth viewed registration of doctors as a state matter and was reluctant to mandate changes, because the Menzies Liberal–Country Party coalition government did not want the resulting political fallout.7 Changes came in 1953, when a resolution of the Australian Labor Party directed state Labor governments to constrain the BMA’s domination of health services regulation.7 The aim of the resolution was to overcome the doctor shortage that had long existed in rural areas. When registration of refugee doctors was enabled, strict state quotas were maintained to ensure that large numbers of unregistered practitioners did not move to states which had commenced registration, which would then have contributed to an oversupply of doctors in those states.7

An estimated 37 of the total 370 refugee doctors arriving between 1947 and 1951 were able to practise medicine in Australia.7,10 Many completed at least 3 years of university retraining but, due to the quota restrictions, registration was not always guaranteed. Retraining proved difficult, as many refugee doctors had no means to pay for university courses or needed to work and study simultaneously to support families.7 Those returning to university had the advantage of their years of experience, but were sometimes embarrassed to be studying with much younger students and taught by academics who, at times, knew less about a subject than they did. For example, Kunz7 reported briefly on the experiences of an unidentified IMG who corrected “an examiner’s quotation from the text book which the [doctor] had himself written some fifteen years [earlier]”.7

The remaining 87.5% of the non-British-trained refugee doctors who came to Australia worked as general labourers or as adjunct health field workers such as medical orderlies, nurses or hospital cleaners.7,12 While working in these roles, younger Australian-trained doctors observed the wealth of experience and knowledge of these non-British-trained refugee doctors.7 Due to the challenges of registration in Australia, 34 refugee doctors were documented as migrating to other countries such as the United States, Canada and Ethiopia, where registration was less challenging and their careers were extremely successful.7

There were other repercussions: by 1956, five refugee doctors were reported to have died by suicide, with the last having been barred from practising in NSW.7 These well educated, formerly middle class refugees had a great deal to lose when they resettled.13 Other factors such as post-traumatic stress disorder relating to their memories of war may have contributed to their suicides, but their postmigration experiences are also likely to have contributed to their poor wellbeing.14

History is not merely about events from the past; it is also about learning from them. The history of IMGs in Australia must be considered so that the landscape of medical workforce for the future can be improved.

Acceptance of IMGs by the Australian medical profession and the general public has vastly improved since WWII. The formal IMG assessment process has also improved significantly, with British and non-British IMGs who pass these compulsory assessments able to practise independently in Australia.9 Nevertheless, for many reasons, such as difficulties with support and integration, a number of IMGs today are in similar predicaments to their 1940s counterparts: unable to register and working as taxi drivers, general labourers or in adjunct health occupations.13 Currently, IMG recruitment remains essential to sustain rural health services,6 but continued recruitment is viewed as “a quick fix and/or a distraction from other home-built solutions to health resources management”.15 Retention of IMGs in rural and remote Australia also continues to be problematic, as relocation to more metropolitan areas is attractive.15

Contemporary IMGs may be a dynamic force in the era of greater globalisation and population movement. They bring knowledge which may include an understanding of tropical health and medical pluralism (concurrent use of biomedical and ethnomedical systems and folk practices). Rather than being used as a stop-gap solution in areas of need, the skills and knowledge that contemporary IMGs bring with them as they migrate can be used to accommodate today’s migrating population. Locally trained doctors do their best, but do not effectively use free interpreter services for patients with poor English proficiency.16 Therefore, the knowledge and language skills of IMGs may be vital links for the one-quarter of Australia’s population born overseas.6

There are several lessons that can be learned from the way IMGs have historically been treated. First, it is important to take a positive view about the backgrounds and potential contributions of IMGs — culturally, socially and professionally — to Australian society. Like all migrants, IMGs in Australia bring cultural heritage, distinctive professional experiences, and a new perspective to the health discourse. Second, rural Australia continues to face shortages of health professionals, and the recruitment and placement of IMGs into rural and remote regions is a key health workforce strategy. A recent Rural Health Workforce media release indicated that more than 40% of doctors in rural and remote Australia are from overseas,17 thus playing a critical role in the sustainability of communities in these areas.

The history of IMGs attempting to practise in Australia in the 1930s and 1950s, and the lingering policies and regulations which remained unimproved until the 1970s, highlight the challenges facing early non-British-trained doctors in Australia.7,10 The historical account and the vast improvements made all help contemporary IMGs to practise in Australia. However, challenges remain, and continue to have an impact on their work, acculturation and wellbeing, and warrant future research.2,4,5,13