International medical graduates (IMGs) in cul‐de‐sacs: “lost in the labyrinth” revisited?

IMGs face a series of obstacles to practise in Australia, which regulatory agencies should address

In 2018, international medical graduates (IMGs) made up 31% of the medical workforce.1 Their contribution was recently acknowledged by the Secretary of the Commonwealth Department of Health:

The processes for evaluating the skills and competencies of IMGs before registration have been refined by the creation in 1984 of the Australian Medical Council (AMC),2 and the agreement of the states in 2008 to cede their licensing roles to the national regulator, the Australian Health Practitioner Regulation Agency (AHPRA).3

In 2012, as a result of representations about difficulties IMGs had negotiating the pathways to registration, a milestone enquiry was held by the House of Representatives Standing Committee on Health and Ageing.4 Their report, Lost in the labyrinth, made 45 recommendations, but many remain unaddressed.

We acknowledge the very important role that the AMC and AHPRA play in helping keep Australian patients safe. But there need to be improvements. The AMC has made considerable efforts to improve the reliability and fairness of its examinations and to cope with the increased number of candidates who currently apply.5 However, we call into question the restrictions imposed by AHPRA that continue to impede many IMGs applying by the standard pathway after their success in one or both AMC examinations (a written and clinical exam sequentially).

The evidence cited comes from oral histories of IMGs recorded during the past 3years (Supporting Information). The research was approved by the University of Melbourne’s Human Research Ethics Committee (approval No. 1750338.3). Participants have been de‐identified, and each gave permission for the use of the material attributed to them.

Problems due to timing of limited or provisional registration

When an IMG passes the AMC’s examinations, they are eligible for AHPRA to give them either limited or provisional registration so that they can obtain a year of supervised practice. The “catch 22”, though, is that they must first get a job offer before AHPRA will process their application.6 But hospitals and teaching general practices are likely to prefer to employ practitioners who are already registered, since there is sometimes a substantial delay between a hospital offering employment and AHPRA processing the registration. For example, a graduate with first class honours from an Irish medical school was offered an intern position at a major teaching hospital shortly after passing the AMC multiple choice question exam. It took 3 months for AHPRA to complete the documentation despite frequent telephone contact from the hospital, anxious to immediately fill its unexpectedly vacant position (IMG A). Another example is an experienced practitioner from a major western European city, who passed both AMC exams in 2020 but had to wait 6 months before a supervised position he obtained in a rural area of need was approved by AHPRA (IMG B). These are examples of IMGs who had their careers hindered by inefficient licensing procedures in spite of their success in obtaining job offers. These hurdles also have an impact on the operations of training sites, causing shortcomings in health care and educational attainments. Numerous IMGs simply cannot get a job offer, despite passing AMC exams many months or years earlier. Such delays have a momentous impact on the viability of medical registration, given their effect on the AHPRA requirement for recency of medical practice. One IMG followed her Australian husband from Serbia in 2004, escaping the consequences of the civil war, but her husband died a year after they arrived here, leaving her stranded with two young children. When they grew up, she had time to study for the AMC exams with the hope of resuming the career she loved. She passed the exams in 2017, but only received provisional registration in 2019 after several unsuccessful interviews (IMG C). Another IMG complained that jobs do come up unexpectedly but are rapidly filled up: “It is like a star falling” (IMG D).

Apart from producing anxiety and uncertainty, there is a financial burden:

Consequence of the requirement of recency of practice

AHPRA’s recency of practice requirement is designed to ensure that practitioners’ skills remain current. It requires that a practitioner work for a minimum of 152 hours per year (or pro rata over 3years) within their scope of practice.7 That skills decline when not used seems self‐evident, although epistemological evidence for this in medicine is surprisingly scant. Pregnancy and child rearing sometimes make it hard for even Australian‐trained doctors to meet the provision, but they at least have the chance to do so by working a day a week.

Restrictions related to recency of practice may affect particularly IMGs who have not yet obtained registration in Australia. For example, a young Indian graduate migrated with her Australian husband. It took a while for her to prepare for and pass the AMC examinations, but then needed to spend time looking after her new baby. By the time she was ready to look for the obligatory supervised job, her recency of practice had nearly expired:

Others caught out in this way, often because of pregnancy, have had to return to their parent country to reinstitute their recency of practice (IMG G).

IMGs stranded by changed rules or procedures

A further difficulty that besets some IMGs is a sudden change of requirement, resulting in them having to start again, usually at additional expense. One IMG arrived in Australia in 2010 having been promised help to find a job in an area of need, only to be told that the program had changed (IMG H). Another got a job offer from a general practice, passed the Pre‐employment Structured Clinical Interview (PESCI), but was instructed by AHPRA to start again because it had delayed the paperwork for 6 months, by which time the practice had been reclassified as no longer in an area of need. In other words, they had to find another job in an area of need, wait till a PESCI tailored to that position could be sat, and again pay the substantial PESCI fee. The authors note with considerable concern that some IMGs were so afraid of possible repercussions from AHPRA that they declined to be quoted in any way, even with the de‐identification method we and the Journal have employed for the others cited in this article (correspondence on file with the authors).

Recommendations and conclusion

We believe the issues described above need to be managed. Firstly, IMGs who have passed both AMC examinations could be immediately provided with provisional registration by AHPRA (rather than waiting for the IMG to find a job), so hospitals or practices would have certainty they could employ them. There would be no risk they would practise without supervision since that is a condition of provisional registration. A variation on this might be that AHPRA delegates to teaching hospitals the ability to act as its agent to confer provisional registration (and then immediately notify AHPRA).

Another solution to consider is for the Commonwealth to provide funding to health departments for 3‐month supernumerary bridging‐course positions in emergency and general medicine for IMGs with the AMC certificate. This would increase their chance to win a subsequent supervised position to meet AHPRA’s requirements, and help some who were at the limit of their recency situation. IMGs could be provided a loan to cover the cost to health departments of these bridging positions, possibly about $15000–$20000 based on costing of a similar program in 2014,8 which would be repayable after they got a subsequent job. We argue this would be a small cost for the benefit it brings to both the health system and the IMG.

As regards the impact of rule changes, it seems more in the spirit of the Australian “fair go” to usually provide transitional arrangements rather than a sudden “dead end” for those who are already part way through a process when it changes.

Finally, the Victorian Government’s recent announcement that it is bringing 350 overseas doctors and nurses to help with the coronavirus disease 2019 (COVID‐19) pandemic deserves comment.9 At the time of writing, some had already started. To us this seems poor policy, since there is already a substantial pool of qualified IMGs, most of whom are Australian permanent residents or citizens, who have completed all our requirements and are ready to be deployed for this purpose.

As we say at the outset, Australia owes a debt to its IMGs. The Lost in the labyrinth report suggested changes to how we manage the transition of an immigrant doctor to the Australian practice. Others have called for this too.10,11,12 It is clear there is still work to be done.