Issue 40 / 15 October 2012

INTERNATIONAL medical graduates require far greater support in adjusting to the Australian health care system, say experts in response to research that found these doctors are at greater risk of attracting complaints and adverse disciplinary findings than their Australian-trained colleagues.

In a study in the latest MJA, University of Melbourne researchers analysed 5323 complaints against 3191 doctors in Victoria and WA and found that, overall, IMGs had 24% higher odds of attracting complaints to the medical boards than Australian-trained doctors, and 41% higher odds of adverse disciplinary findings. (1)

The researchers said this increased risk was largely driven by a higher incidence of complaints against doctors trained in seven countries — Nigeria, Egypt, Poland, Russia, Pakistan, the Philippines and India. IMGs trained in 13 other countries, including Hong Kong, Bangladesh, Germany, Malaysia and New Zealand, were no more likely to face complaints than Australian-trained doctors.

The adjusted annual probability of experiencing a complaint ranged from 1.2% among doctors trained in Hong Kong, through 2.4% for doctors trained in Australia, to 8.6% among those trained in Nigeria.

In an editorial, Dr Balakrishnan Nair and Dr Mulavana Parvathy, of John Hunter Hospital’s Centre for Continuing Medical Professional Development, wrote that the findings highlighted the need for a proactive and tailored approach in assessing and supporting IMGs. (2)

“Instead of setting IMGs up to fail, we should be doing everything to set them up to succeed”, wrote Drs Nair and Parvathy, who are both IMGs and Australian Medical Council examiners.

Professor Merrilyn Walton, professor of medical education (patient safety) at the University of Sydney, said it was important to acknowledge that IMGs deserved and warranted support.

She said many IMGs entering the health system were “tacked on” to an already stressed supervision system in which IMGs were supervised alongside Australian-trained interns. “These two groups have different training needs”, she said.

“We need an interim preparatory stage, where it’s not necessarily only about learning medicine, it’s about learning context — how our hospitals are organised, how health teams relate and work together, how to manage the hierarchies in health care, the relevance of guidelines and protocols, because many countries don’t have organised clinical systems designed to improve patient care”, Professor Walton told MJA InSight.

She said a possible confounder to the research could be that people who made complaints about this particular group were more likely to complain about a person from another culture in circumstances where they might not complain if the treating doctor was Australian born. However, the research had also identified doctors from non-English-speaking backgrounds who did not attract a higher number of complaints, which indicated that racism was not the only factor driving complaints.

Professor Walton said until it was recognised that IMGs required specific support, it was likely that the number of complaints would only increase and would feed into racism.

Dr Viney Joshi, president of the Australian Doctors Trained Overseas Association, said he was unimpressed with the study because it focused on only two states and contradicted research published last year in the MJA, which found that IMGs in private practice in Victoria were at lower risk than other doctors of experiencing a complaint. (3)

Dr Joshi said while IMGs required greater support and mentoring it was just as important to stamp out discrimination against IMGs in Australia. “There is still a lot of discrimination, harassment and bullying against the overseas-trained doctors. So that nonsense has to stop”, he said.

It was also crucial to stop changing the goal posts for IMGs, Dr Joshi said, citing changes in requirements for the English exam. Dr Joshi, who teaches medical students at the University of Queensland and James Cook University, said many of the locally trained students would be unable to pass the English exam.

“You don’t have to read Tess of the d’Urbervilles to your patients, you need to be able to communicate with them effectively”, he said.

Royal Australian College of General Practitioners WA faculty chair Associate Professor Frank Jones said it was important to fund initiatives to introduce IMGs into the Australian community.

“Doctors I have mentored have been brought in by one of the many recruitment agencies, had one week’s orientation and they’re out on their own — in a different country, different health care system, Medicare rules, PBS [Pharmaceutical Benefits Scheme] rules, different pathology”, Professor Jones told MJA InSight.

Professor Jones said there had been successful programs for IMGs to help to reduce complaints. State college faculties were also conducting information forums for IMGs, with WA’s inaugural forum to be held next month.

– Nicole Mackee

1. MJA 2012; 197: 448-452
2. MJA 2012; 197: 428-429
3. MJA 2011; 195: 25-28

Posted 15 October 2012

35 thoughts on “Give IMGs support to succeed

  1. Rose says:

    The AMA does a great job for members and non-members in private and public practice in my experience.
    IMGs, like local graduates, deserve support.
    Like us, they are victims of a political agenda, which is far removed from the Hippocratic Oath.

  2. Paul of vienna says:

    Australian govt needs cheap labour to provide service which they can only get via IMGs. All Australian doctors are in private practice.They have pressure lobby like AMA who uses scare tactics to get what it wants for private practice. If govt had guts then they would impose 10 year moratorium on their own doctors like IMGs and make them work in public hospitals where they get trained. IMGs do not use any public resources to get trained. Why don’t you guys ask govt to stop this doctor importing business and make it compulsory for Australian trained doctors to work in public hospitals? It will happen eventually due to tsunami of doctors anyway.

  3. Mike in Tassie says:

    One cannot but be impressed with the resolve of folks who come to live and work in a country where almost everything is alien- the food, the language, the social mores, the law, even which side of the road to drive on. Add to that isolation from usual supports, lack of readily available information on such things as getting the electricity connected, opening a bank account or joining the local library. Then top it off with having to work in a stressful job, for which one may or may not have been adequately prepared, in a completely foreign system, with the expectation of acceptable performance from day one. What you get is a recipe for personal and professional disaster. Whatever the political and economic pros and cons of “importing” medical staff from other countries, the fact remains that such folk are here and need our collegial support as much as formal programs to provide the neccessary information and skills to help them achieve both the health outcomes that Australians expect from their medical practitoners and their own personal goals, the ones for which they left their homes to come to an alien land. Personally I think lumping all “IMGs” in the same bag is logically flawed and clouds the discussion. I have worked with folk from other countries whose training,experience and committment were better than my own home-grown variety. I have also worked with some folks who have proven lazy, untrustworthy and knowledge-poor. That’s people for you and I don’t think any one country or system has a monopoly on that.

  4. David the obstetrician says:

    I have trained (and examined) medical students, local graduates and IMG’s for many years. The standard of medical education in some countries is at least equivalent to that in Australia. However, sub-standard medical schools do exist and their graduates usually fall well short of the basic requirements to practice in this country. This is not the fault of the IMG’s but rather the system in which they have been trained. If we want these doctors to work here, we need to ensure that their standards are raised to the level of a local graduate. It is not racist to require that all doctors in Australia be assessed at the same level and it is offensive to label those who express that opinion as racists.

  5. Greg the Physician says:

    We seem to have gone off topic to some extent. The original thread was on giving additional support to IMGs coming to work in Australia. The point was made, quite correctly in my opinion, that IMGs should have to meet the same professional standards as domestic graduates. Now we’re discussing how and why IMGs come to Australia – some by choice, some by recruitment, some as refugees. It is a fact that there has been active recruiting of IMGs to relocate to Australia in recent years.
    Here is a quote from today’s “Australian” newspaper regarding the lack of intern positions in Australia for 2013:
    “Yet as hospitals and health services import overseas-trained doctors to fill the gaps, domestically trained medical graduates face being forced overseas.”
    Surely this is an unacceptable situation. We also have many excellent domestic applicants being denied entry to medical schools, which apparently need full-fee paying students from overseas for financial reasons.
    So my criticism is of recruitment programs for IMGs and of any proposals to lower professional standards to enable them to practice in Australia. My comments apply equally to IMGs of every nationality and ethnicity, and is in no way racist.
    Sue, if it is so difficult for IMGs to practice in rural and remote regions, let’s limit the intake of IMGs and fill the gaps with more local graduates.

  6. Sim says:

    Neil, I am sorry if I am picking on you too much. This is because I would like you to moderate your bias on IMGs. By ethical standards and hippocratic oath doctors are suppossed to be brothers and sisters who support each other irrespective of nationalities and race. Your assertion that “IMGs are good at passing tests but my experience is that they don’t check VA or evert the eyelid if a patient complains of FB in eye” is unfair. In addition, you assert that they are low standard. If they are good at passing exams they will surely pass UMAT/GAMSAT/ tests that Australian citizens have to pass.

  7. Sue says:

    Sim – you appear not to have read my post. Of course Australia is a country of migrants – that is why so many migrants – including the IMGs I work with – and including my own parents – value the opportunity to come here to make a better life for themselves and their families. I was responding to your comment that you have not come from a war-torn country or dictatorship, and that you are yet to see “the sky; let alone the sun and the opportunities.” Either you were coerced and came to Australia under false pretenses, or else you stay willingly – like any other migrant. You can’t have it both ways. Migration doesn’t work out for everyone.

  8. Neil Ozanne says:

    Dear Sim, Why do you have a problem with me asking that IMGs to have to pass the same UMAT/GAMSAT/interview that Australian citizens have to pass? What evidence do you have for your assertions that IMGs are better than Australian trained doctors?

  9. Sim says:

    Sue, you have written that “IF you, on the other hand, left a country where things were better for you, don’t you have the option of returning there?”. My answer is Australia is a country of immigrants. You are likely to be one too unless if you are first generation Australian Aboriginal. If all immigrants returned, how would Australia be? No migrant has a right to tell another to go back where they came from!!! That attitude has its roots in the belief that some people are superior because they belong to a particular ethnicity or national group.

  10. Sim says:

    Neil Ozanne, Why should Australia recruit a lower standard educated IMG? It is actually the opposite. Why can’t you tell your government instead of bashing IMGs? It is a pretext to abuse highly qualified and experienced IMG by denying them many basic rights. Racism has always been both an instrument of discrimination and a tool of exploitation. It renders inferior some groups and perpetuates deep rooted historical, social, cultural and political inequalities in society. Evidence is there for those with eyes to see happening in Australia. Racism has its roots in the belief that some people are superior because they belong to a particular race, ethnicity or national group. Stop covering up your racism for sub-standard educational foundations.

  11. Rose says:

    Having spoken to some IMG’s today,I am now wondering whether our health services, directly or indirectly , are recruiting them on dubious pretexts to work under unreasonable conditions in AON and that their relocating to non Areas of Need after this is part of the deal to attract them to AON , knowing that IMG’s, like Australian doctors, can only tolerate onerous hours and conditions including being understaffed, undervalued, answering to non-clinical administrators, for a short time.

  12. Sue says:

    Sim – it is disappointing to hear of your experience, but that doesn’t negate the experiences of many. You say “The assertion that many IMGs come from war-torn impoverished countries, or dictatorships to have a better life and better opportunities for themselves and their families is offensive. Only refugees come from such countries, and even if they are doctors or engineers, they survive by doing odd jobs like taxi drivers.” That is patently not true for all – including the many doctors from Iraq, Sri Lanka and Zimbabwe with whom I work every day. These doctors are not coming as refugees, but on work visas. They are not coming via agencies, but applying directly, having heard of us through their own networks. All of these countries have been disrupted by war and/or dictatorial governments – in comparison, life in Australia IS fantastic. IF you, on the other hand, left a country where things were better for you, don’t you have the option of returning there?

  13. Sim says:

    Sue, I am reflecting on my own experience. I am an IMG who was a senior lecturer at medical school and running a very successful practice in my home country. Unwittingly Recruiting agents came to my country to recruit, promising the sky is the limit and how fantastic life and opportunities are in Australia. I am yet to see the sky; let alone the sun and the opportunities. I have FRACGP Fellowship but discrimination is rife and every opportunity is systematically blocked. The assertion that many IMGs come from war-torn impoverished countries, or dictatorships to have a better life and better opportunities for themselves and their families is offensive. Only refugees come from such countries, and even if they are doctors or engineers, they survive by doing odd jobs like taxi drivers. Poaching is acquiring something in an unfair way. If Australia acquired IMGs officially from their home governments, they would not be treating them that bad.

  14. Sue says:

    I have never met an IMG who did not come to this country of their own volition. many come from war-torn or impoverished countries, or dictatorships. The migrate to have a better life and better opportunities for themselves and their families. On what basis would we ban them from doing that? Would we then ban all skilled migrants, on the basis that they are a brain drain from their countries of origin? On that basis, we would only permit the unskilled to migrate. Strangely, that is the opposite to our current migration policy. I suspect users of the term “poaching” don’t realise that all doctors who come to Autralia have “willingly” applied to come here. What do you mean by “poaching”?

  15. Neil Ozanne says:

    Sim is right – we should stop poaching doctors from overseas. Although we should allow any doctor in the world to willingly apply to work here, assess them against the same standards we apply to Australian citizens, and accept those who meet the standards in numbers commensurate with need.

  16. Sim says:

    Greg the Physician, It is actually quite offensive to downgrade the contributions IMG make to healthcare in Australia. These IMG were poached free of charge from their countries that trained them. Training a doctor is not cheap.

    Your key point should be appreciating IMG as well as training your local medical students to address the doctor shortage instead of continuing to poach doctors from overseas and then denying them opportunity to grow and succeed, bullying, discriminating and humiliating them as if they are cheap stuff.

  17. Sue says:

    Greg the Physician – you are indeed fortunate to have worked with post-FRACP exam IMGs who have been both hard-working and excellent clinicians. What you may not be aware of is the process required to get them there. There are inevitable issues of adaptation before people from a very different medical culture can perform at their best. Frequently, they are also struggling without their social networks, families and peers, and feeling inadequate during the time they are adapting. We need to recognise that people in the early phase of adaptation my not be workign at their peak level, but still deserve a chance. As far as forcing them out of capital cities goes, why force culturally diverse people out of the communities, to areas where Australian-trained doctors are not flocking, and into communities that are largely Anglo-Australian? The shortages of all professionals in rural areas are inevitable, and can be addressed through other measures like recruiting rural people to medical school. In that way you staff rural areas with people who belong there rather than people who are isolated there, feeling like a fish out of water.

  18. rose says:

    I support Greg’s comments. If we bring in IMGs whose aim is to work in capital cities, it will contibute to a maldistribution of doctors. What are the statistics on how many Area of Need IMGs remain permanently in areas of need ?

  19. Greg the Physician says:

    I actually find some of these posts quite offensive in playing the race card in response to any criticism of IMGs. For the record, I have had several IMGs work under my supervision as advanced trainees, and at least one return later as a valued consultant colleague. I have found them without exception to be hard-working, excellent clinicians and terrific people. But they had all passed the Australian FRACP examinations before commencing advanced physician training. That is the standard in this country, as it should be, regardless of ethnicity, race, religion or country of birth or medical training. My understanding is that the AMC exams are set at the same standards as our medical schools use for domestic final year students, so there is no discrimination there either.
    My key point remains that we should be increasing our numbers of local medical students to address the doctor “shortage” (really maldistribution) in this country, not importing medical graduates, or for that matter medical students, from overseas.

  20. Sue Ieraci says:

    It would be informative to know the details of the situations these “complained about” doctors found themselves in. I have supervised many, many international graduates, and the main thing I have learned is how much intellectual effort is required for adaptation, just to survive every day. I have seen doctors struggle for up to a year before showing their true value as clinicians. We need enough supported, supervised places for these doctors to adapt and grow, and then they re-pay the investment with interest. Most of these people I have encountered have left war-torn countries or dictatorships to make a better life for their families – just like previous generations of migrants have done. Our society and health system is all the richer for them.

  21. Neil Ozanne says:

    I gave an example that demonstrates the failure of the AMC’s Area of Need Pathway – – ie, NO standards need to be met for UMAT/GAMSAT (critical thinking, problem solving, understanding people and abstract non-verbal reasoning) and NO standards need to be met at interview (Communication Skills, Explaining Skills, Awareness of social diversity, Ethics and values, Self-awareness, Trust and trustworthiness, Working with others).The fault is in the system – not the IMGs – the band-aid political response administered by the AMC. ALL doctors should meet the same standards – which are assessed in the same ratios – ie, UMAT/GAMSAT:Academic:Interview = 1:2:2
    For the record I am not racist – I am a 50yo WASP male GP, who is the only non-Chinese Dr (4 Australian trained, and 1 IMG) working in a Chinese-Dr-owned practice. My best medical friends include an IMG from India and a Chinese Dr in my current practice. I have taught white medical students and I currently mentor a Chinese medical student. If you want to label me, then call me a “standardist” – a rule for one is a rule for all.

  22. SAMADI VALID says:

    I am surprised with some of the thoughts about health systems of other countries. I agree that Australia has a health system with high standards, but this does not mean that other countries are living in the medieval era. Many countries in the world are doing well, having excellent training systems. Nowadays a lot of doctors from Africa, Middle East and Asia are working in USA, Canada and Europe with high levels of expertise. Despite the fact that Australia is a big island, I think it’s time to think globally, because the borders and limitations are going to disappear.

  23. Sim says:

    Neil Ozanne, You must be saying this from your heart and not from your head. You describe that IMGs are good at passing tests but your experience is that they don’t check VA or evert the eyelid if a patient complains of FB in eye, is narrow minded description. You think Australian standards are better than everywhere else? Many Australians are going overseas for treatments like everyone else. Many of the IMG are Global Doctors who have worked in many countries around the world and possess Global standards above local standards. Many are specialists with Masters and PhD degrees but treated as bad. Can you reveal your qualifications and experience?

  24. rose says:

    I accept each of the above points of view. Having supervised 2 IMGs from Pakistan, in a remote area, where local graduates chose not to work thanks to successive governments,(who even downgraded the local airport where retrieval flights land,downgraded the hospital maternity service,) I was grateful for their hard work in the GP practice, and experience in Public Hospital emergencies. They relocated to urban areas. I made representations to the local NPA on improving conditions for relieving (Australian) RMOs, who like myself, (a FACRRM,) were offered a hotbox room with no aircon in temperatures to 47 degrees celsius, no security, when on call for the hospital-you sweated waiting for air retrieval,for an unconscious trauma patient while the flying Surgeon is in the air hundreds of km away, ,for a breech labour, while the flying O & G is in the air over Cloncurry, and sweated while trying to sleep. I asked the NPA at a luncheon how they expected any doctor to return or stay under those conditions. That town and the next town are currently I believe unable to recruit any permanent or locum doctor for those hospitals. There are not many voters in remote areas, so governments do not care that relieving RMOs are overfaced, nor that IMGs are thrown in the deep end, and I suspect in some areas coerced into working more than acceptable hours, while patients suffer. What may help, in my opinion, is an increase in rural student places at all UNIs, increase in rural training positions , from intern to GP registrars, and upskilling for rural GPs in teaching hospitals, as well as improving conditions at rural and remote hospitals, which could be funded by the mining industry in many areas.

  25. Anonymous says:

    Sim: “No country can have enough doctors for their entire population.”
    Really sim, your telling me it’s actually impossible for a country to have enough doctors to supply its own population?

  26. Neil Ozanne says:

    ??Why should a doctor who has had a lower standard of education be afforded the same rights as a doctor who has been trained to the Australian standard?? Stop covering up for sub-standard educational foundations and training, by labelling the proponents of uniform standards as racist.

  27. Bi says:

    @Neil. I agree! We should get all local medical graduates to do the AMC exam before they are offered full registration!

  28. Anonymous says:

    It is not racisim if the doctors do not feed the standards. however it is discrimination if remedial measures are not applied equally!

  29. Krishnan says:

    I agree with Dr viney joshi that is definite bias against IMG. Doctors who have done well despite that have worked harder than the counterpart. There is undertone of racism which can not be denied. Recent visitors from sub continent have not fared well due to 2 reasons- existing bias and the standard of medical education. Programs such as run in JHH should be availabe to all the IMG.

  30. Neil Ozanne says:

    ?? Is it racist to require all doctors to meet the same standards ??

  31. Sim says:

    Neil Ozzane and Greg the Physician, are good examples of 75%of Australians who never appreciate the contributions IMGs have made to the general healthcare of Australian public. IMGs are deeply involved in training Australian medical students for years everywhere including the bush hospitals and surgeries and also involved in treating and caring for Australians in areas where the privileged Australian doctor never thinks of working as first priority. These so called areas of need are filled in by IMGs, some of whom are overqualified and specialised but not recognised. The dichotomy is the media and political lobby against IMGs where racism plays a major factor. This negative lobby corrodes the doctor-patient relationship and forms negative attitudes. Remember doctors have global knowledge and skill to work anywhere in the world. No country can have enough doctors for their entire population. IMGs are not refugees to be spat on. They arrive by air sponsored by Australia government and other parties. Australia is taking advantage of expensive IMG for free. Please give the expatriate IMGs their due respect.

  32. Greg the Physician says:

    I completely agree with Neil Ozanne. We should be training our own medical workforce in Australia, not importing half of it from overseas, especially from countries where medical practitioners are desperately needed and in very short supply. We already have a situation where there is pressure to expand intern positions for overseas medical students and now we have local medical graduates in Victoria who may miss out on post-intern training positions in favour of IMGs. This situation has arisen because medical schools need full-fee paying students to remain financially viable. How about we review funding arrangements for medical schools and stop rejecting thousands of excellent Australian applicants every year? Then we wouldn’t have to worry about problems with IMGs – we wouldn’t need them. And this is NOT a racist approach, only one in which Australian taxpayers’ money is used to preferentially fund the undergraduate and postgraduate training of Australians; there’s nothing unethical about that!

  33. Neil Ozanne says:

    According to Reference 2: “Providing medical care is a complex process requiring medical knowledge, good communication skills and the ability to work in a collaborative way with other health professionals.”

    This is true BUT it ALSO requires a good foundation in general logic & science, an understanding of WHY not just what, what is important & why, what do things mean, etc.

    IMGs are good at passing tests but my experience is that they don’t check VA or evert the eyelid if a patient complains of FB in eye; don’t know how to test near vision (Dr told me he tells the patient to go closer to the Snellen chart!), doesn’t even know how big 30cm is!

    Why worry about the colour of the roof, when the foundations are not laid? If Australia really needs IMGs then have them do the same entrance tests our students have to do – UMAT or GAMSAT. And only accept those who pass, just like Australian students. Why does the AMC accept lower standard from IMG than from an Australian?

    Surely we should be putting our resources into post-grad training of Australian students, rather than trying to retrain IMGs.

  34. Anonymous says:

    IMGs like any other locally-trained doctor have to have a proper orientation to the system before they start work. Supervisors often don’t understand this necessity and that can lead to a below par assessment report. This can create undue stress, depression and a feeling of inadequacy which can be very detrimental to the IMG’s self-confidence.

  35. shamu says:

    Finally some one has raised the issue and planning to address the issue in a sensible way.Thank god!!

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