more_vert
INTERNATIONAL medical graduates continue to be burdened by “unfair hindrances” say experts who have called on the federal government and medical authorities to implement the recommendations of a 2-year-old inquiry into registration and assessment processes.
In a Perspectives article in this week’s MJA, Professor Carlos Zubaran, conjoint professor of psychiatry at the University of Western Sydney, and Dr Susan Douglas, chair of the Australian IMG Support, Advice and Advocacy Network, wrote that the failure to implement meaningful reforms in line with the 45 recommendations contained in the inquiry meant that a two-tier system for international medical graduates (IMGs) and Australian-trained doctors persisted. (1)
The Lost in the labyrinth report was tabled in the House of Representatives in March 2012 by the Standing Committee on Health and Ageing. (2)
The MJA authors wrote that “unfair hindrances faced by IMGs are irreconcilable with principles of equity and mateship that are at the core of Australian society”.
They highlighted several areas where inequities remained, such as restrictions associated with 457 visas, including a lack of access to Medicare benefits; and the so-called 10-year moratorium, requiring IMGs to work in underserviced areas for up to 10 years. “This restriction is unparalleled in the developed world”, the authors wrote.
Australian Medical Council (AMC) CEO Ian Frank told MJA InSight the council had been “busy” streamlining processes to address many of the registration issues highlighted in the Lost in the labyrinth report.
“Most of the major recommendations that involve AMC have either been implemented or are well on the way to being implemented, but there is still work to be done in fine-tuning some of those processes”, Mr Frank said.
The development of a purpose-built National Test Centre in Melbourne, which opened in July 2013, has enabled the AMC to increase its examination capacity to assess around 2500 IMGs a year, and reduce the waiting time for candidates from 24 months to 12 months.
“This was a major breakthrough,” Mr Frank said.
Since July this year, overseas-trained specialist candidates have been able to apply directly to specialist colleges for registration once they had received their primary source verification from the AMC, which was also being streamlined.
In further responses to the Lost in the labyrinth report, Mr Frank said the AMC was working on improving feedback to candidates and redesigning websites to ensure information was readily accessible to IMGs.
The MJA authors also drew attention to the limited availability of workplace-based assessment (WBA) for IMGs. “It has been shown that WBA is a cost-effective form of assessment that facilitates a straightforward integration of doctors into the local health care system”, they wrote. (3)
Professor Kichu Nair, director of Centre for Medical Professional Development, Hunter New England Local Health District, said the 6-month WBA program was also proving to be effective in retaining IMGs in areas of need.
“What we have found is that when they do the [WBA] program, the candidates get exposure to other doctors and other specialists. They get to know each other and become part of the local medical community — then they tend to stay there too”, said Professor Nair, who developed the program in conjunction with the University of Newcastle and the Local Health District.
He said the program was slowly being expanded to other centres around Australia.
Mr Frank told MJA InSight that while it had recently launched WBA Online to help standardise the delivery of WBA, it was a labour-intensive form of assessment.
“It’s going to take a little while for WBA to get going, but we’re still confident it’s a very powerful way of assessing IMGs and integrating them into the workforce.”
Late last week Assistant Minister for Health Fiona Nash announced a revision of the District of Workforce Shortage system, which would have “a beneficial impact” on IMGs who were required to practise in these areas to access Medicare billing arrangements.
The Minister’s office released a statement saying the revised system would be updated to use the latest Australian Bureau of Statistics population data and geographic boundaries, which would be reviewed annually.
“This is likely to provide more certainty around opportunities for IMGs to gain employment in private practice, and addresses some of the issues raised in the Lost in the labyrinth report”, the statement said.
1. MJA 2014; 201: 509-510
2. House of Representatives Committees: Lost in the labyrinth 2012
3. MJA 2014; 200: 41-44
(Photo: Stuart Jenner / Shutterstock)
Many of IMGs who come to Australia came after being married to Australian citizens, or as refugees fled civil wars in their countries ,or immigrants seeking better lives for themselves and their children in a developed country with a multicultural community .
I wish if I could find answers to these questions:
-How the AMC would know that IMG training or qualifications do not the Australian criteria , when Australian medical graduate they do not go through the assessment process of knowledge and clinical skills ? in United States all international and local medical graduate go through the same exams!
-If someone passed the clinical AMC exam why he has to go through something called PESCI (Pre-Employment Structured Clinical Interview ) when it is actually not an interview ,it is a mini clinical exam where the candidate will be assessed in only 4 cases from whole general medicine?
-Why an IMG who got an offer to work under supervision “level one” where the supervisor takes direct and principal responsibility for each individual patient 100% needs to go through PESCI?
– How can the AMC be sure that the candidate in the clinical exam is not being discriminated for any reason in the assessment by the examiner who physically exists in room with the candidate while taking history..etc from the role player . Also this makes it more stressful to the candidate.
-I worked as postgraduate clinical fellow “senior registrar” in pain management for 3 years at main tertiary hospitals in Sydney, and I finished a master degree in Medicine in pain management from the university of Sydney and when I wanted to set the exam of the faculty of pain medicine ,the faculty told me that even if I pass the exam for pain management,I will not be able to work as a specialist in pain management without getting a general registration from AHPRA by going through AMC exams ,pesci and one year of supervised experience as a GP !!?
-Why not offering IMGs who finish the AMC part one a supervised assessment for 6 to 12 months at different places to save their money, their time and fill shortage! Through this assessment the supervisors can assess them in a more realistic situation instead of the unrealistic subjective clinical exam.
-Or follow the American assessment criteria in terms of exams ! In USMLE part 2 and 3 which is video recorded ,the role player will be inside the room ,then the candidate come inside take history, examine the patient, document on a specific sheet : the findings , DX of at least 3 diseases , request investigations and explain to the patient what s/he thinks. Then the candidate will leave the sheet which has only his USMLE number -no name or photo on it -in the room. The role player will fill another sheet . The examiner then will mark the sheets without knowing who is the candidate or whether IMG or local MG! which is more fair.
As an unemployed junior doctor I empathise with IMGs and certainly believe that all efforts should be made to reduce inefficiencies in the accreditation system. But in some respects David De Leacy has hit the nail on the head. There is an absolute oversupply of junior doctors relative to training positions, with very few senior staff aware or sympathetic of the perils facing modern day trainees. I for one have spent close to $100,000 on further education developing a CV competitive for SET training. Yet since returning from a year spent obtaining a first class honours Master’s degree from one of the best universitiies in the world, I have been unable to find permanent work in any surgical capacity, including going back to training years that I have previously completed. So how about we fix our own house before making life even harder for home grown graduates?
WBA does lead to a manipulated fail (as happened to me with the RACP in 2004 in Ballarat). Mobbed bullying is toxic and can be related to commercial reasons, to the ambition of a college fellow to displace a threat etc. I have no experience of the AMC exam but as it is run by a private company by members of other private companies – i.e. specialist colleges. Till there is reform to extinguish this toxic culture – as they say “Business as usual”
WBA is only provided is a few hospitals around the country with almost 100% pass rate with only 6 months assessments while AMC exams are done in a day with current status of having a success rate of about 15-20% and a higher fail rate of about 48-68% with a retest rate of 18-30%.
AMC clinical exam is done in one half of the day with improvised patient and case scenarios which are out of this world. For example, an obese patient on the scenario but inside the exam room a lean patient who looked well and fit-talking about lifestyle changes to someone like this is unreal as compared to a real patient seen in the rooms or ED as in the case of WBA.
I have worked with AMC graduates who are working in the health care system and even though they have passed their AMC clinicals are way off the grid in terms of applying their medical acumen to solving simple medical issues, what has AMC given them? A green light to practise with limited knowledge of current practise acumen and guidelines-its a fuss!
I suggest hospitals with IMGs should start WBA as soon as an IMG is employed and so can continue to be able to be employed in their hospital.
Over to the bureaucrats!
Lift the pass numbers for AMC
Sorry for the broken link – no 100% fidelity in the cut and paste exercise:
http://www.parliament.nsw.gov.au/Prod/Parlment/committee.nsf/V3ListSubmi…
No. 8
No. 52 was my submission.
Between 2003 and now, I have been traversing the long path to freedom, with obstacles all the way – even after securing a permanent visa, general and specialist registration – during the journey, falsely damaged by the rACP and NSW Health. http://www.parliament.nsw.gov.au/Prod/Parlment/committee.nsf /0/1C7D39E1C473847ACA257CEF0009B3E2
This is only part of my story as I continue in the struggle with Australian victims (not OTDs) to seek justice. The sickness is not affecting OTDs alone – it is just that OTDs (as defined in the 1996 amendments to the Health Insurance Act 1973 (Cth) – are easier and softer targets. So, the bullies choose the vulnerable.
What continues to amaze me is that I keep finding new information about the convoluted system every few weeks – e.g.
1.All Australian specialist colleges are registered companies, accountable only to ASIC.
2. There is no continuation of the head of power between the Australian Constitution and the Colleges – thus making them possibly unlawful in their activity of ‘assessing’ candidates
3. AHPRA (which delegates some functions to the AMC Ltd) is regulated by State laws and ‘National Law’ is a misnomer.
4. Every single State Department of Health in Australia is registered as a Corporation in some form or another
Another (Federal Senate) Inquiry on matters in QLD has recently been announced. http://senatorlazarus.com/
The truth must get out into the public domain. Health professionals intending to come to Oz must not be lured and deceived.
Only a Royal Commission may reveal the truth: http://tiny.cc/7hhrlx
Nothing wrong with robust discussion with points worth pondering. Healthcare professionals leaving their countries could be viewed in light of other skilled people e.g. engineers, teachers, accountants and business people with capital to name a few, who choose to migrate, work hard, contribute to their community and feel welcomed in their adopted country. Why should IMG medicos be treated any different ?? Years ago after gaining general registration in a country deemed a ‘competent authority’, we came to Australia and I called the medical board at the time to gain an understanding of registration process. The gentleman wasted no time to enquire where my primary qualification was from, to which he replied .. “you will always be an immigrant”. I wonder how far I would get if I treated patients that way in the AMC exam ?? My wife and I qualified from the same university, her skills as RN receive praise and recognition while I set about improving my knowledge and skills, rather than just a qualification. Hence I can understand a sense of unease when phrases such as ‘fair go and mateship’ are used loosely. We should be honest about the reality of supply and demand on a playing field where your postcode says a lot about your health and acces to resources. Having said all that, don’t waste your time being dragged down by negativity, hence my conscious decision to focus on the task at hand and grasp every opportunity. In our service we don’t separate patients into seeing locally trained vs IMG service providers, hence I remain committed to my team striving to deliver the best quality care possible given increasing challenges we face serving our community.
Of course we need a national standard and measures to ensure patient safety and the quality of medicine. But why not apply that standard to all doctors as they do in the US? The treatment and placement of IMGs in the areas of most difficult medicine and least support is anything but and that wrongful practice has been clearly demonstrated in the 2012 ‘Lost in the Labyrinth’ paper and by many posts here.
Why not let all doctors sit the AMC under the same conditions, at the same time, at the same cost and see who is safe and who communicates clearly and who is compassionate and retrain the ones who do not meet those guidelines – no matter where they were born or where they studied? Australian Uni exams do not follow a national standard, it has been described many times by leading Deans that they don’t and the exit exams are nowhere near as difficult as the AMC exams – I have witnessed both first hand and am sure many dual examiners would agree.
As to the costs for the Australian taxpayer and medical community mentioned by David in the first post it might be worth while remembering which doctor cost the Australian taxpayer more in the first place and how much the community is getting back for their respective investments. Maybe a rural tax payer would be more happy to support an Australian medical graduate through med school when there is a requirement for all doctors to serve their rural community, not just for foreign-trained ones who come at a considerably lower cost to the taxpayer.
Always a topic that evokes strong opinions, and one that I follow with interest. As an Australian trained (QLD) doctor who has worked in many countries since I graduated (14 years), I would offer the following opinions for thought.
1. There is definitely a variation in standards of graduates from some other countries. I have IMG colleagues who agree that there is great disparity in the quality of graduates from different med schools in their own countries. Hence, there needs to be structured assessment of knowledge/skills in IMGs.
2. The current system is cumbersome, expensive and time consuming. Additionally, the AMC exams would seem quite difficult technically. Are AMC expectations really on par with what we expect of our own graduates?
3. There is a disconnect between the specialty colleges and the AMC in terms of their expectations of IMGs. After achieving full registration, Colleges then place significant requirements in front of the IMG doctor before they recognise foreignspecialty qualifications. Alternatively, they require a completion of domestic training programs in full.
4. The system seems inflexible. I know of an experienced surgeon (IMG consultant) who was required to do a paediatric term as an RMO to appease the AMC. Is this a realistic assessment of his skills/knowledge?
5. Medicare, AMC, Colleges, State Health – lots of organisations with their own system for managing IMGs. This adds to bureaucracy.
Whilst I don’t profess to have the answers, I can’t help think we could be doing better with this issue as a whole.
I support David De Leacy’s comments. Let me state first that I have successfully siupervised and mentored several IMGs from different racial and etnic backgrounds doing advanced physician training and have been very impressed by their medical standards. I have also referred both my elderly parents to IMGs for specialist care. So I do not have any inherent bias. However the medical authorities in this country have both the right and responsibility to ensure that IMGs can practice safely and effectively in Australia. This means assessing both their medical competency and their communication skills. We seem to be moving towards a complex and expensive process of individual assessment and mentoring of IMGs. The elephant in the room is the large number of Australians who cannot gain entry into medical school (and yet would make excellent medical practitioners) because most of our universities are chasing full-fee paying students from overseas and won’t offer these places to Australians. The other point is the moral issue of taking IMGs from their home countries where the lack of medical graduates may be a bigger problem than in Australia, where there are now shortages of postgraduate training positions in most specialties. It is a complex issue but I believe that David’s comments are much more objective than those of the other correspondents and the editorial writer.
You cant get a job without registration, you cant get registration without a job.
You cant get on to training program because you havent completed AMC process or permanent residency not because you lack the competence.
Your colleagues from UK are deemed competent and therefore by inference you are deemed…
Oh, so you ve done all your schooling in english, and that was the London GCE Curriculum, and you scored an A at O levels too. No, you must wait 4 months to do your IELTS because you studied in India so you cant speak english.
You are judged by your accent not your content.
You are a trained and experienced pathologist/surgeon… lets test you on OnG
Mr David de Leacy, you are well intentioned but ultimately misguided.
Mr Frank at AMC needs to get real.
AMAQueensland has discussed, in good faith, the plight of IMGs over and over.
Whilst we are keen to be of assistance, one of our problems has been to identify those doctors (Members and Non-Members) who consider themselves to be IMGs. There are different types of IMGs. I am one myself but, coming from Scotland, maybe less so. As a Specialist doing Outreach Clinics, I work closely with IMGs all the time and empathise with them.
Should any IMG feel that there may be a role for the AMA to play, and not only in Queensland, please feel free to contact me directly.
Dr William Boyd M.B.Ch.B., F.R.C.O.G., F.R.A.N.Z.C.O.G.
Chairman Branch Council
AMA Queensland
boydgyn@bigpond.com
David De Leacy, I think you are barking up the wrong tree.
The reference to “mateship and equity” surely refers to fair and timely process, instead of the present total chaos, blatant bureaucratic abuse, insane inefficiency, and not just duplication but multiplication of effort (albeit vastly improved compared to 15-20 years ago). Patient safety has nothing do do with it. It does not help patient safety one bit if you rip off IMGs financially and treat them like subhumans.
When I came to Australia 16 years ago, I came from an arguably better health system (Norway) with a demonstrably better health outcome (and a better income for doctors too). I came for the adventure, and the sunshine. And yet, I was pushed around by the authorities in ways that would make Kafka blush and only due to a series of coincidences and intervention of friends “higher up” I eventually managed to navigate the byzantine labyrith of Australian medical bureaucracy towards full general registration. I knew several very competent and capable IMGs, mainly South Africans with plenty of clinical experience, who were not that lucky those days.
All I would have asked for is access to the same exams as Aussies do, preferably at the same time and at the same cost without discrimination.
How does sending IMGs out into the sticks with minimal support to do the jobs Australians won’t do constitute looking out for “safety and quality”?
And how does acceptance of a system equate to the acceptability of the system?
Underemployment for Australia trained doctors is a real problem, yes, but let’s not conflate that with the IMG issue, especially given the very different circumstances in which the 2 issues arise.
It seems that the doctors who are not supportive of the IMGs have very little argument on their side. I have no reason to be for or against them. Things are stacked against them at the moment and whether or not the local graduates are rurally bonded or not guaranteed a training place in the GP program is a moot point. The fact is things are definitely worse for IMGs. Why can’t we make it fair for them? They’re not horrible people. They have worked hard just like us!
Also David there was nothing emotive in the article. It was very objective. The only emotional voice has been yours. You have no substance to your argument. Perhaps you should argue on an issue on which you are informed.
As an IMG working in Australia for over 10 years I have come to appreciate how difficult this sitation really is at multiple levels. Speaking of fairness when we have our own interests at the forefront seldom leads to a solution. With a patient focus you do have to wonder ‘why’ IMGs are often deemed fit to practise where it would appear patients don’t have a choice …
Australian medical graduates also have restrictions regarding bonded rural and other bonded placements – should these also be abandoned because they are contrary to “mateship”? And as far as I am aware entry into the GP training programmes is also not assured for Australian medical graduates. Should Australians receive prioity in entry to their own training programmes, or is that also contrary to some notion of fairness?
With regards to the comments from David de Leacy, apologies I don”t know your background, but it would be wise to know the facts before mouthing off. Nobody is talking about singing Cumbaya and no IMGs have been asking for handouts. I would advise him to read the report “Lost in the labyrinth”. IMGs even today are subject to bullying, harassment, discrimination and unfair behaviour. Would you like some examples? Lets stop this crap of feeling warm and fuzzy, believing nothing is wrong and the IMGs are a bunch of morons who expect handouts. There are plenty of IMGs who have been sent to places they are least equipped for even today, and then get blamed when they fail. These folk are being setup for failure. Nobody has asked for dilution of the standards but FOR THESE DARNED STANDARDS TO BE APPLIED FAIRLY. The way things are conducted are arbitrary and adhoc.
The less said about the colleges the better. Things have improved slightly, case in point, a person doing a PESCI in Victoria gets a different rating than a PESCI done in Queensland, Can you justify that to me? Lets stop burrying our head in the sand and wake up to reality. IMGs are not a bunch of evil demons with two horns. To talk about standards there are as many serious medical mishaps that have occurred at the hands of our Australian-trained colleagues. Lets stop this crazy,’discriminatory bigotry and develop tolerance and treat these people with the respect they deserve rather than generalising crap. If David wants to get in touch with me I would give him umpteen examples of what goes on.
Dr Viney K Joshi, President ADTOA
IMGs like me, take few years to get into the Australian Health care system; after AMC exams and english test. But the struggle doesnot stop there.
In my case, I was working in Melbourne as a GP and I was not eligible to apply for GP training program as I didnot have permanent residency status. If I took the permanent residency, I will have to leave my practice as 10 years moratorium rule would apply to me. So, for me , it was a choice between do I leave my regular practice and join the training program or do I continue with my practice and have no permanent residency (hence all the benifits like medicare as well as the chance to get into training). I made a tough choice of leaving my practice and moving rural, but by then I had missed out on applying for the following year for the training program. Sometimes it makes us feel that the talk about fair go is so remote for IMGs.
With all due respect to the activist authors of the above emotive and hyperbolic article, they really do compromise any attempt at rational discussion of its content by prejudging the important issues involved for the readers and assuming a faux moral highground. Disagree at your peril so to speak. I contend that what is far more important for our country and for our own home-grown medical graduates (who face underemployment) is a system that puts “safety and quality” way ahead of any nonsense “mateship and equity” argument. After all this process is all about patient welfare not about joining hands and singing Cumbaiya. All of our authorities need to act in a measured and very considered way resist this overly emotive clamour for immediate change.
Lets be quite clear, every IMG who comes to our country is fully aware of the procesess involved, the limitatons of practice initially required and the time course needed to obtain full registration here before they arrive. The Colleges and the Government and regulatory authorities have all moved remarkably rapidly thus far to streamline the process for IMGs and the ”costs” to both our medical community and our taxpayers are not inconsiderable.