Risks of complaints and adverse disciplinary findings against international medical graduates in Victoria and Western Australia

To the Editor: Elkin and colleagues acknowledged that “most [international studies] have found no association” between acquiring a medical degree overseas and being the subject of a complaint;1 however, their principal findings — which differ from these other studies — require care in interpretation.

In the study by Elkin et al, the “clinical specialty was missing” for 75% of registered doctors. Yet, certain medical specialties are associated with a higher risk of attracting complaints. In one US study, surgeons attracted significantly more lawsuits than
non-surgeons.2 Therefore, a disproportionate number of complaints involving international medical graduates (IMGs) could have been owing to working in, for instance, surgical specialties.

Further, neither “race” nor ethnicity was examined. In an analysis of 14 314 doctors in the United States, non-white professionals were at significantly greater risk of being disciplined than their white counterparts.3 Similar findings for the United Kingdom have been published.4 The authors of the British study referred to “possible inequalities and unfairness”, including racism, in official procedures involving doctors from ethnic minorities and IMGs. A recent parliamentary inquiry into the registration processes in Australia noted that while “IMGs generally have very strong community support, they do not always receive the same level of support from the institutions and agencies that accredit and register them”.5

Elkin et al analysed data from only two Australian states. The authors of a study conducted in California not only revealed that certain personal characteristics and medical specialties were associated with increased disciplinary action, but also cautioned that those findings could not be extrapolated to the entire country.6

Call for global action to halt the superbug

Abdul Ghafur explains that we need to move beyond national boundaries to tackle antimicrobial resistance

The Chennai Declaration, a roadmap devised by medical specialist groups from across India to tackle antimicrobial resistance, and published in December 2012, states the following:

Microbes are global citizens; their spread across the earth not being restricted by the national boundaries or national flags. If we intend to challenge microbes and tackle the situation, we have to pursue the behaviour and tactics of bugs, by becoming global citizens and thinking beyond national boundaries. High quality infection control set-ups in developed countries may not be fruitful unless countries with high resistance rates and less stringent infection control facilities take serious measures to control resistance.1

High-income countries spend a good share of their health care budget on establishing and improving infection control standards in their hospitals, whereas in the developing world, infection control is often neglected due to a lack of awareness, lack of infrastructure and financial constraints.2 International travel is a well established mode of global dissemination
of multiresistant microorganisms, or “superbugs”. Carbapenem-resistant Enterobacteriaceae that produce the enzyme Klebsiella pneumoniae carbapenemase (KPC) originated in the United States, spread to Mediterranean countries and then to the rest of the world.3 In contrast, the Indian subcontinent gave rise to bacteria carrying the enzyme New Delhi metallo-β-lactamase (NDM-1), which have since been introduced to other countries including the US and the United Kingdom.3

Microorganisms teach us a very basic and important lesson: unite or perish! Unless we initiate a global and united effort to tackle the issue of multiresistance in microorganisms, they will have the final victory. The developed world should assist developing countries by sharing technology and resources to help improve infection control measures and microbiology laboratory facilities. Urgent international diplomatic efforts are needed to convince countries without antibiotic stewardship policies to formulate and implement such policies. Barriers to the implementation of antibiotic control policies (such as overcrowding, poor sanitation, large populations and inadequate health care infrastructure) must not discourage serious initiatives in regions with high antimicrobial resistance rates.1,4

Australian health authorities should be commended for now requiring hospitals to have a formal antimicrobial stewardship program in place to achieve accreditation. But even countries with excellent infection control setups must tighten their policies to keep up with the ever-increasing superbug challenge. We need to improve compliance with hospital antibiotic policies. The job of an infection control physician sometimes requires intruding into the lives of colleagues and providing unsolicited advice on the use of antimicrobials. This demands a diplomatic but persuasive approach, requiring both assertiveness and sensitivity, and a willingness to face criticism. Successful implementation of an antimicrobial policy depends on gaining the support of the hospital administration, and serious efforts are needed to educate and convince our colleagues of the importance of these policies. Basic infection control measures such as hand hygiene and isolation precautions should be strictly adhered to.

In countries without strict antibiotic policies, where incorrect antibiotic prescription is very common, pharmaceutical companies should be willing to modify their marketing strategies to encourage sensible antibiotic use. The use of antibiotics as growth promoters in livestock production is a well known factor contributing to the development of resistance, and is still inadequately tackled in many countries despite major international efforts to reduce such use.

Initiatives such as ReAct — Action on Antibiotic Resistance, World Alliance against Antibiotic Resistance, (WAAR), Antibiotic Action and the Chennai Declaration have made significant contributions to tackling antimicrobial resistance by mobilising political will at international and regional levels. The Chennai Declaration instigated interaction between all involved stakeholders: medical societies within India, Indian government bodies such as
the Drug Controller General’s office, the Medical Council of India, the National Accreditation Board of Hospitals and Healthcare Providers, the World Health Organization, the media and the public.5 We hope this will initiate a dialogue with health authorities that will lead to the formulation of
a national antibiotic policy, mobilising medical societies
and creating extensive media discussion. The WHO can coordinate and strengthen such initiatives, help those countries most affected by the ever-increasing resistance challenge and help governments in developing countries to implement the Chennai Declaration recommendations after incorporating necessary modifications applicable to their own regions.

Risks of complaints and adverse disciplinary findings against international medical graduates in Victoria and Western Australia

To the Editor: The article by Elkin and colleagues1 has certainly reheated the long-simmering debate about bringing highly trained international medical practitioners from other countries to provide health care in Australia. Yet, it does not discuss the clinical and cultural acclimatisation they need. There are many moral and social issues associated with condemning an IMG without helping them to adapt to their locality. The study indicates that an effective orientation process of integration for individual doctors from overseas is needed.

Australia actively recruits doctors from overseas on limited registration to provide adequate services in rural and remote areas. These doctors have limited access to Medicare, to free public education for their family members and to other services that Australian residents enjoy. This is not conducive to good medical practice.

IMGs are required to pass a series of examinations that test their language and technical competency, but this does not guarantee employment. Supervised positions, vital for clinical competency, are scarce for these doctors. Most high-level governance and administrative positions do not include IMGs who could represent other IMGs in deciding policy matters. Furthermore, complaints against IMGs appear to be more likely to attract publicity than similar cases involving local graduates, which affects their reputation.

Lastly, the countries from which IMGs have come, many of them less privileged than Australia, have significantly invested in their training. In proper acknowledgement of this, they should be able to work here as doctors. The path of professional development of IMGs should be monitored by the government to ensure this is possible. The Australian Indian Medical Graduates Association strongly objects to the current trend for IMGs in Australia to remain wastefully unemployed or underemployed for prolonged periods, and considers this trend to be unethical and inequitable.

Neela

The dusty lanes of Suryakollam follow the slow course of the tarry river below. It’s close to noon — a man wearing a lungi stands by the water brushing his teeth. The whitewashed mud-brick houses and thatched roofs glow in the hot sun. Cloth doors hang listlessly in the heat. A vintage Bollywood tune mixed to reggae booms through the air, adding unexpected festivity — unexpected because Suryakollam is the local red-light district. I’d assumed that a red-light district in India would be a sad sort of place.

Neela was waiting for me on her front step, her dog Kennedy was sitting beside her. With his silky white hair and slender fox nose, he was a strangely opulent dog to find in such surroundings — but that was part of Neela’s, and perhaps Suryakollam’s, enigma.

Once we were inside, she began her story.

***

Many years ago, when she was seventeen, Neela left her family and village in search of work. She arrived in Vellore in the dark, penniless. A woman who saw her alone at the bus stop let her sleep on her verandah for the night with the promise of work the next day. The following morning she was taken to a house to work as a maid. Before she knew it, there was a quick exchange of money and the door was decisively bolted behind her. She was now the property of a brothel. From there began the painful story shared by many women forced into sexual slavery. Neela discussed those days with the distance and sterility offered by words, calmly hiding her wounds.

Eventually, she smiled as she told me about her husband. He was a local rickshaw driver and used to be one of her clients. Unlike the others, he was nice to her — he would pay for her time and take her out to the cinema instead — sweet gestures in an awful place. Slowly, they forged a relationship until he was able to pay enough for her release from her bond. Their subsequent marriage was a tenuously woven arrangement. There were better times filled with genuine loyalty and love, and the birth of a precious daughter. But there were also periods of conflict and separation, when Neela was forced to return to the trade she knew best.

He finally left her for good — for another woman who also lived in Suryakollam. Of course, Neela was angry, and refused to have anything more to do with him. Months passed, until one day she heard he was very unwell and went to visit. She walked into a room and saw a gaunt, skeletal man lying in the shadows. The rumour was of AIDS — many others were also affected in Suryakollam.

It didn’t take her long after that to discover her own HIV status. Although she didn’t like the other woman, Neela visited almost every day, and together they cared for him till the day he died.

Neela’s home was a bare, low-ceilinged room; a few metres of space that she maintained with pride. During our interview I couldn’t help but focus on each of her few possessions.

A threadbare sleeping mat, rolled tight, leaning against the wall.

A small mirror with a blue plastic comb, perched on a window ledge.

The ever-silver plate she shares with her daughter during meals. Each time they eat she prays not to give her daughter HIV, even though her doctors tell her it isn’t possible.

It didn’t take me long to notice a large framed photo adorned with fairy lights. Stray beams of sunlight fell across the face of a woman wearing a modest green sari. Neela caught my glance and looked up, joining her palms in respect. That’s her, she told me with a quiet smile.

It seemed there was another part to the story she hadn’t yet narrated. When and how, she didn’t know, but over time her relationship with her husband’s mistress flowered into a lasting friendship. But sadly, she too had eventually succumbed to AIDS, and Neela cared for her till she died. In return, she gave everything she possessed to Neela, including her home — this home — one of the few owned by its tenant, one of the few pucca houses.

***

Neela glowed with health. A simple silver nose stud sparkled against her polished black skin, her arms lean with graceful muscles. She had regular blood tests but didn’t need treatment yet, the doctors said. Life had not been easy, but it seemed she was determined to smile, nonetheless. Money was a perennial problem. She now worked as a scavenger and the wages were abysmal. They led a precarious daily existence grasping at any sliver of opportunity. She went to various HIV network meetings and charitable events in the hope of getting microloans, better employment — anything to sustain them, especially her daughter’s English-medium education — but nothing ever seemed to continue long term. A benevolent doctor used to bring them a sack of rice every few months, but they hadn’t seen him for a year.

As I left, I asked how she felt living in Suryakollam
after what had happened to her there. She told me with confidence that things were changing now. Ever since it was cleaned out by the collector a few years ago, it had been a safe place. But I knew that those who owned the brothel she was enslaved in still lived nearby.

***

I walked through the busy streets filled with life — cattle, rickshaws, burly policemen, a raucous funeral procession. From the dust and mayhem, I emerged into the quiet,
air-conditioned confines of the Centre for Epidemiology. At this moment it was filled mainly with American researchers. Many worked for the CDC and other influential organisations, and travelled between multiple countries. As important words and numbers were being furiously keyed into laptops, I couldn’t help but smile.

Armed with facts, figures and literature reviews, I thought I had some idea of what HIV meant in India. With my Tamil heritage, I also thought I understood this culture, its norms and taboos. Neela had completely disarmed me.

***

This is meant to be an essay that discusses the challenges of working in a resource-poor setting. Instead, I give you pieces of Neela’s story. Listening to her was a humbling and illuminating experience. No degree, however prestigious the institution may be, could have prepared
me for it. No amount of facts or figures or statistical manipulations could ever convey who she was.

Often, in our enthusiasm to fix systems and offer big solutions, we forget the most crucial first step — the story of a community and its people. Most of us do not stay long enough or get close enough to the front line to ever be
able to discover these stories. “Resource-poor” settings
are worlds brimming with opportunity, creativity and resilience. The challenge is in leaving behind our laptops, our qualifications, our preconceptions and, instead, learning to truly listen.

We cannot know the solutions until we first know the people — and understanding their unique stories can take an entire lifetime.

Glossary

CDC: Centers for Disease Control and Prevention

Collector: a high-level Indian government public servant who is transferred between districts. The new collector forcibly closed down and demolished brothels in Suryakollam a few years ago, dispersing many commercial sex workers

English-medium: the more prestigious English-based curriculum schools that are privately run, as opposed to the free, local, state-government-run Tamil schools

Ever-silver: colloquial local term for stainless steel utensils. In many poor Tamil households, multiple members of the family eat meals together from the same plate

Lungi: a traditional sarong-like garment worn mainly by south Indian men

Pucca: a Hindi term now used throughout India for solid and permanent housing

Scavengers: those who collect discarded recyclable material such as plastic bottles, for which a fixed rate is paid based on quantity

Suryakollam: loosely translates to “Golden River” in Tamil

Vellore: a town in the southern Indian state of Tamil Nadu