Making the Grade

Australian Doctor

 27 February 2004

The MedicarePlus plan will bring more overseas-trained doctors to Australia to help address the workforce shortage. But amid the promises are voices raised in concern. Lynnette Hoffman reports.

Helensburgh Family Practice is only about 50 K out of Sydney-- it’s the sort of spot real estate agents have a field day with—close to beach, not far from national park, easy drive to city. But for Dr Annette Beaufils, who opened her practice nearly 20 years ago, finding doctors to ease her growing workload has become increasingly difficult. Extensive advertising in medical magazines and community newspapers went unanswered until finally in 2002, Dr Beaufils applied for and was granted Area of Need status, which she hoped would simplify the process. But it didn’t work out quite that way.

Calls and CVs came in, but rarely from anyone who met the entry standards required to work in areas of need. Then there were financial considerations. Dr Beaufils was hit with requirements to advertise in national newspapers at a cost of $1500. Later she paid $1500 for one overseas trained doctor she planned to hire to take his medical exams—only to have him fail. The application itself was lengthy and time consuming, and the results frustrating.

In the end Dr Beaufils and Dr Trevor Kemper, who has been at the practice five years, are back where they started—without another doctor to share the workload. Dr Beaufils hasn’t taken more than a week-long holiday in years—in January she was forced to cancel a planned two-week ski trip to Canada and the US because it was just too busy for one doctor to handle.

But when their area of need status ran out last year they decided not to renew.

“I’m so fed up I’m leaving it all behind—I’ve stopped actively looking. I just don’t even want to deal with it anymore,” Dr Beaufils said. Still, she says if a suitable doctor came along she’d hire them in a heartbeat.

With the national doctor shortage showing no signs of slowing and complaints from doctors like Annette Beaufils on the rise, the federal government announced plans to bring 725 OTDs to Australia by 2007 as part of its MedicarePlus package (see below). But the new package comes amid growing concerns about the current system for assessing and registering OTDs.

While areas of need must be approved federally, there are no national standards to assess OTDs applying for conditional registration to work in them—something the General Practice Representative Group, an advisory council to the government that includes the ADGP, AMA, RACGP and RDAA—has been calling for. In a submission to the Senate Inquiry, the RACGP has openly voiced its concerns that current entry standards are often not at an acceptable level. It called on the government to “ensure that all doctors working as general practitioners in Australia meet appropriate Australian standards before they are able to practice medicine in Australia.“

"What we want are consistent national standards so that the public can feel confident about those who are providing medical care anywhere in Australia," College president Professor Michael Kidd recently told Australian Doctor.

Instead it’s up to each state board to make that determination on a case by case basis. In most states and territories applicants are interviewed by a panel of doctors or a delegate with experience in rural and remote areas who know the sorts of situations the doctors will face. Interviews are flexible and there’s generally not a standard format. The one safeguard required across the board is that all unrecognized doctors be supervised—though again, the standards for supervision vary from state to state. And some critics question just how much supervision OTDs are actually getting in understaffed rural areas.

Two years ago Egypt-trained Dr Ayman Shenouda passed the MCQ and made the shift to a fully registered GP. It wasn’t his first attempt at the test, or even his second—like many overseas trained doctors, Dr Shenouda spent years working long hours as a conditionally registered doctor in a hospital with no additional support or assistance to prepare for the exam, and little free time left over to study.

His struggle is not unique: A telephone survey of 77 overseas trained doctors initiated by researchers in Victoria in 2000/1 found 58% of doctors who had passed only the MCQ and 42% of those who hadn’t passed either AMC exam were employed as doctors—almost all in public hospital settings. Many had repeatedly failed.

One of the researchers, Associate Professor Lesleyanne Hawthorne, assistant dean of the faculty of medicine, dentistry and health sciences at the University of Melbourne, published research last December that showed the trend was continuing. Professor Hawthorne’s report on OTDs employed in general practice in rural Victoria found 69% of those surveyed had achieved only conditional registration in Australia. Between January 2000 and June 2003 5,304 temporary entrant OTDs were approved to come to Australia to fill ‘area of need’ positions—without having to pass the AMC exams or the Occupational English test—though not all of them actually came.

“There are different norms, different medicare systems and different pharmaceutical systems in Australia— and that requires different training,” Hawthorne says. Her views have been echoed by countless others, OTDs included, but so far there has been little in the way of accessible, across the board training available, and what’s offered differs substantially from state to state and region to region.

Interestingly there is no evidence to suggest OTDs have higher rates of litigation or complaints than Australian-trained doctors, and medical boards in most states say they’ve received few complaints regarding competency. Of almost 400 OTDs approved in NSW, only about 10 approvals have been withdrawn, says Mr Andrew Dix, NSW Medical Board registrar. In Queensland, where the highest numbers of OTDs are concentrated, there has been no disproportionate number of complaints, says Mr Jim O’Dempsey, executive officer of the Queensland Medical Board.

Much more widespread, however, are complaints over communication and cultural sensitivity, says Dr Graham Slaney, vice president industrial of the Rural Doctors Association of Australia. Doctors have been reluctant to openly discuss the sorts of complaints and problems they encountered, though several sited language difficulties and incidents where doctors began procedures without first gaining consent from their patients. One GP said one of his patients, a 12-year-old boy, was shocked when an OTD who had recently begun at the surgery lunged in and pulled something out of his eye without warning. Other patients complained of skin lesions being removed when they didn’t think it was necessary, often more than 20. Two out of three OTDs at one surgery kept medical notes that were far below par—leaving out things like details of immunizations.

Some hospitals and local general practice divisions have begun taking steps on their own to provide more help for OTDs to adjust to both the Australian way of life and its health system.

Take Mersey Hospital in Devonport Tasmania, where 100 percent of the junior doctors are overseas trained. Most of these doctors will stay two to three years before moving on, often into general practice in the community, says Dr Ian Hoyle, Director of Emergency Services (formerly the Director of Medical Services, he continues to assist with recruitment). Until now, there has been no formal training available to these doctors whatsoever.

“They come to Tassie and they are like fish out of water; there is no social support and they’re not given any educational support.

“The only training they receive is what we give them at the hospital and what we put on in our own time,” Dr Hoyle says.

That’s set to change, as the Postgraduate Institute of Tasmania launches a program targeting a group of 75 OTDs working in Tasmanian hospitals. Professional educators will deliver lectures and seminars that ease OTDs into Australian medical culture, teach them the ins and outs of the health care and social security systems, assist in exam preparation and offer trial exams.

Project officer Dr Bryan Walpole says the program will also have a mentoring component with the AMA.

All up, Dr Walpole expects OTDs will have to pay about 30% of the cost, or about $250 a year, and won’t have to travel more than two hours to participate in the trial exams.

Workforce agencies, postgraduate medical councils and other organisations in other states are developing similar programs. But many doctors are pushing for more.

“It’s starting to happen, but it’s ad hoc. There’s not a structured program that’s integrated throughout Australia, and there’s not appropriate funding,” Dr Slaney says.

The amount of clinical training is also limited. Only a small minority of OTDs are eligible for the free training offered by General Practice Education and Training. To be eligible, doctors must be either citizens or permanent residents of Australia or New Zealand and have passed the AMC exams or be well on their way to doing so. Conditionally registered temporary residents are not eligible.

OTDs who can afford the time and the money can take private courses or sign up for a bridging course or exam preparation program offered through the RACGP by General Practice Education Australia. Last year’s prices were $3500 to prepare for the AMC’s multiple choice exam, plus $1500 to sit the exam, plus airfare and accommodation for OTDs to fly to metropolitan areas for the exam. The cost of a course to prepare for the clinical exam was $5250. Six-month courses for doctors preparing for the RACGP fellowship assessment are also available at a cost of $2750 for a workshop series and $9790 for an intensive course.

“The government is just not resourcing to an adequate level to assist doctors in the transitional period, nor are they helping to prepare them to pass the examinations which they want to pass,” Professor Hawthorne says.

Entry standards for overseas-trained doctors

OTDs on permanent work visas:

— Must pass the English Language test;

— Must complete the Australian Medical Council multiple-choice and clinical examinations. Some doctors can apply to work in areas of need without passing the AMC requirements;

— Conditional registration is granted by the relevant medical board after passing the AMC exams;

— Must be under supervision (requirements vary state to state);

— Must apply for a place in the Australian General Practice Training Program.

OTDs on temporary work visas for areas of need (visa applies for two years for those who have not passed the AMC exams):

— Must meet requirements determined by medical board in state where applying. The requirements do not necessarily have to meet RACGP standards;

— Not required to meet QA&CPD standards.

Different world

ALTHOUGH he attended a Western-style private school and Cairo University, Dr Ayman Shenouda admits he was surprised at just how different the medical culture was in Australia compared with his native Egypt.

"I had some awareness, but to be honest I wasn't quite expecting it -- working in a hospital helped in that matter without causing any problems, but it can be a shock for some doctors in the beginning," Dr Shenouda says.

In Egypt doctors don't explain things to their patients; they make the decisions, no questions asked. It's a hierarchical system with little communication between the doctor and patient, he says.

"I have changed my attitude since being here. In Egypt there is a whole different system. It's not bad medicine, but there's not enough money to support it and there is a great deal of corruption."

Dr Shenouda didn't receive any formal training or introduction to the Australian system until last year, when the Riverina Division of General Practice ran a tutorial to help OTDs preparing to take the RACGP fellowship exam (which he passed). Thirteen O TDs attended the weekly two-hour sessions, which included discussions with registered doctors on different case studies. By then Dr Shenouda had lived in Australia for 12 years. Even so, he says the tutorial was a great support on several fronts.

"It brings up language and social issues and gives you a chance to discuss what's acceptable or not acceptable in specific situations," Dr Shenouda says. "It's in a group setting, so it's a brilliant opportunity to learn from the experiences of other people, and that's really the best way to learn."

Medicare Plus

THE Federal Government will spend $432.5 million to "recruit and support" the equivalent of 725 full-time overseas-trained doctors by 2007. Final details of the plan are yet to be finalised, but so far the Federal Health Department says it will:

— Provide a national, overarching process to enhance recruitment by state and private organisations;

— Begin direct marketing in developed countries such as the UK, Ireland, US and Canada;

— Develop a web site where employers will be able to promote localities and specific medical vacancies;

— Reduce red tape in approval processes;

— Assist employers and OTDs in arranging placements;

— Develop support services to provide information and referral to other agencies;

— Create information packages regarding immigration, registration, employment, specialist and GP recognition processes, training issues, and access to Medicare rebates;

— Increase training support for selected OTDs to complete both the multiple choice and clinical components of the Australian Medical Council exams;

— Provide support for permanent resident doctors who are finding it difficult to access training;

— Develop a nationally consistent orientation training program, including language and communication skills, cultural awareness and professional standards;

— Provide opportunities for more OTDs to undertake training to obtain conditional or full medical registration;

— Expand opportunities for doctors to stay longer or obtain permanent residency through changes to immigration arrangements.