The registration and accreditation of international medical graduates in Australia--a broken system or a work in progress?

Author:Douglas, Susan
Position:Report
 
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Australia's policy for registering and accrediting overseas trained doctors (OTDs) is dysfunctional. Some OTDs, who are well qualified and here on permanent visas, are being denied registration and accreditation. This is despite the acute shortage of medical manpower and the fact that OTDs on temporary visas, with similar qualifications, are being actively recruited and put to work. Current reforms may improve the situation but these must address problems of accountability and the potential for conflicts of interest that mar the present system.

'Shallow understanding accompanies poor compassion, great understanding goes with great compassion.'.

Thich Nhat Hanh

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Australia's new national accreditation and registration scheme for health professionals will consist of four major components:

* Ministerial council

* Health workforce advisory council

* National Agency

* Nine separate professional boards representing the major health professions including medicine.

The ministerial council will consist of the commonwealth and state/territory health ministers. The council will have a range of responsibilities including the appointment of members to other key bodies including the health workforce advisory council and the profession-specific boards. The council will also be responsible for approval of registration and accreditation standards proposed by the specific professional boards including those involving overseas trained practitioners. Decisions will ideally be made by consensus. If consensus cannot be achieved the matter will then be referred to the health workforce advisory council whose main role will be to provide independent advice to the ministerial council at its request. The professional boards will assume a range of registration and accreditation functions relevant to the profession including the assessment of qualifications and skills of overseas trained practitioners to determine their suitability for registration in Australia. Finally, the National Agency will be responsible for overseeing the administrative and business aspects of the scheme to ensure efficient operations and will have a presence in each state and territory. (1)

In Australia a doctor must be registered by one of seven state or territory medical boards to be eligible to practice medicine. This registration is not portable across state or territory borders, which hinders the effective deployment of critically needed medical manpower.

On 26 March 2008 the Council of Australian Governments (COAG) signed an intergovernmental agreement for the establishment of the national registration and accreditation system outlined above for the nine major health professions including medicine which would standardise the registration process. (2) Opposition to this scheme has been publicly expressed by the Australian Medical Association (AMA), which argues that the proposed system poses a serious threat to patient care and is largely driven by a desire to engage in workforce reform rather than by concerns about patient safety. (3) The Royal Australian College of General Practitioners (RACGP) has also voiced its concerns. (4) While these organisations acknowledge the need for reforms, particularly more consistent national standards, they argue that the basic organisational framework of the current registration and accreditation system should remain intact. (5)

Missing from the RACGP and the AMA statements was acknowledgement of the predicament of those caught within the web of the Australian registration and accreditation system, particularly international medical graduates (IMGs). My own journey reveals a system that is confusing, complicated, fragmented, and inflexible.

In this paper I review current Australian policy for registering and accrediting overseas trained doctors, outlining its impacts on recruitment of doctors trained overseas. I present my own experience as a case history in the complexities of accrediting and registering a qualification from overseas, in this case a vocationally trained Canadian family physician/general practitioner qualification. Mine is one of many stories of overseas trained doctors who have been unable to navigate the registration and accreditation system satisfactorily, and consequently are temporarily or permanently lost to clinical practice. (6) I discuss how the proposed COAG reforms have the potential to significantly improve this system for IMGs. I conclude by indicating areas that need to be addressed to ensure the COAG scheme is successful.

AUSTRALIA'S CURRENT SYSTEM

What do we mean by the terms accreditation and registration? In general, accreditation refers to the establishment of specific standards for professional education and training in educational institutions and assessment of the degree to which these standards have been met. (7) Registration, on the other hand, largely involves assessment of an individual's fitness to practice, a large component of which involves determining the degree to which the individual has attained the predetermined standards set out in the accreditation process. (8) With regards to IMGs, the processes of accreditation and registration are often blurred. This is because assessment of IMGs' education, training and their fitness to practice in an Australian context is often done concurrently. (9) For the purpose of this paper accreditation will refer to the assessment of an individual's educational and professional qualifications whereas registration will refer to the process by which a doctor is granted entry into the Australian medical system.

Australia's current accreditation and registration system (hereby to be referred to simply as the 'system') is highly complex. In December 2005 the Productivity Commission and the Australian Health Workforce Advisory Committee tabled a research report on the Australian Health workforce to the Council of Australian Governments. The report identified a number of problems with the existing system of accreditation and registration, including fragmentation of responsibilities, difficulties in coordination, rigid regulatory arrangements and entrenched workplace behaviours. (10) While the report was referring to all the major healthcare professions, the system for the registration and accreditation of medical professionals are singled out for being particularly complex. The report concluded that, in order to address the current health workforce shortages in Australia: 'it is critical to increase the efficiency and effectiveness of the available health workforce and improve its distribution'. (11)

IMGs themselves have expressed concern about direct and indirect discrimination against them in the current system. (12) In 1997 permanent resident IMGs staged a 21-day hunger strike in NSW to lobby the government for changes to the existing system. Similar hunger strikes were also held in Melbourne and the ACT. (13) At that time permanent resident overseas trained doctors, who did not meet the criteria for general medical registration, were prohibited from working in areas of unmet medical need positions while overseas trained doctors with similar qualifications were being actively recruited to fill these positions under temporary visas. This meant that an IMG's ability to work was largely determined by their visa status rather than their qualifications. One of the outcomes of the hunger strike was an agreement by the NSW government to commission a research report into the employment of IMGs in that state. This report, The Race to Qualify, issued 32 recommendations and confirmed that the differential treatment of IMGs holding temporary visas from those on permanent visas could be considered unlawful discrimination. (14) It also recommended that standards for assessment of medical workforce qualifications be separated from those used to determine the composition of the medical workforce.

Australia's accreditation bodies for medical professionals

In Australia there are three bodies involved in the accreditation of IMGs: the Australian Medical Council (AMC), state/territory medical boards, and the specialist medical colleges. In general the AMC and/or the specialist medical colleges have responsibility for accreditation, while the medical boards register those with accredited qualifications as fit for practice. However, in regard to area of need (AoN) positions filled by temporary or permanent resident IMGs, state/territory medical boards also take on accreditation responsibilities. (15)

An IMG has one of two avenues to obtain unconditional medical registration; the standard AMC pathway or the pathway provided by the specialist medical colleges. In the standard AMC pathway, the AMC accredits the primary medical qualifications of overseas trained doctors. Doctors who undertake the standard AMC pathway are not accredited as specialists.

In the specialist pathway the AMC assesses the doctor's primary medical qualifications but then refers the case on to the relevant specialist college for assessment. The role of the specialist college is to assess whether that individual has the skills and knowledge to be deemed a specialist. (16)

If the IMG is not successful in getting his or her specialist qualifications accredited by the specialist colleges, the only other route to unconditional registration is through the AMC pathway which involves a two-part exam followed by 12 months of supervised training at an Australian hospital. The two-part AMC exams are a significant hurdle for IMGs. (17) One of the reasons for this is that the exams are designed to assess the level of knowledge expected from a new Australian medical school graduate, including their knowledge of basic medical sciences. (18) Most IMGs, however, are experienced clinicians. Medical education research shows that there is an inverse relationship between clinical expertise and knowledge of basic medical sciences in comparing the performance of medical students with...

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