Thousands of overseas trained doctors (OTDs) are being recruited each year to practice medicine in Australia who have not had to pass a formal test of their medical knowledge or clinical skills. These include OTDs recruited on temporary entry visas to 'area of need' positions in general practice or as hospital registrars (some of whom perform specialist services), those recruited as Occupational Trainees, and OTDs who hold permanent residence visas who have been appointed to temporary positions in the public hospital system. There have been various statements from Australia's health authorities to the effect that a national assessment system will be put in place by the end of2006. This article examines action towards this end and concludes that these promises will not be met.
This is a subject that the writers have explored on numerous occasions. (1) Why revisit the issue? The answer is that in the aftermath of the 'Dr Death' catastrophe at the Bundaberg base hospital, (2) it is all the more important that Australian patients can be confident that the medical knowledge, clinical skills and English language ability of the overseas trained doctors (OTDs) they encounter have been assessed carefully by Australian medical authorities. There have been numerous statements on the part of medical authorities that such tests should, and indeed, are about to be put in place. But have they been?
Our interest in this matter comes from various perspectives. Birrell and Hawthorne drew attention to the inadequacies of OTD assessment well before the early 2005 revelations concerning Dr Patel. They noted the incongruous situation that doctors trained in Australian universities must complete a rigorous set of curriculum and practice standards, including a full year as an intern at a training hospital, yet a growing number of temporary resident OTDs had been permitted to practice in Australia without any test of their medical knowledge or clinical skills. This is despite the fact that in recent years a high proportion of the OTDs have trained in non-Western medical schools where their education and experience is likely to be quite different from that of Australian trained doctors.
This situation came about because of a serious shortage, and maldistribution, of doctors in Australia, which OTDs are now playing a major role in alleviating. For at least the next decade there will be a continuing and perhaps increasing need to attract OTDs to Australia. The problem for the medical authorities in Australia is how to balance the urgency of the further supply of OTDs against the maintenance of the skill standards expected in Australia.
The central issue is the enormous variability of training standards in the non-Western medical training institutions from which OTDs appointed to practice in Australia are being drawn. By March 2005 1,981 medical schools were listed by the International Medical Directory as operating in 170 nations. There is very little information available on the calibre of student selection and curricula, the length of training, or the level of clinical infrastructure in many of the Asian and African sites. (3)
It is true that the OTDs coming to Australia have only been registered by the State Medical Boards on a provisional basis and can only work in specified positions detailed by their sponsor (usually the Australian medical employer). Nonetheless these OTDs are permitted to practice and, from the point of view of Australian patients, are no different from their Australian-trained medical counterparts. Yet there are prima facie concerns about the quality of the care OTDs provide if there has been no assessment of their capacity, and if they come from a country where little is known about the standards or focus of the medical training they have received.
Schwartz has campaigned over many years on behalf of OTDs who hold permanent residence in Australia but who have not been accredited to practice in Australia because they have not completed the requirements of the Australian Medical Council (AMC). Since its establishment in 1984 the AMC has been responsible for accrediting medical training in Australia and New Zealand. The AMC also administers a test for medical knowledge and clinical skills for permanent residents with overseas medical training who wish to practice in Australia. For full registration a permanent resident OTD must satisfactorily complete these two tests as well as a one-year intern position in an Australian training hospital. Schwartz's concerns have been that permanent residents (who are often citizens of Australia) cannot practice until they have finished the accreditation process just described, yet OTDs entering Australia on a temporary resident basis have been allowed to practice without any equivalent test.
Schwartz believes that permanent resident OTDs offer a readily available potential source of supply of additional doctors that the Australian medical authorities have tended to ignore. This is indicated by the paucity of funds provided to help permanent resident OTDs complete the studies needed to pass the AMC assessment. This is despite evidence showing that, where such bridging courses have been provided, as with the program run by the Post Graduate Medical Council in Victoria, OTDs taking the courses have achieved very high pass rates in subsequent AMC examinations (over 90 per cent). There are thousands of medically qualified OTDs living in Australia as permanent residents and citizens, who wish to practice medicine but have been unable to pass the AMC accreditation examinations, often because of the costs of the required preparation. They provide a potential reserve workforce already resident in Australia and unlikely to leave. Yet Australian medical employers are spending millions recruiting OTDs on a temporary basis, most of whom will leave after a short period of service, thus requiring a further expensive recruitment cycle. The final irony is that such is the shortage of doctors, as detailed below, that hundreds of OTDs who hold permanent residence are actually working in Australian hospitals on provisional appointments without having passed, or in some cases even having begun the AMC accreditation process.
The Australian Government has responded to concerns about the growing dependence on OTDs for medical care in Australia. It has increased the number of fully funded medical places in Australian universities substantially and has permitted an increase in the number of full-fee students who can study medicine to 25 per cent of domestic intakes. However, it will be at least a decade before this increase in local training will have much effect on the shortage of doctors currently evident in Australia. As a result there will be a continuing and increasing reliance on OTDS over the next decade.
COMMITMENTS TO THE ESTABLISHMENT OF AN ASSESSMENT REGIME
There have been numerous recommendations from medical authorities and State Governments that a formal assessment procedure be established for OTDs before they take up temporary medical positions. For example, in 2005 the Australian Rural and Remote Workforce Agencies Group (AR-RWAG) noted that: 'some jurisdictions allow doctors to practice with very limited assessment of their qualifications, experience and capabilities. Worse still, doctors who are unable to practice in one part of the country will be deemed...