Terrorist Medical Politics

Dr Haneef has finally been released after his singular charge of "recklessly" providing support to a terrorist organisation (i.e. his cousin) was dropped.

But the controversy continues. Here are a number of issues that continue to perplex me.

Natural Injustice

From this evening's PM (ABC Radio):

CONOR DUFFY: On Saturday Kevin Andrews said Mohammed Haneef had no choice "but to return to India".

KEVIN ANDREWS: Indeed, the effect of the visa cancellation is that he should remove himself; he should depart Australia in any event.

CONOR DUFFY: But by yesterday, the fact Dr Haneef did leave the country so swiftly was being cast by the Minister, almost as a sign of guilt.

KEVIN ANDREWS: But the fact that he, being let out into the community as he has been, the fact that as an appeal in place in which he says he's innocent coming up in just a week's time, that his lawyers may have indicated to my department as soon as possible he wanted to get out of Australia as soon as possible. If anything, that actually heightens rather than lessens my suspicion.

What does Kevin Andrews expect Dr Haneef to do? He has been locked up for 25 days, every day he has said he wants to go home to visit his wife and newborn daughter, you let him out with no visa to stay in Australia - of course he is going to leave the country! Does he seriously expect this poor man to hang around in Australia and spend a few days on holiday, waiting for the AFP and DPP to create some more evidence against him? Whatever happened to natural justice? Oh, I forgot that it does not apply to Immigration Proceedings.

Kevin Andrews on July 18th:

QUESTION: So even if it goes to court, evidence produced – now, you've actually said that AFP gave you information. But if it all goes to court, if he's found innocent, why shouldn't he be allowed to stay?

KEVIN ANDREWS: Well, there are two – can I say to you, you have to separate that there are two entirely separate procedures, and two entirely separate tests. The test of an association on the basis of a reasonable suspicion is an entirely different test to whether or not he is guilty of a charge which must be proven beyond reasonable doubt in a court of law. They're entirely – they are two entirely different processes.

The Secret Evidence

Kevin Andrews is apparently considering releasing the "secret evidence" upon which he based his decision to cancel Dr Haneef's work visa.

Mr Andrews later said he was waiting on written advice from the solicitor-general before he could reveal his reasons for refusing to reinstate the visa.

"The reality is that I've had one hand tied behind my back because this information was provided to me under the legislation by the federal police as protected information," Mr Andrews said.

"There's nothing to apologise about because in my discretion, looking at the evidence that the AFP provided to me, he failed the character grounds."

Australian Federal Police Commissioner Mick Keelty said he stood by the information provided to Mr Andrews.
Sydney Morning Herald, July 30, 2007 - 7:40PM

Unfortunately, this seems pretty unlikely, as from my reading of Section 503A of the Migration Act 1958 ("Protection of information supplied by law enforcement agencies or intelligence agencies") is quite clear that

(c) the Minister or officer must not be required to divulge or communicate the information to a court, a tribunal, a parliament or parliamentary committee or any other body or person; and

(d) if the information was communicated to an authorised migration officer--the officer must not give the information in evidence before a court, a tribunal, a parliament or parliamentary committee or any other body or person.

The only exception arises if the Minister makes a declaration to allow disclosure of

... specified information in specified circumstances to a specified Minister, a specified Commonwealth officer, a specified court or a specified tribunal. However, before making the declaration, the Minister must consult the gazetted agency from which the information originated.

Even then, the Federal Court seems bound not to disclose that information to anyone else, including the applicant, their legal representative, or any other member of the public.

The only means by which this secret information can be released is if the originating agency decides it is no longer secret - but that means releasing it through separate channels, as Kevin Andrews remains bound not to reveal the secret submission or details of the agency from which it was received. So how do we know that any information that Kevin Andrews releases is real? We can't, because by law he cannot release it, and therefore anything he releases is untrue, or else he goes to jail for 2 years.

Boy, what a bind!

The Visa Shuffle

Kevin Andrews has consistently denied that Dr Haneef's visa was cancelled in order to keep him detained in Australia. It was cancelled due to character grounds. If that was the case, he had an obligation to deport him immediately. But he did not.

Instead, Dr Haneef was issued with a Criminal Justice Visa because the Commissioner of the AFP issued a Criminal Justice Stay Certificate on behalf of the Attorney-General, Philip Ruddock. Once this was done there was no choice but to detain Dr Haneef.

This was therefore not a decision made by only Kevin Andrews to detain Dr Haneef. It was a decision by the PM, Philip Ruddock and his delegates to detain Dr Haneef, and Kevin Andrews acquiesced by cancelling the work visa and replacing it with a Criminal Justice Visa.

Even if Kevin Andrews rolls over and resigns - Philip Ruddock is still heavily implicated in this Visa Shuffle.

Character, Goodstanding, and Medical Registration

Should Dr Haneef's visa remain cancelled on the basis of bad character, and he choose to resume his career elsewhere, he will likely be asked to produce a Certificate of Goodstanding from his previous Medical Registration Board.

At this time, the Medical Practitioners' Board of Queensland has no reason to cancel his registration. He has not been convicted of a criminal offence. Even should it choose to cancel his Medical Registration, it would not be as a result of bad character or being unfit to practise (unless Kevin Andrews were to advise the MPBQ of his "secret evidence"). He would in all likelihood be issued a Certificate of Good Standing.

What does this say about his character? Officially he is still fit to practise medicine in Queensland. Here is his Medical Registration. Officially he is also unfit to enter the country. There seems to be some disagreement here. Can anybody explain how this discrepancy can be resolved?

The Teflon Man

John Howard will, at some stage, obviously deny any direct involvement in these decisions. He has already started.

Haneef unlikely to get visa back: PM

Exonerated terror suspect Mohamed Haneef is unlikely to get his Australian visa back, Prime Minister John Howard said tonight.

Mr Howard and senior ministers are refusing to apologise to the former Gold Coast Hospital registrar, who was held in custody for almost four weeks as part of a bungled terror investigation.

Mr Howard conceded that the Director of Public Prosecutions (DPP) had made mistakes in the case, which collapsed last Friday.

But he stood by Immigration Minister Kevin Andrews' decision to cancel Dr Haneef's visa on character grounds, saying his minister was acting on "secret information".

"The question of whether he should have a visa again depends on assessments made as to his associations and I suspend judgment on that," Mr Howard told the Seven Network.

"Because I think at the moment the cancellation of his visa was wholly legitimate and I can't see therefore the circumstances in which it's going to be restored, certainly in the near future."
The Age, July 30, 2007 - 7:52PM

I wonder if John Howard has seen the "secret evidence"?

Haneef brief to be released tomorrow
PM - Monday, 30 July , 2007 18:10:00
Haneef unlikely to get visa back: PM
Sydney Morning Herald, July 30, 2007 - 7:40PM
No Apology or Visa for Haneef
The Age, July 30, 2007 - 7:52PM

Mind the Gap: Part 7 - Private Hospitals

And now we return to normal programming. This is the last instalment of a series outlining the Australian Health Insurance industry from the perspective of a health provider.

7. Private Hospitals

Private hospitals get some money from the Governments but on the whole these are relatively small amounts compared to Public hospitals. They make their money by charging their patients. If a patient has no insurance then they have to pay out of their own pockets. If they have insurance then they can get the insurance company to pay the hospital, or the patient pays the hospital and gets the money back from the insurance company.

This only covers the costs of the beds, the food, the nursing staff, any equipment used during the patient's treatment and other care that is received at the hospital. Usually there is also a co-payment that the Insurance company charges the patient (often $50/day), though this depends on your level of cover and whether the hospital has an agreement with the insurance company.

A doctor who consults on a patient or performs an operation at a private hospital will charge the patient separately. This is again eligible for a Medicare payment, and the doctor is entitled to charge the patient more if he feels that it was worth more than the CMBS rate. The CMBS fee itself usually relates to the type of operation and how difficult the operation was (in general terms). Where possible, most surgeons will give the patient an estimate of the expected surgeon's fees and gap costs, but this will depend what exactly was done at the operation, since it is impossible to accurately predict what needs to be done until the patient is on the table, asleep, and the operation starts.

Furthermore, unexpected complications that arise still need treatment, and therefore patients and insurance companies will occasionally receive further invoices beyond what was originally planned. This is part and parcel of all medical care, and while insurance companies understand this often patients do not, unless this is clearly explained to them early on in the piece.

The components charged by a surgeon in a Private Hospital will usually consist of consultation fees related to visiting the patient in hospital (prior to any operations) and surgical fees related to the time and effort involved in each operation or procedure performed. These fees usually include a component referred to as "aftercare" - namely postoperative management of a patient for reasonable time and effort incurred after an operation that proceeds smoothly. Where complications arise or a more complex situation develops, further consultation fees may be raised, but Medicare requires some justification that such fees are "Not Normal Aftercare (NNAC)".

Beyond the physician or surgeon who admitted the patient, fees may be raised by other specialists who are involved in the patient's care, such as the Anaesthetist, a Surgical Assistant (usually a qualified doctor assisting the primary surgeon), Intensive Care Physicians, Radiologists, and other Specialists (e.g. General Physicians, Cardiologists, other Surgeons etc.). The overall costs can be quite high, but again in most cases Medicare covers the CMBS portion of the fees, and the patient will only be left with small gap fees to pay.

All in all, a typical patient being admitted for a hip operation will receive bills for:

• Hospital charges (Nursing care, meals, bed and equipment costs) - usually reimbursed or paid by the insurance company, co-payments paid by patient
• Implantable Prosthesis charges (e.g. a Moore's Prosthesis) - usually reimbursed or paid by the insurance company
• Surgeon's Preoperative Fees (CMBS portion paid by Medicare via insurance company, Gap fee paid by patient)
• Surgeon's Operative Fees (CMBS portion paid by Medicare via insurance company, Gap fee paid by patient) - usually includes aftercare
• Anaesthetist's Fees (CMBS portion paid by Medicare via insurance company, Gap fee paid by patient)
• Surgical Assistant's Fees (CMBS portion paid by Medicare via insurance company, Gap fee paid by patient)
• Other specialist's fees where necessary (CMBS portion paid by Medicare via insurance company, Gap fee paid by patient).

In cases where a patient has no private health insurance, they will find that most of the fees raised by doctors will be covered by Medicare, and the Gap Payments should be relatively small. The most expensive out-of-pocket costs are those billed by the hospital for facility costs and prostheses. Not uncommonly, the Gap Payments may only add up to several hundred dollars, while the Hospital and Prosthesis charges may be many thousands.

Not all private hospitals are new and flashy.

• Public hospitals chase private patients
  
• Performance bonuses for veterans hospitals
  
• Abbott proposes private management of public hospitals

---

Hopefully this series of posts have been enlightening, and help to unravel the world of Australian Private Health Care. Basically, there is a lot of money shuffling around the system, oblivious to the patients who receive the end-product. The costs of health care are far greater than many people think, and the current health insurance and Medicare system have done an amazing job of blinding patients to the true cost and value of health care - making it something that we take for granted.

Obviously it has done wonders for the underlying health of our society - we have some of the highest standards of health care in the world, and it is readily available to the vast majority of Australian Citizens (with notable exceptions in the Indigenous population). It has kept health-care costs down quite successfully. But it has also led to the result where we do not appreciate the value (both financial and otherwise) of our own health.

Health Insurance companies are making vast amounts of money by "value-adding" to a Government-funded service. They present the costs of having your operation in a Private Hospital as being something they pay for, when in fact it is still largely paid for by the Government. They are working hard to further hide the true cost of doctors' fees from the public, to make the Gap Fee an exception rather than the rule. And they are being very successful.

This is the end of this series of posts. I hope you enjoyed it.

Playing Politics with Other Peoples Lives

It is unusual that I comment on anything outside medicine. But the treatment of Dr Haneef has been so abominable, and the actions of the Federal Government so despicable, that I feel I would be standing by allowing evil to occur if I were to keep quiet.

I am no expert in terrorist activities, national intelligence, legal matters, or politics. I am not privy to any confidential or classified material, and I have no direct acquaintance with any of the involved parties that I know about. But I am a taxpayer, and vote-holder, and (I hope) intelligent enough to see when we as a society are having the wool pulled over our eyes.

On July 4, Federal Police Commissioner Mick Keelty was asked:

CHRIS UHLMANN: So do you think you'll be in a position to charge him, release him or extradite him to the UK any time soon?

MICK KEELTY: By the end of the week I think is the time frame that we would give.

And of course one of the things I wanted to emphasise is the presumption of innocence here. I know there was a lot of sensational reporting yesterday of the case. And I understand that. It's the first one of its kind and the first time that we've resorted to the new legislation in this country.

Understanding all of that, I think now is the time to calm down and settle back and allow us to go… sift through the evidence or the information that's been obtained through the search warrants, and to allow the joint terrorism team, the Queensland Police and the AFP team that's been working on this since, basically since the bombings occurred in London, to go through what evidence might be available so we can make a decision.

Note the cautious response, the reinforcement of the concept of the presumption of innocence, and the estimate of a week's time to determine the outcome of the case. At this stage, it seemed reasonable to allow time for things to pan out.

Several days later on July 7, Attorney-General Philip Ruddock reinforced the presumption of innocence, in his usual, round-about way:

PHILIP RUDDOCK: Well, I am concerned for any individual when police question you that people might draw any conclusion other than that the police have questioned the individual in relation to inquiries that they're making. And even if the matters were taken further and the police had serious and continuing concerns, until such time as the person is charged, all you know is that they have formed a view that there is a case to answer. And the further point is that even if charges are brought in Australia, people are presumed innocent until proven guilty. And those propositions apply here in exactly the same way as they do every other investigation.

The interview continued:

ELIZABETH JACKSON: Is there anything else you can tell us at this point about the Queensland-based doctor, Mohamed Haneef, who was being detained I think since Monday without charge? I understand that he's being held over the weekend. Is that your understanding? Have there been any developments on that front?

PHILIP RUDDOCK: Well, the point I made, and it was mentioned I think in Chris' piece, that counter-terrorism laws were invoked. In fact, the provisions in the Crimes Act, which enable a person to be detained for questioning have been used in this particular instance, and that was, I think, because the gentleman concerned was about to take a flight abroad with a one-way ticket. And I think the police wanted him to remain available for questioning.

Is it unreasonable to ask whether the Police invited Dr Haneef to voluntarily assist with their investigations, rather than being arrested and detained involuntarily? Given his behaviour so far, Dr Haneef may well have agreed! Perhaps this was just a test case to try out the new detention laws?

A week later, it became clear that the AFP and Commonwealth DPP were not getting very far. Philip Ruddock blamed part of the delay on:

PHILIP RUDDOCK: Something of the order of 120 gigabytes of computer data is being examined. And as I said at the weekend, that's the equivalent of 31,000 single page documents. So, it gives you an order of magnitude, and it's one of the reasons that the matter takes so long.

PETA DONALD: He also says police need the extra time to liaise with authorities in Britain, and that as Thursday's 6pm deadline approaches, police may well apply for a third time to hold Dr Haneef for longer.

Now I found this a little hard to believe - it takes very little time to get a working idea of what is on someone's computer. The vast majority of files are Operating-System related. The remainder can be rapidly classified into video, audio, and documents, which it takes a few seconds to screen for relevance. I could understand if he had said they were encrypted, or something like that, but this excuse was lame.

Mick Keelty expanded on the scope of the investigation on July 10.

TONY EASTLEY: Is it one of the biggest investigations in recent times?

MICK KEELTY: We've had a large number of these … well not this type of investigation, but we had Operation Pendennis two years ago, which was of a similar size and nature.

These are always complex, this type of investigation, and the thing that we want to ensure that we do is abide by the law, afford people their rights and, you know, stick by the principles of the law which is innocent until proven guilty. And it's up to us to gather that evidence.

On July 12 the 120Gb of computer data ("equivalent to 31,000 pages") doubled:

Mr Ruddock yesterday stressed the complexity of the investigation, saying police had to analyse 120 gigabytes of computer data and 31,000 pages of paper. "These are the issues the court has to take into account in deciding whether or not the (detention) period is reasonable," Mr Ruddock said.

July 16 arrived, and Dr Haneef was finally charged when it became clear that detention would no longer be allowed and he was granted bail, but this was quickly superceded by the cancellation of his Working Visa by Immigration Minister Kevin Andrews on the basis of secret evidence which suggested that Dr Haneef was of bad character.

While Kevin Andrews was (sadly) entitled by legislation (brought in by this Federal Government and in particular Philip Ruddock during his time as Immigration Minister) to cancel any non-citizen's visa on little or no basis whatsoever, it flies in the face of earlier statements that Dr Haneef should be presumed innocent until proven guilty - a right already compromised by the detention laws under which he was being held.

From the ABC's 7.30 Report:

KEVIN ANDREWS: I can't go into the detail Kerry, because that information is protected under the law. But can I say that having looked at it quite carefully and quite seriously, I came to that conclusion that he has had and has associations with people who have been involved in criminal conduct, namely alleged terrorism in the UK.

And the next day in the ABC's AM program:

Kevin Andrews says he formed a reasonable suspicion that Dr Haneef was associated with people involved in criminal activities.

KEVIN ANDREWS: The basis upon which I acted wasn't that there was just some trivial association, it wasn't just because, as has been said in the media, that he happens to be a cousin of a particular person. It wasn't just trivial.

KATHRYN ROBERTS: Speaking to Fran Kelly on Radio National, Kevin Andrews would not be drawn further on the issue.

FRAN KELLY: But the end result is we have a man locked up on your decision, based on secret information, with no recourse.

KEVIN ANDREW: Well based on a decision of the Parliament that certain information provided to me as Minister by the Federal Police is protected information and shouldn't be made public.

The Prime Minister backed his Immigration Minister the following day:

In Sydney, the Immigration Minister, Kevin Andrews, was continuing to defend his actions.

KEVIN ANDREWS: This is not on the basis that the man is related to two of the people in England, that they are cousins, it's much more detail about activities than simply a familial relationship.

KATHRYN ROBERTS: Kevin Andrews made his decision after a secret police briefing but today he was again asked why that information wasn't put before the court during the bail application.

KEVIN ANDREWS: The Director of Public Prosecutions is an independent statutory office holder in Australia, who makes decisions based on the law and the evidence and the prosecution guidelines that they work under.

KATHRYN ROBERTS: The Prime Minister John Howard has spoken for the first time about the decision, and is firmly backing his minister.

JOHN HOWARD: He has acted properly, he has acted in accordance with the law, and it's plain on any reading of the Immigration Act that his decision was correct, it was justified, and it was in the national interest.

It was bad enough that the Federal Government was misusing the laws it drafted to detain and charge alleged terrorists with minimal or no evidence, but it acted to co-ordinate that abuse of power with the laws it drafted to eject undesirables from the country based on a similar lack of evidence. Not only that, but it had no intention of deporting Dr Haneef, merely to keep him locked up and in isolation from his laywers, the media, and any support he may have from family or friends, while charging him for the privilege of being housed in solitary confinement at Villawood.

Furthermore, the Immigration Minister is basing his decision on information which is secret, and will likely never be disclosed. This means that he can stand by his decision, even if all of the publicly available evidence which he considered is rendered obsolete or proven incorrect, as is already becoming the case. He is effectively saying: "Dr Haneef is a bad man. Trust me."

The judge handling a direction's hearing against the visa revocation even commented:

A Federal Court judge has described as "astounding" the Federal Government's position that an association of any kind with criminals - "a cup of coffee, a picnic with the kids" - is enough for a non-citizen to fail the Migration Act's character test. ... "I have been associated with persons involved in criminal activity. I have defended them, charged with murder. Unfortunately I wouldn't pass the character test on your statement," the judge said to Roger Derrington, SC, representing the minister.

"You're not a non-citizen," was the government barrister's reply. "The purpose of the migration legislation is to protect the national interest … the Commonwealth doesn't have the power to investigate the relationships of people overseas."

Justice Spender's voice rose. "That's absolutely astounding, Mr Derrington."

More information about this evidence subsequently came to light. First was the concern that Haneef's visa was revoked on the basis of his personal acquaintance with suspects in the UK who had not yet been charged with an offence. From the Sydney Morning Herald on July 20:

However, UK authorities have not yet charged Kafeel Ahmed while Sabeel is only facing one charge of withholding information.

The basis for Haneef's charge - given neither Ahmed brother has been charged - of being part a terrorist organisation was something Mr Russo said he cannot understand.

Then the SIM card that Haneef was said to have given a terrorist organisation turned out to have no direct relationship to the attempted attacks:

RAFAEL EPSTEIN: Last year when Mohammed Haneef left Britain, he gave the SIM card for his mobile phone to his cousin, Sabeel Ahmed. When Mohammed Haneef appeared in a Brisbane court last Saturday, the prosecutor acting for the Government, Clive Porritt, spoke about the SIM card. He said it was found inside the Jeep Cherokee vehicle that had been smashed into Glasgow airport on June the 30th.

That was a [sic] cited as a reason behind the charge that Mohammed Haneef had recklessly supported a terrorist organisation. Placing his SIM card at the scene of the failed attack was also part of the prosecution's argument opposing Mohammed Haneef's bail.

From July 20:

Hedley Thomas is a senior journalist with The Australian newspaper who's analysed the police record of interview with Haneef and the AFP's affidavit to the court.

He's also sighted immigration department documents which he says were used to advise Kevin Andrews' in his decision to cancel the visa.

HEDLEY THOMAS: These are the documents that were written and compiled by Peter White a senior public servant and in that, he's basically advising the Immigration Minister Kevin Andrews, and he writes Dr Haneef advised the AFP that "he resided with Dr Sabeel Ahmed at a boarding house located at 13 Bentley Rd, Liverpool, UK."

Now the problem is that is not what Dr Haneef advised the AFP.

KATHRYN ROBERTS: So does that in your mind raise questions about the information on which Kevin Andrews has based his decision to cancel Haneef's visa?

HEDLEY THOMAS: Well I think the question has to be asked whether this influenced Kevin Andrews in any way. The record that was produced by the police for the benefit of the Brisbane Magistrates court is more misleading because it claims that Dr Haneef participated in a taped record of interview with the AFP and stated following, "whilst in UK he resided with suspects 1 and 2."

Suspects 1 and 2 you should know are Kafeel Ahmed and his brother Sabeel Ahmed, but I've been through the record of interview with a fine-tooth comb and that statement is just false he doesn't say he resided with suspects 1 and 2 at 13 Bentley Rd, Liverpool, in fact, the opposite is the case according to Dr Haneef's testimony. So you just have to ask how does this kind of material get into official documentation, it's a complete misrepresentation.

KATHRYN ROBERTS: Hedley Thomas says the public can't be confident the information provided to Kevin Andrews by the police was accurate.

HEDLEY THOMAS: The evidence that the AFP are themselves collating they're not interpreting properly and you know you're just left wondering if they can't properly and accurately interpret their own evidence and what it means, then how can we sort of be confident that they're going to be appropriately investigating and prosecuting terror suspects.

I think the whole case is looking like an absolute debacle.

As the Crown case unravelled, John Howard acted on the same day to distance himself from the investigation:

JOHN HOWARD: I have no comment to make about the handling of the prosecution because it's not being handled by me. I think it would be a good idea if people - no disrespect to the media - but I think it would be a good idea if everybody let the prosecution be conducted and let the matter be properly ventilated.

But I am not conducting the prosecution. It's been done by the police and the DPP and if anybody has questions about the conduct of the prosecution then those questions should be directed to the DPP and the police, not to me because, under our system of justice the executive has no role in the prosecution of people nor it should.

Justifiably, community criticism has grown against Dr Haneef's detention and the charges levelled against him.

KATHRYN ROBERTS: Those concerns have been echoed by immigration lawyer Glenn Ferguson from the Law Council of Australia.

GLENN FERGUSON: The puiblic's really got to be concerned because obviously the information that the Minister has based the withdrawal of that, Mr Haneef's visa, is on the basis of what, I take it, he's been told by the federal police so accuracy is very important and particularly when it's not in the public domain.

KATHRYN ROBERTS: He says factual errors could be significant during Haneef's Federal court appeal against his visa cancellation.

GLENN FERGUSON: If it's a situation where incorrect information has been provided and obviously no one's saying it's not intentionally or not at this stage but if there is any in accuracy it should be remedied immediately and the assessment by the Minster obviously has to be made again once that correct information is in his hands.

KATHRYN ROBERTS: But the Immigration Minister Kevin Andrews is standing by his decision. He says he won't be reviewing the matter and nothing reported in the media alters his opinion.

ALISON CALDWELL: Greg Barnes is a criminal defence barrister who has been closely following the developments in the case against Mohamed Haneef.

GREG BARNES: We have seen this case run from farce to farce, from Monday through to Friday this week, and I think what is shows is that the terrorism laws, despite what John Howard said last weekend, these terrorism laws are not working.

It also shows that there is need to lift the veil of secrecy over the terrorism laws. If it hadn't been for leaks and for the media's assiduous work this week, on the ABC, The Australian and various other media outlets, and exposing the flaws in the prosecution case, then none of this would have come out and I think that's an important lesson.

ALISON CALDWELL: Julian Burnside QC is a barrister specialising in commercial and human rights litigation. He's also President of the Victorian Council for Civil Liberties.

He says the Haneef case has highlighted serious concerns about the way the new laws are being implemented.

JULIAN BURNSIDE: The presumption of innocence is not just an empty formula, it is a reality. I think many people would be very disturbed to know that an innocent man has been treated during this week the way Dr Haneef has been treated.

He's been thrown into solitary confinement, carted around in a Guantanamo-style suit. His reputation has been publicly trashed by the Attorney-General and the Minister for Immigration, and all of this to a person who's presumed innocent.

Now that we know the facts, which the prosecution side have, it looks as though he may be innocent, and I think that has made people feel very uncomfortable as it should. Now, if the presumption of innocence means anything, we ought to give it real force and assume that people are innocent, and then look at that whether the way we're treating him is justifiable.

And now the Federal Goverment wants to get out of trouble by deporting Dr Haneef:

Several senior Government sources have told The Sunday Age they were furious at the Australian Federal Police for their handling of the case and wanted to shut the issue down before it did more damage to the Government's credibility.

"Our best option is to cancel the Criminal Justice Certificate, which was issued to keep Haneef here in Australia after we cancelled his visa, and that is my understanding of what our intentions are," one Government source said.

"Cancel the certificate and get this guy out of Australia. The story ends there and he can become someone else's problem."

Mr Ruddock issued the Certificate of Justice so that Haneef's deportation could be stayed pending judicial proceedings. But with the federal police case surrounding Haneef collapsing after revelations that the SIM card he left in Britain was not used in the failed suicide bomb attack in Glasgow, Government strategists believe there is little point holding him in Australia.

"There is no upside proceeding with this. We keep him here, then it remains an issue every day until the election. We deport him and it's over," the source said.

Let me tell you, it is not over. Federal Prosecutors must either prove their case against Dr Haneef in court, while treating him with some humanity by allowing him bail or, at the least, letting him out of solitary confinement. If it is not going to do this, then restore his working visa or issue him with a temporary visa, and compensate him for inconvenience caused. Unless it stands up and does the right thing, the Liberal Party and this Federal Government has one less vote come Polling Day. And unless the Labour Party comes out to stand up against this injustice they will not get my vote either.

To deport Dr Haneef is to completely circumvent natural justice, allowing Dr Haneef no means to clear his name, and only acts to compound the injustice imposed on Dr Haneef. Philip Ruddock, John Howard, and Kevin Andrews - your actions disgust me and make me ashamed to be Australian. And it scares me that this could easily happen to any one of us.

• AFP urges caution over terror arrest
  ABC Radio AM - Wednesday, 4 July , 2007 08:03:36
  
• Ruddock on terrorism investigation
  ABC Radio AM - Saturday, 7 July , 2007 08:06:00
  
• More time to hold Gold Coast doctor
  ABC Radio AM - Tuesday, 10 July , 2007 08:00:36
  
• AFP may seek more time in Haneef probe: Keelty
  ABC Radio AM - Tuesday, 10 July , 2007 08:11:36
  
• Indians angry at AFP over Haneef
  The Australian, July 12, 2007
  
• Govt defends cancelling Haneef's visa
  ABC Radio AM - Tuesday, 17 July , 2007 08:00:00
  
• Haneef's lawyers to launch detention appeal
  ABC Radio PM - Tuesday, 17 July , 2007 18:26:00
  
• I would fail character test: judge
  Brisbane Times, July 18, 2007
  
• Lawyers launch campaign to restore Haneef's visa
  ABC Radio PM - Wednesday, 18 July , 2007 18:22:00
  
• Haneef caught in new anti-terrorist law net, by Claire Macken (Lecturer and PhD candidate at the School of Law, Deakin University)
  ABC News, Thu Jul 19, 2007 8:16am AEST
  
• Haneef court information incorrect, source says
  ABC Radio AM - Friday, 20 July , 2007 08:00:00
  
• Prosecutors accused of overstating Haneef case
  ABC Radio PM - Friday, 20 July , 2007 18:10:00
  
• Haneef visa cancellation unchanged despite discrepencies
  ABC Radio PM - Friday, 20 July , 2007 18:14:00
  
• Haneef case needs proper explanation: Beattie
  ABC Radio PM - Friday, 20 July , 2007 18:18:00
  
• Legal fraternity concerned at terrorism laws
  ABC Radio PM - Friday, 20 July , 2007 18:22:00
  
• Haneef lawyer sceptical from the start
  The Sydney Morning Herald, July 20 , 2007 13:30
  
• Call for Ruddock to explain case
  The Australian, July 21, 2007
  
• Government play to jettison Haneef, end backlash
  The Age, July 22, 2007
  
• Patient hunters wait to spring the trap
  The Sydney Morning Herald, November 12, 2005

On Anonymity

I had a haircut last week. It is one of those things that I keep procrastinating about and delaying. It's been a good two months, and I have had a mop of unmanageably long hair around my ears that I hoped my patients would ignore.

In any case, I went to a new hairdresser, and it was only a matter of time before they asked what I did for a living. I knew it was coming, but my reaction is always the same. I hesitated before admitting that I was a doctor. I avoided saying that I was a surgeon until pressed, and did not elaborate further.

I don't like having my profession displayed on my shoulder like a scout's badge. I am quite happy not to use the title "Dr Sheepish" in public. My credit cards say "Mr Sheepish". My plane tickets say "Mr Sheepish". I'd rather not be recognised in public. The last time a television crew came into the hospital I actively avoided them, despite being in the same operating theatre and treating the relevant patient.

One of my colleagues a few years ago asked me if I knew anyone who would let a journalist follow them around for a few days. I replied that the kind of doctor who volunteers to let a journalist follow them around is not the kind of doctor that you want splashed on the newspaper representing our profession.

Despite that, I did reluctantly agree to an interview and photo in the local rag once. It was a once-off, on an issue that I strongly felt was not being portrayed fairly. I insisted that the final text was read to me first before I approved the use of my name and picture. I have a copy in a drawer somewhere, but it is not framed or displayed proudly on a wall.

I'm not sure what my aversion is to publicity - be it shame, shyness, or whatever. I think I just like to be treated as a person, not a profession, and that sometimes I like to just sit and watch things play out, hoping that I am not influencing them by my mere presence. Perhaps that is changing - and perhaps this blog is representative of that.

Global Doctor Trading 2

Am I imagining, or did these journalists get the same brief? Nevertheless, a good piece from The Age.

Carol Nader and Adam Morton
July 14, 2007

IT MIGHT be the lure of opportunity, or the promise of a better life. The chance to flee from a bleak existence. Or it might just be the pursuit of adventure. In Dr Julie Miller's case, it was the love of a good man. The day after her wedding six years ago, Miller left New York and, following a spectacular African honeymoon, moved to Melbourne with her Australian husband. Soon after, the US-trained endocrine, general and trauma surgeon started work at the Royal Melbourne Hospital.

It should have been easy coming from an English-speaking country. But Miller found she had to learn a whole new language — medicine in the Australian tongue. An American clamp or hemostat became an Australian artery forceps. America's acetaminophen became Australia's paracetamol.

But among the growing army of overseas-trained doctors who ensure the Australian health system ticks over, Miller counts herself as lucky. She is married to another doctor who works at the same hospital, which helped make the transition relatively smooth. And English is her first language.

"American and Australian cultures are very different but they're not as different as other cultures," she says. "I really admire people who come here to try to get a better life for their families."

Miller's story shows that importing doctors can have a happy ending, but for many others — especially doctors from developing countries — it's a slog. The Federal Government says about a quarter of doctors in Australia are foreign trained. Health Minister Tony Abbott says overseas-trained doctors account for about 28 per cent of Medicare-billed services. Some have lived here for many years. Many work in suburban and regional practices, filling the jobs Australian-trained doctors do not want.

How did it come to this? The experts are in near universal agreement — shoddy workforce planning. According to a paper published this year in the Medical Journal of Australia, led by Catherine Joyce at Monash University, medical school intakes steadily rose during the 1970s, from 851 in 1970 to 1278 in 1980. By then, the medical workforce was believed to be in oversupply. By 1990, the numbers had slipped to 1030. There was little workforce planning by governments throughout the 1980s and 1990s until there was a realisation there was a problem. Since 2000, the Howard Government has started work on increasing the number of places again. But this has all happened late in the picture, and it will take years before these students start to work as qualified doctors.

It was always going to be a crisis, says Melbourne University's dean of medicine, Professor James Angus. "We're paying for about 20 or 25 years of static medical school production," he says.

The result some years later? Eighteen-year-olds desperate to get into medicine who can't, and state governments desperately recruiting doctors from overseas to fill the gaps.

Says Australian Health Policy Institute director Professor Stephen Leeder: "There's no doubt that we got it wrong in terms of protecting the number of doctors that we need, both now and for the future. I think everybody has got to take a share of that responsibility though. I don't think it's just government short-sightedness."

With fewer graduates coming through, the Government increased the number of doctors brought in on temporary visas. According to some researchers, monitoring of the standard of doctors coming in under the temporary skilled migration program is not as rigorous as it should be. Now the system is being patched up, but again, insiders say, it will be years before we see the results in the workforce.

Abbott says it is true that part of the problem is due to decisions made in the 1980s and early 1990s. "In those days the orthodox view was that supply created its own demand, and we needed to keep a tight cap on the number of health-care professionals. I think it was the view in those days that we were comparatively over-doctored and we didn't need as many doctors as we thought we had in those days. No one thinks that now."

In Victoria, there are 19,792 doctors registered with the Medical Practitioners Board of Victoria, of whom 5164 — about a quarter — learnt their profession abroad. Almost 1000 come from Britain, more than 800 from India and 500 were trained in New Zealand. At the other end of the scale, there is one doctor registered from each of Jordan, Tunisia and Malawi.

There is undoubtedly a great need for people such as Julie Miller, one of 29 American-trained doctors now registered in Victoria. Australia needs more doctors. And this need will be felt even more urgently as more and more older, fatter and sicker people need medical attention. But no one can nail precisely what the shortfall is. Estimates put the number somewhere in the thousands. The experts agree that Australia has no choice but to poach doctors from other countries.

While some people may view overseas-trained doctors with suspicion, there is no doubt that they are a pivotal part of the workforce. Few would say that Australia should shut its doors to them. But what is clear is that assessing the competency of international medical graduates is more fraught, particularly if they come from a vastly different health system.

There are multiple ways doctors can apply to be registered in Australia, an issue that the nation's governments are starting to address. In addition to clinical competence, there are language barriers, dealing with different cultures and ensuring foreign doctors have an understanding of the Australian health system. For the Australian Medical Council, the state medical boards and the specialist colleges that assess these doctors, it is a tricky job.

Tony Abbott says there is nothing wrong with overseas trained doctors working in Australia, as long as they are properly qualified. He says a degree of cross-cultural experience is healthy for the medical profession.

Much of the recruiting is from other wealthy countries such as Britain. But Australia has increasingly been drawing doctors from the developing world, hurting the health systems in those countries. It is a situation some say is outrageous.

"They shouldn't be coming from Third World countries who need basic medical services," says Doctors Reform Society president Dr Tim Woodruff. "It's an appalling situation for Australia to be having to bring in doctors from countries which desperately need them."

The optimum situation, says Woodruff, is to produce medical graduates in sufficient numbers so that we can actually help the developing world by exporting doctors instead.

Melbourne University's Professor Angus says Australia's problems mirror a worldwide health workforce crisis. "Every country, including a wealthy country like Australia, must play its part in training. It's an outrage that we pinch doctors from other sectors less wealthy than ours — absolutely an outrage," he says.

But Abbott says Australia does not actively seek out doctors from the Third World. "It would be a far worse thing for us to say to properly qualified doctors from Third World countries, 'Sorry mate, you can't come here,' " he says. "Shouldn't their doctors have the freedom, should they wish and should they be suitably qualified, to come to Australia?"

State Health Minister Bronwyn Pike recently went to Britain to try to recruit more doctors for Victoria. Pike led a chorus of people accusing the Federal Government of short-changing the state in terms of the number of university medicine places it funded.

Now that the Commonwealth has come to the party, the challenge will shift to the states providing more clinical places in hospitals to ensure that medical students get proper training. "The Howard Government has failed Australia and Victorians by not training enough doctors," Pike says.

But the Australian Health Policy Institute's Professor Leeder makes the point that the doctor shortage is relative. Adding to the desperate situation is an unwillingness by some doctors to work in remote areas.

"If you go to the more affluent suburbs in Sydney, there are so many GPs that you're tripping over them," he says. "Whereas in the outer suburbs in Sydney, or once you go to the rural or remote areas, there are too few … There's a shortage of doctors in some areas and goddamn too many in others."

Nowhere is the situation more urgent than in the bush. The more remote the area, the less desirable it is. Why would a doctor choose the harsher conditions of remote Australia over a plum gig in the city?

The rise in university places coincides with new medical schools opening at Wollongong and Western Sydney universities in NSW, Griffith and Bond in Queensland, Notre Dame in Western Australia and Deakin at Geelong. Melbourne and Monash — Victoria's other two medical schools — also won funding for 30 extra medical places each last year. Medical deans say new clinical schools have been created at suburban hospitals, and training in the regions is improving.

From next year, Deakin will enrol 120 Commonwealth-backed students in its new graduate medicine degree. Sixty full-fee payers from Australia and overseas will be added in 2009, bumping up the annual intake to 180. But it will be some time before people in the bush start to feel the benefits of this — the first Deakin graduates will be interns in 2012, and will then need further training. Many academics say there is a need to do something in the short to medium term as well. Which brings us back to recruiting overseas doctors.

Rural Doctors Association of Victoria president Dr Mike Moynihan, who is originally from Britain, estimates some 30 per cent of doctors working in country Victoria are now overseas trained.

Quite often, it's because they don't have any choice but to go to the country. Carrots and sticks are used to try to coax doctors to go to these areas. Doctors who come to Australia on temporary visas are given no option but to work in areas of need. There, in addition to trying to adjust to life in a new country, with a different culture and in some cases a different language, they also face social and geographical isolation.

Enticing locally trained doctors to want to work in those areas will also be harder. Melbourne University's medical school has lifted its intake so that it will soon produce about 330 graduates each year, a figure it expects to maintain as it moves from being mostly an undergraduate school to teaching only graduates under the US-style Melbourne Model. Under this new system, a growing number — the target is a third of Australians enrolled — will pay full fees of between $180,000 and $200,000 for the four-year course.

As James Angus acknowledges, would-be doctors paying this much are unlikely to be drawn to suburban or rural practice. Highly lucrative areas, such as plastic surgery, will become much more attractive to those wanting to erase debt in a hurry.

Says Angus: "I think it is a great pity that higher education has moved this way in this country, but if you want universities to survive we have absolutely no alternative."

He says the medical training level is now saturated — no more doctors can be trained until the full impact of the current changes can be assessed. "We should just draw breath for three or four years until the huge change that we have had flows through, and then we should revisit our capacity."

In the meantime, opinions are divided about whether overseas-trained doctor numbers will remain steady or continue to grow. What is clearer is the need to provide them with support.

Dr Joanna Flynn, president of the Medical Practitioners Board of Victoria and the Australian Medical Council, says some overseas-trained doctors get lots of support and do well. But some are vulnerable because they depend on the sponsorship of their employer. This is even more so for doctors who are here on temporary visas, who have no choice but to go to the more isolated rural areas.

"I think it's very important that people are mindful that overseas-trained doctors can be exploited. They're pretty powerless," she says. "They don't get access to Medicare, they don't get access to free health care, to free education for their kids.

Says Dr Neil Cunningham, an emergency consultant at St Vincent's Hospital who did his medical training in Britain and moved to Australia in 1999: "It's probably irresponsible to just bring people over and send them to a rural area without providing them with that support." Cunningham, who also trains medical students and junior doctors, moved to Australia as a qualified doctor because the specialist training for emergency medicine was superior in Australia. "The climate is much better and the more active lifestyle appealed to me as well," he says.

Cunningham easily slotted in to the Australian medical workforce, but says coming from an English-speaking country was on his side. He can see that it's not so easy for others.

"If we're going to bring people over and thrust them into an environment where they are expected to work in a second language and different culture, then we need to make as much effort as we can to support those people."

Carol Nader is health editor. Adam Morton is higher education reporter.
http://medicalboardvic.org.au/

Julie Miller is from one extreme end of the foreign doctor spectrum - the lucky end. She comes from a first world country. She has (effectively) no language barrier to overcome. Her specialist surgical qualifications have been automatically recognised. She has landed a plum job at a major teaching hospital. Not all foreign doctors are so lucky - but then not all foreign doctors are so desirable an asset to attract to Australia. Neil Cunningham is similarly blessed.

M&TS asked in a comment to the previous post:

Sheepish, do you think the medical students of this great efflux will receive a decent enough education to ensure they are as competent as you were at graduation?

I think that the infrastructure in place is probably good enough to maintain the competency of medical students at graduation - after all, interns are in reality only of limited competency, and there is a large postgraduate structure in place to supervise, maintain and compensate for intern competency. Truth be told, we don't expect all that much of a finishing medical student. Recent experience has shown that to perform at intern level, the rigour of academic knowledge that is necessary is not the same as what used to be required.

The issue will be what happens as these graduates progress through the advanced training system. The level of academic knowledge and sound judgement that is required at current standards is very high - and the gap between the standard of medical students at graduation and the standard of specialists at graduation is growing.

Global Doctor Trading

An excellent article from The Sydney Morning Herald.

A bright, shining dilemma
July 7, 2007
Australia has an acute shortage of doctors. Julie Robotham and Connie Levett reveal why we need to poach health professionals from around the world.

Dr Joga Chaganti is a man with options. The highly regarded Indian radiologist has just taken over as head of Sydney's St Vincent's Hospital MRI and cranial imaging department. He has studied in France, Germany, Britain and the United States and and worked for 20 years in the Indian public hospital system, most recently as the director of imaging for Bangalore's 1000-bed Manipal Hospital.

No health system needed him more than India's, but he chose Australia."I was doing very high-end work but my children wanted to achieve big things, and I didn't have the means to support them," Chaganti, 49, says. In India, the highest salary a specialist with his qualifications can earn is $38,000; in Australia it is three times that.

Even with the higher cost of living, the move will allow him to fund his children's education. His 20-year-old daughter, enrolled in a triple major in engineering at the Australian National University, hopes to study space engineering in the US. His 14-year-old is leaning towards studying human genetics.

"There is a parallel objective. I have always wanted to do cutting-edge research. It was always my desire," Chaganti says, showing off the hospital's new $4 million high-field strength MRI machine.

Chaganti's stellar career is the positive face of an unprecedented global migration of medics. It has long been standard practice for young doctors to do an international tour of duty. In a kind of rite of passage, they come home with new skills and connections, and the confidence to take their place as fully-fledged specialists.

But that is now being underpinned by a much larger migration of junior doctors, typically trained in poorer countries, who are recruited to the health systems of privileged nations which - somehow - have neglected to adequately develop their workforces.

The trend was thrust centre-stage this week with the detention of Dr Mohamed Haneef, a doctor at the Gold Coast Hospital, after the failed terrorist attacks in Britain. The Indian-trained 27-year-old had worked as a medic in Liverpool, in northern England, before arriving here last year to work under supervision on a temporary visa in Australia's busiest emergency department in its fastest growing city.

When an unlucky colleague of a similar career background as Haneef's was also hauled in for questioning, a picture emerged of itinerant communities of overseas-trained doctors, hopping between continents chasing emergency-department shifts like backpackers following the fruit-picking seasons.

On the Gold Coast - as in most other rural and regional areas of Australia - at least half the medical workforce was trained outside this country. Doctors work here under a motley collection of temporary and permanent visa rules, and expedient registration conditions, that could most kindly be described as inconsistent.

At least a quarter of the present Australian medical workforce was trained overseas, according to the Australian Medical Workforce Advisory Committee, while 2001 census data shows almost half of Australian citizens with medical qualifications were born overseas. The discrepancy is because of the high proportion of those who attended medical schools in other countries who have not been able to register as doctors here.

"We have just not been training enough doctors. These people have been the only option," says Professor Brendan Crotty, the head of Deakin University's new medical school, which plans to start training doctors next year.

The federal Health Department commissioned Crotty to report on how overseas doctors are trained and registered after the Queensland scandal involving a criminally incompetent Indian-trained surgeon, Dr Jayant Patel. Crotty found a minefield.

"It's been incredibly complicated and very hard for overseas-trained doctors themselves to follow," he says. State rules vary, and need to be pursued through "so many different agencies that are not very well co-ordinated [in addition to] vaguely-worded requirements for supervision". A plausible result of the rag-tag system is an unsuitable doctor who is inadequately supported in an unfamilar place. But if that scenario sounds far from the ideal, Crotty is also sympathetic towards the pressures put on them. "Employers in those locations are faced with a difficult choice," he says. "It's this particular person or no one."

Where a problem exists with an individual, Crotty says, it is almost never simple incompetence or malice, but more usually a cultural gulf too wide to bridge.

"Medical schools are trying to produce doctors fit for the purpose in the environment they're working in," he says. In developing countries that might mean concentrating "predominantly on infectious diseases, where there's limited diagnostic modalities or treatments". Such training simply might not shoehorn into general practice in outer-metropolitan Sydney.

Andrew Dix, the registrar and chief executive of the NSW Medical Board, says he has "no evidence that there is higher concern about the competence or conduct or performance" of overseas-trained doctors, compared with Australian graduates. In fact, he says, junior doctors who come to Australia to plug holes in regional hospital rosters may be less likely to attract complaints - because they are working in a structured environment with senior colleagues.

The board's brief, Dix says, is to ensure individual doctors are suitably qualified and experienced for a particular job. For temporary "area of need" positions this involves an interview and assessment process, after which 20 to 30 per cent of candidates are knocked back.

Those who succeed receive on-the-job supervision, including progress reports to the board at intervals set individually.

If a person does not make the grade, Dix says, that is the end of the matter. Despite the urgent need for medical staff, the standard should not shift. Nevertheless, he says, "we don't operate in a vacuum. We'd be stupid not to be aware [of the doctor shortage], and we'll look for different ways to make sure appropriate standards don't become ossified."

Of about 1500 overseas trained doctors working in NSW, about three or four have their registrations curtailed or withdrawn annually, Dix says, because their actual practice fall short of what the assessment suggests.

Proposed national standards for overseas trained doctors will involve - except for graduates from Britain, Ireland, New Zealand the United States or Canada, and those applying for specialist jobs - supervision based on individual assessment.

But NSW Health has so far resisted the streamlined assessments, out of concern they might add an extra hurdle for well-qualified would-be medicos.

That is no idle worry. The number of vacancies for rural GPs in NSW recently crashed through the 200 threshold, after hovering at about 120 for most of this decade. "In terms of the overall picture for rural GPs, we have a fairly pessimistic view for the next 10 years," says Mark Lynch, the general manager of Rural Doctors Network NSW, the agency that brokers medical appointments in the bush.

Baby-boomer GPs are reaching retirement age; younger doctors are less willing to adopt the long hours traditionally synonymous with country practice. "I think it's going to get worse before it gets better," says Lynch, who believes communities will need to adjust their expectations of doctors and employ nurses to cover more routine work. His organisation has focused on getting the pool of medically trained individuals already resident here into the state's workforce. But depending on where they trained and how long ago, it may still be unrealistic to give some doctors a leg-up into Australian practice.

How could a prosperous nation, socially conscious and a leader in medical research, have devised a skills shortage so severe it threatens to cripple the provision of health care in some regions? From the vantage point of 2007, it seems inconceivable that only a decade ago bureaucrats feared not a doctor shortage but the oversupply of medics. The wanton distribution of Medicare provider numbers, they thought, would lead to a blow-out in health care costs. Strict containment of student numbers was the solution.

Professor Allan Carmichael says nobody anticipated how changing career expectations among medics would combine with shifting population demographics and personal expectations to pull supply and demand in opposite directions.

"I don't think those factors had hit home," says Carmichael, the president of peak group Medical Deans Australia, which represents medical schools. "People are living longer and wanting access to [operations] in their 80s or 90s that even 15 years ago you'd have have thought twice about giving to people in their 70s."

Female graduates, who began pouring out of medical school in the 1980s, on average work shorter hours and spend fewer years in the workforce than men; but men, too, are less likely to accept the on-call lifestyle older doctors took for granted.

Rebuilding decimated student numbers is a hard slog, with a long lead-time. The trends to longer medical courses and sub-specialisation mean it can take 10 years before a young doctor is able to hang out an independent shingle.

Commonwealth bonded scholarships to tie graduates to rural communities were introduced from 2004. Medical schools may now offer full-fee places - at first capped at an extra 10 per cent on top of the public student allocation, then moved to 25 per cent, and from this year uncapped.

But those are tweaks compared with the expected effect of an explosion in the number of young medics set to graduate over the next decade. Enrolments in medical courses are tipped to surge from about 2100 this year to 3500 by 2010 - courtesy of new schools at the universities of Wollongong and Western Sydney, and several others around Australia, as well as rising intakes at established medical schools. That, though, is only the beginning of the story.

Students need lecture theatres, course materials and a teaching skeleton. New doctors still on training wheels also need the opportunity to rehearse their new-found skills under close and supportive supervision, until they have the confidence to practise independently.

Professor Allan Spigelman believes the transmission of those clinical skills is the biggest looming bottleneck in turning out the next generation of doctors.

In part, it is a matter of sheer volume.

Postgraduate training, traditionally, happens in the public hospital system, but it is here - where urgent cases frequently bump planned operations off surgical lists - that it may be hardest to ensure a trainee gets all the experience they need.

In the public system, Spigelman says, "there's very good emergency operating exposure for trainees … but you do need that mix [of routine operations] - hernias, gall bladders".

And medical practice has moved on. "The majority of elective surgery gets performed in private settings," says Spigelman, professor of surgery at the University of NSW and clinical associate dean at St Vincent's Hospital.

The private system - heavily underwritten by the Federal Government's private health insurance subsidies - will have to take on its share of the training burden, Spigelman says, and the Federal Government has recently begun to allow private hospitals to bid for registrar places.

But that raises a different conundrum: how to present the idea to a patient that a trainee will remove their cataract when they have paid good money to be able to choose an elite surgeon. "How are we going to ensure they cannot only watch, but do?" Spigelman asks.

Beyond the practicalities of shunting an expanding roll call of juniors through their paces, Spigelman believes cultural shifts within medicine may inhibit long-standing informal training practices.

The present generation of senior doctors undertook their medical degrees largely free of charge, on Commonwealth scholarships. "The majority see [training] as handing on the baton … that they have a moral and ethical obligation to train the next generation, in a pro bono fashion," he says.

But a new generation of full-fee paying medical students may carry heavy financial debts without a comparable debt of gratitude, breaking that unspoken social contract.

Joga Chaganti has had more cause than many to reflect on how to balance what medicine has given to him against what he can contribute through it. In Sydney, his research will focus on cellular changes in the optic nerve that might predict the course of multiple sclerosis and HIV-related dementia.

"To be what I am today, the huge experience I have behind me, the money that was spent on my education by my hospital, by society, that has been a loss [to India]," the Hindu doctor says. "If and when God permits, I want to set up at least two or three primary health care centres for people in need in my country, even if I don't go back."

However, as he points out, the brain drain works two ways. His home town of Bangalore, an information technology centre, draws foreign specialists from around the world.

For now, Chaganti has applied for permanent residency, and his wife, also a radiologist, is applying for the right to practise here. "I can't look at the far distant future," he says. "We would like to stay here until my children settle down."

There has always been a mismatch between medical student numbers and projected demand for doctors. This is due to many factors including:

• the long lag time between the intake of medical students and their permanent placement as a specialist or otherwise,
• doctors go through various stages in their careers, and that there is fluctuating demand for junior and senior doctors at the same time,
• the variety of specialty paths that doctors can follow, and the fact that not all specialties are equally in demand,
• the resources available for medical training are supervised and assisted at many levels, between universities, hospitals, medical colleges and societies, State and Federal Governments, not all of whom agree or even talk to each other,
• the rapidly increasing health expectations of the community and the medical community,
• the widespread lifestyle changes adopted by current-generation doctors (more part-time work, fewer solo practices),
• the temptation of quality, well-paid overseas postings.

All of the first-world countries use overseas doctors as a flexible employment pool - to fill in vacancies caused by a lack of effective workforce planning and fluctuating demand. I'm not saying that managing medical workforces are easy... after all, the way that we do it currently is more like one hand trying to control global warming while the other tries to stop it raining in Beijing. Hmm... maybe that didn't make sense.

Unfortunately for the developing nations that invest great amounts of money in training these doctors who get sucked into the brain-drain vortex, they lose money and staff at a steady rate, while we gain cheap labour, and a workforce that will just go elsewhere when either we or they are tired of the arrangement.

Doctors and Terrorists

The Glasgow car-ramming incident and the attempted car bombings in London have featured heavily in the news recently, even more so because the alleged perpetrators have been identified as doctors, and further links to doctors and health professionals in the UK and Australia are being pursued.

These were deplorable acts, and serve no positive purpose.

I am not really interested in commenting on these events, because I think that it says little about the medical profession.

I am, however compelled to comment on this opinion article by Dr Tanveer Ahmed: The Rough Road from Carer to Killer

I'm sure that Tanveer is a smart guy. He certainly does his share for the AMA and Doctors in Training. I lost his point a little though. Is he saying that there is a concrete link between doctors and terrorists or not? Does being a doctor make you more likely to be a terrorist?

A few examples of radicalised doctors mean nothing to me. Every few months I get a newsletter from the Medical Board describing cases of doctors who have made various ethical errors. Does that mean that being a doctor makes you unethical?

I suspect that he has no intention of implying that doctors are more likely to become radicalised, or that radicals are more likely to be Islamic - but that is how his article comes across. I think his purpose was merely to point out the ironic juxtaposition of a healer being a killer, but that message is lost in the rest of the text. In reality, I think all that he does is reinforce a social stereotype that you might see in a bad Hollywood movie.

As far as I am concerned, doctors are just people. And sometimes people do bad things. There you go.