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.
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.