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.