10 Year Challenge

Seasoned readers may recall my previous post "10 Years in Limbo" about the 10 year moratorium placed on overseas-graduated doctors.

The 10 Year Moratorium applies to New Zealanders as well, as despite their special visa status they are not considered permanent residents even when enrolled in Australian Medical Schools, and the only way around this is to obtain permanent residency prior to commencing Medical School in Australia.

Well, Dr Mike Belich wants to do something about that, and he has challenged the validity of the 10 year lockout and is currently going through the courts, as reported in The Australian. To be honest, I don't really understand his argument for seeking an exemption from the current rules... but I guess this is how precedents are set.

No doubt all the New Zealander's over at Paging Dr will be all excited. I better go let them know...

GP goes to court fighting country duty - The Australian
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GP goes to court fighting country duty
The Australian
Adam Cresswell, Health editor | August 15, 2009

A NEWLY qualified general practitioner has launched a David and Goliath legal challenge to the head of Medicare, filing a Federal Court action over a ruling he says will force him to abandon his home and partner and spend the next 10 years working in the bush.

Byron Bay doctor Mike Belich passed his postgraduate exams to qualify as a GP three months ago but is on borrowed time in the northern NSW coastal resort because of a retrospective ruling by Medicare that he was an overseas student when he enrolled at the University of NSW in 1999.

The ruling means he is subject to a moratorium set up by the Howard government in 1996 that forces overseas-trained or foreign-origin doctors to work for 10 years in the outback before attaining the right to practise where they like under Medicare.

Belich could not apply for permanent residency when he first moved to Australia with his family at age 14 because as New Zealanders they were considered to be, effectively, permanent residents already. He became an Australian citizen while at university, but later found out that the day he started medical school was the cut-off point used to classify him as an overseas student. He's challenging the ruling as unfair and beyond parliament's original intentions.

If successful his case, lodged with the NSW registry of the Federal Court this week, could affect up to 100 other doctors of New Zealand origin who, it is understood, may be in a similar position.

Belich tells Weekend Health that while at university he was treated the same as a local student, to the extent that he graduated with a HECS debt.

He was first informed of Medicare's decision to classify him as an overseas student when he applied to join the GP training program, more than a year after he had qualified as a doctor and when an Australian citizen.

He says his case is a fight for "natural justice and transparency".

"They have gone against the intention of the law, and have acted in a way to get me and 100 other people into a 10-year binding contract where we had no idea (this would apply)," Belich says. "I'm not going to work where they want me to work ... the government has spent all this money training me as a GP, they are short of GPs and they need a GP here in Byron."

Belich, who has recently bought a house with his partner in Byron Bay, says subsequent attempts to overturn the decision - including direct appeals to then federal health minister Tony Abbott and his successor Nicola Roxon - have brought sympathetic noises but no practical concessions.

The situation has been in limbo during Belich's four-year period of GP training, when he was allowed to continue working in Byron Bay under a temporary exemption from the 10-year rule.

But with his GP fellowship secured, the exemption is due to expire on October 19. Belich says he cannot comply with the 10-year rural service order because his partner is unable to leave the area under the terms of a Family Court order granting her former partner access to their two children.

Belich's solicitor Adam van Kempen, partner with the Byron Bay law firm Bottrill van Kempen, says Belich is asking the Federal Court to make a declaration that Belich is not a former overseas medical student under the terms of the Health Insurance Act.

Further, the case, which cites the chief executive of Medicare Australia as the respondent, seeks a declaration from the court that the act does not prevent Medicare benefits being paid in respect of services Belich provides.

Other doctors who may be affected by the outcome of the case will be New Zealanders who study in Australia under the same conditions as Australian students but who later are told by Medicare that different rules will apply, van Kempen says.

"The contention is that the legislation has captured this group of people and it was an unintended consequence of the legislation," van Kempen says.

Given the October 19 deadline, van Kempen says he expects there will be an application for the case to be heard urgently.

In a letter sent by then Royal Australian College of General Practitioners president Michael Kidd to Abbott in July 2006, Kidd says it is "evident ... that the Department of Health and Ageing's classification of Dr Belich as a 'former overseas medical student' appears to be a contradiction to the information publicly available" from the Department of Family and Community Services,

Department of Education, Science and Training, Department of Immigration and Multicultural Affairs and other agencies.

Kidd concludes that the college believes the moratorium should not apply to Belich and requests Abbott "use (his) ministerial discretion ... to overrule this restriction and allow Dr Belich to practise freely".

A Medicare Australia spokeswoman says it would "not be appropriate ... to comment on foreshadowed legal proceedings".

Haneef's Christmas Present

This is really just a followup post to mention that Dr Mohammed Haneef has finally jumped all the hurdles to retain his working visa and return to work in Australia as a doctor.

Perhaps his trip to Mecca has made all the difference, perhaps it is the Federal Court giving him a Christmas Present. It doesn't matter - common sense has prevailed.

And as for the rest of you, may you all make the most of the holiday season! I will be spending my holidays on call yet again!

Haneef keen to return to Gold Coast - The SMH
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Haneef keen to return to Gold Coast
December 22, 2007 - 7:15PM

Former terrorism suspect Mohamed Haneef is keen to reapply for his position at the Gold Coast Hospital after the federal government yesterday paved the way for his return.

New Labor Immigration Minister Chris Evans said the Indian national was entitled to return to work after the full bench of the Federal Court upheld a judge's earlier decision to reinstate his work visa.

The doctor's visa was withdrawn by the former Howard government on character grounds despite terrorism charges against him being dropped.

Dr Haneef's Brisbane-based lawyer Peter Russo today informed the devout Muslim, who is currently in Mecca with his wife and mother, of Mr Evans' decision not to appeal the court's ruling.

Mr Russo said Dr Haneef was pleased with the news but had been hard to contact because he was in prayer at the annual religious pilgrimage.

"When I spoke to him yesterday it was prior to the minister making the announcement," Mr Russo told AAP.

"He is very, very happy and keen to talk to his family to resolve any outstanding issues with them and then try and get organised to come back."

The doctor has agreed to speak to Australian media from Mecca on Monday afternoon.

Mr Russo said Dr Haneef was due to return to his Indian home in Bangalore in early January when he would investigate options to return as a medico to Australia.

"He's got to get his medical registration first and if there is a position available there, I understand (the Gold Coast Hospital) is going to be his preference," Mr Russo said.

A Queensland Health spokeswoman said Dr Haneef was considered a competent young doctor by colleagues at the Gold Coast Hospital.

"If he is in a position to seek employment, Queensland Health would be happy to consider his application," the spokeswoman said.

She said he would first have to obtain a work visa from the Commonwealth and appropriate registration from the Medical Board of Queensland.

Mr Russo said his client would also try to organise a visa for his young baby daughter and wife Firdous, who continued to harbour concerns about their return following their treatment at the hands of Australian authorities.

Australian Federal Police arrested Dr Haneef at Brisbane International Airport on July 2 as he attempted to board a one-way flight to India, just days after failed UK terrorist attacks.

He was held for 12 days before finally being charged with providing support to a terrorist organisation for giving his mobile phone SIM card to his cousin Sabeel Ahmed, one of the men accused of the attempted UK bomb attacks.

The charge was dropped a fortnight later after Commonwealth Director of Public Prosecutions Damien Bugg found there was no reasonable prospect of securing a conviction against the 27-year-old.

But former immigration minister Kevin Andrews had already cancelled his visa on character grounds, meaning Dr Haneef was unable to return to work.

A full judicial inquiry will now investigate the saga.

AAP

Triumph for Haneef in terror farce - The SMH
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Triumph for Haneef in terror farce
Cosima Marriner, Tom Allard, and Amrit Dhillon in New Delhi
December 22, 2007

THE former terrorism suspect Mohamed Haneef is free to return to Australia after a court victory for the doctor yesterday, but the new Labor Government may pass laws to ensure it can reject foreigners with questionable links.

The full bench of the Federal Court dismissed the former immigration minister Kevin Andrews's appeal against a decision to reinstate the Indian doctor's visa.

The court found the law did not allow the government to revoke a visa on character grounds simply because a person had an "association", no matter how innocent, with an unsavoury individual.

But the new Immigration Minister, Chris Evans, has reserved the right to change the Migration Act if the verdict sets the bar too high to revoke a visa on character grounds. Senator Evans is also not ruling out a High Court challenge to yesterday's ruling, although he said this was unlikely.

Dr Haneef's brother, Shuaib, said that he told his brother about the verdict on the telephone from Bangalore. "He said that it was what he had been expecting all along but he was relieved that it had turned out the way he expected," Shuaib said.

Dr Haneef is on the Muslim pilgrimage to Mecca with his wife and mother-in-law. The Queensland Premier, Anna Bligh, said he would be welcome back in the state's hospital system.

Dr Haneef was working at Gold Coast Hospital before he was arrested on July 2 while trying to leave Australia on a one-way ticket to India. Mr Andrews cancelled his visa on the grounds that he failed the character test because two of his second cousins were allegedly involved in British car bomb plots, and he had been communicating with one of them, Sabeel Ahmed, just days before he tried to leave Australia.

Dr Haneef was charged with "intentionally providing [a mobile phone SIM card] to a terrorist organisation". This was dropped on July 27 after it was revealed the SIM card was in Liverpool, nowhere near Glasgow Airport, where Sabeel's brother, Kafeel, rammed a burning Jeep into a terminal.

The Federal Court's Justices Black, French and Weinberg agreed with the August finding of Justice Spender that Mr Andrews had applied "too wide" a definition of Dr Haneef's association with the Ahmed brothers. They rejected the minister's argument that it "did not require any suspicion that Dr Haneef was sympathetic to, or supportive of, or in any way involved in the criminal conduct of which the Ahmeds were suspected".

A spokesman for the Haneef family in India, Imran Siddiqui, said they had hoped for an apology from the Government.

"We were hoping that it would say it regretted what had happened to Haneef and that it would welcome him back and give him a helping hand to see what can be worked out for him in Australia," Mr Siddiqui said. He indicated the family could seek compensation. Dr Haneef has not worked since leaving Australia.

Queensland Health said Dr Haneef was considered "a competent young doctor". Ms Bligh said: "If Dr Haneef satisfied the visa requirements and the registration requirements, I would be very pleased to have him … We have a lot of pressure on our hospitals. We want to see qualified doctors working in them as soon as possible."

After reviewing the latest federal police material on Dr Haneef, Senator Evans said: "There are no grounds to take further action in relation to [his] visa." But he said: "Should any further relevant information come to light in relation to Dr Haneef, I will re-examine the situation at that time."

Senator Evans's lawyers sought to stay yesterday's ruling pending a possible High Court challenge. The court rejected the application.

10 Years in Limbo

As a follow-on to a recent discussion thread over at PagingDr, I had cause to review the effect of the 10 Year Moratorium on Medicare Provider Benefits.

This has been a big deal because it effectively limits non-Australian Citizens or Permanent Residents from gaining access to Medicare Provider Benefits.

You may recall from the first instalment of my Mind the Gap Series that outside of the public hospital system the Federal Government funds medical services via the Medicare system (including the PBS and the Commonwealth Medical Benefits Schedule [CMBS]).

This renders the Federal Government extreme power and influence over who delivers medical care to the community via the allocation and restriction of Provider Numbers, and also how that care is delivered via limitations, restriction and conditions placed upon services before they are eligible for reimbursement via Medicare.

Note that this is a relatively roundabout method of control over medical practitioners. The Federal Government does not tell doctors what to do. They merely tell doctors that unless they do things in a specific way, satisfying Medicare guidelines and Ministerial Determinations, that their patients will not be able to have their medical costs reimbursed.

Therefore in theory it is not the doctor who is being punished, but the patient. Unfortunately, the doctor is the one that the patient sees face to face. The bills and invoices carry the doctors name. If the patient can't get money back from Medicare or their insurance company, it is the doctor they complain to, not the 17 year old counter chick at the Medicare office, or the faceless call-centre operator on the end of the phone line.

And if you are unfortunate enough to be one of the 90% of doctors that do not get payment upfront then you end up unpaid because the patient can't get their Medicare reimbursement.

What does this have to do with the 10 Year Moratorium?

Well, the 10 Year Moratorium is one of the limitations (along with Bonded Medical School Places) that the Federal Government applies to restrict access to Medicare benefits. It's purpose is to encourage doctors to enter and remain in the public hospital system, or to work in "areas of need" as defined by Medicare, brought in as part of John Howard's 1996 Provider Number reforms (More Info).

It applies to Overseas-Trained Doctors who migrate to Australia as well as non-citizens and non-permanent residents who commence studying medicine in Australia.

Basically if you fall into the target population, patients who see you in private (in your clinic or rooms) or on whom you operate in a private hospital will not have their medical costs reimbursed or subsidised by the Federal Government. In a system where patients are accustomed to paying little or nothing out-of-pocket this is tantamount to shutting these doctors out of the market, unless you do what the Government tells you to, and work where they tell you to work.

Fine, it's primary purpose is to encourage doctors into "areas of need". But what about non-resident doctors who gain their medical qualifications in Australia? These include full-fee paying students from overseas, as well as New Zealanders (who are on Special Category Visas) who study medicine in Australia. These students take up valuable medical school positions, but are discouraged from working in Australia for 10 years after their graduation, when they have careers they can easily go to in New Zealand and elsewhere.

Furthermore, they aren't banned from working in Australia - only from working outside the public hospital system. That means that they are free to pursue their specialist qualifications and postgraduate degrees (but GP trainees have to enter the Rural Training Program). After this, however, they have to go overseas or off to the bush (which increasingly means outer metropolitan urban fringes) to bide their time.

It seems a colossal waste of university and hospital resources to train people who can easily avoid the rest of their Provider Number limbo by heading overseas (and most likely never returning).

But then again, maybe the Department of Health knows what it's doing...

Exemption guidelines for doctors need fixing: report - The Australian
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Exemption guidelines for doctors need fixing: report
The Australian
Sean Parnell | November 17, 2007

THE much-criticised system of regulating overseas-trained doctors has been dealt another blow, with the Department of Health and Ageing confirming the existence of a damning internal report on its distribution of Medicare provider numbers.

Two years after the furore over the alleged criminal malpractice of foreign doctor Jayant Patel in Queensland, which prompted a concerted reform push across Australia, the commonwealth is under fire over its use of overseas-trained doctors to fill gaps in primary care and private practice.

Section 19AB of the Health Insurance Act stops overseas-trained doctors receiving Medicare benefits for 10 years, unless, as temporary residents, they agree to serve in an area of need known as a District of Workforce Shortage. At the end of October, 4148 overseas-trained doctors had been given exemptions -- double the 2004 figure.

More of Australia is being classified by the department as a District of Workforce Shortage and, with the staffing crisis now reaching into the suburbs, its own research has found Section 19AB exemptions are considered vital to filling outer metropolitan GP vacancies.

But a report commissioned by the department last year pointed to serious flaws in the Section 19AB process, which has existed since 1997 and is now covered by six-year-old guidelines.

A department spokeswoman confirmed doctor Eleanor Long, a renowned Australian medical education consultant, had used her report to recommend the guidelines undergo "major revision".

According to the spokeswoman, Long wants the validity of the guidelines improved as they apply specifically to GP numbers through an overhaul of the District of Workforce Shortage process.

Long believes more attention should be given to the factors leading to shortages, and how the department should assess District of Workforce Shortages and applications for an exemption from Section 19AB.

The spokeswoman said Long also wanted the department to improve the reliability of the guidelines through the development of a proper assessment tool, in effect doing away with a largely discretionary process.

Yet despite the findings, the spokeswoman said the guidelines were only being monitored and a statutory review of Section 19AB was not due until 2009-2010.

Her comments suggest a review has been considered and delayed, given a department spokesman in July said a review of the guidelines would be undertaken within a year "with input from medical professional peak bodies".

Efforts by Weekend Health to obtain a copy of the otherwise secret report have failed. Long is restricted by a confidentiality agreement, and a freedom of information application was rejected on the grounds that a review may yet occur and the information contained in Long's report might undermine the system.

David Dennis, assistant secretary of the department's Workforce Distribution Branch, ruled "to the extent that the document exposes weaknesses or 'loopholes' in the current scheme, disclosure could compromise the integrity and viability of the decision-making process in granting or rejecting exemptions".

Dennis warns of a premature public debate on the issue if the report is released. "This has the potential to disrupt the policy review process, delaying the important reforms which are intended to improve the operation of the legislation; and disclosure could disrupt the strong public interest or faith in the policy-making process leading to the allocation of Australia's medical workforce, particularly in relation to districts of workforce shortage."

But it appears both overseas-trained doctors and Australian-trained doctors have lost faith in the department's short-term response to the doctor shortage.

Surgeon Russell Stitz, chairman-elect of the Committee of Presidents of Medical Colleges, says the District of Workforce Shortage process is "flawed" and hides problems in the system. Stitz says the colleges should be involved in the assessment process to determine why Australian doctors are not filling vacancies and whether, for example, it is due to a lack of support staff or infrastructure.

Andrew Schwartz, from the Australian Doctors Trained Overseas Association, says the Section 19AB guidelines are also discriminatory in that they favour temporary residents over permanent residents.

"Australian Governments all favour temporary residents because they can be more easily restricted to where they work, and kept out of the private market," Schwartz says, again accusing the colleges of market protection.

But Stitz says the colleges acknowledged the doctor shortage and believed there would continue to be scope for overseas-trained professionals to work in Australia.

He says the Section 19AB exemptions should not allow doctors to bypass Australian Medical Council assessments and all overseas-trained doctors should first work under supervision to learn the system, the culture, and where they could seek help.

"What happens with area-of-need specialists -- and you must feel sorry for them -- (is) they get brought in, often very rapidly put through the system, and sent to an area where they have no support and are expected to function in a very difficult environment."

GP shortage in outer suburbs: report - The Australian
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GP shortage in outer suburbs: report
The Australian
Sean Parnell | November 14, 2007

JOHN Howard's bid to upstage Labor with a promise of after-hours medical clinics has been undermined by a federal government report, which reveals suburban GPs are already struggling to meet demand and unable to recruit enough staff.

The confidential report, which also damages Labor's policy, was written by Woolcott Research and delivered to the Government in August.

It advises the incentives it offered general practitioners to work in outer metropolitan areas had only limited success and 68per cent of clinics felt they were still short-staffed.

"These outer metropolitan practices indicated that they were trying very hard to recruit doctors ... by various methods, but often these methods were unsuccessful and ineffective," says the report, obtained by The Australian under Freedom of Information laws.

The Prime Minister has vowed to establish 50 Family Emergency Medical Centres, half of which would be open around the clock.

Health Minister Tony Abbott argues the centres would complement existing clinics, unlike Labor's plan for GP superclinics on predetermined sites, which he claimed would compete with established practices.

But while training more doctors has bipartisan support, GP shortages will continue for several years.

The Woolcott Research report and the decline in bulk-billing indicates policies that congregate GPs at certain sites will only force patients to travel further for treatment.

The report questions the Government's ability to address the maldistribution of doctors in outer metropolitan areas. Three initiatives are used to fill outer metropolitan vacancies: pay Australian-trained doctors a Relocation Incentive Grant of up to $40,000; force GP registrars to undertake a six-month placement in those areas; and offer to fast-track overseas-trained doctors into areas of need.

"Whilst these initiatives have been successful to a degree, with relatively high numbers of doctors relocating to or increasing their hours in outer metropolitan areas as a result of the Relocation Incentive Grant, as well as the placements of registrars for their six-month periods, evidence suggested that they had not been fully subscribed, and that more recent uptake of the RIG in particular was declining," the report finds.

GPs surveyed for the report found the RIG initiative was "viewed more in terms of being a retrospective bonus, and was not necessarily seen to offer sufficient incentive in itself to initiate the relocation of a GP."

Australian General Practice Network chairman Tony Hobbs - who raised concerns over the Coalition's plan for 24-hour services - said after-hours clinics would succeed only if they had enough staff.

Dr Hobbs welcomed any policy that fostered a team environment.

"What we really need, though, and it's a big call, is an over-arching primary healthcare policy in this country," Dr Hobbs said.

"What we've had is a piecemeal policy approach from both sides - something about clinics, something about practice nurses, something about dental care - but it virtually operates in a policy void without long-term, structured planning."

• Doctor Connect on Provider Number Restrictions for OTDs
  
• Health Insurance Act 1973 Section 19AB
  
• Student Doctor Forums (US) Discussion Thread
  
• Dept of Health & Ageing - Medicare provider number eligibility (section 19AA) - Temporary residents
  
• Dept of Health & Ageing - Medicare provider number eligibility (section 19AB) - OTDs
  
• GP Registrars Australia Website on the 10 Year Moratorium
  
• Tropical Medicine Training Website (source of image below)

Haneef on 4 Corners

I have previously given my opinions on the treatment of Dr Mohammed Haneef.

• Haneef, Andrews and Howard
  
• Terrorist Medical Politics
  
• Playing Politics with Other People's Lives
  
• Global Doctor Trading

Tonight's 4 Corners program on the ABC has given a good summary of the situation so far.

The Flash Video version is here. Also available is some background reading from 4 Corners as well as the program transcript

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

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.

Hospitals Behaving Badly

Why is it that I only seem to see bad news? Is it, as Barbados Butterfly points out, that feel-good, all-goes-well news is not interesting?

Well, a little while ago this piece of masterful journalism was brought to my attention concerning an NHS trust in the UK being fined for inadequately supervising its Senior House Officers. The Australian link lies in that one of the SHOs was employed in Perth prior to departing for the UK. No doubt Dr Crippen will be familiar with it.

Hospital faces up to patient death - BBC News 11 April 2006

Nearly six years later, the Southampton University Hospitals NHS Trust (SUHT) has been fined £100,000 for admitting it did not adequately supervise junior doctors in the trauma and orthopaedic department in June 2000.

Two of them - Dr A [edited] and Dr R [edited] - were convicted of Mr P's [edited] manslaughter due to gross negligence in April 2003 - and given 18 month suspended sentences.

...

The prosecution also said that if the hospital had organised daily ward round visits by a specialist registrar the chances of Mr P's [edited] condition being missed would have been lessened.

There were also issues regarding why nurses treating Patient P [edited] did not contact senior medical staff.

...

And BBC News has learned that the hospital trust never checked the previous employment reference of Dr A [edited].

Professor Allan Skirving, of the Royal Perth Hospital in Western Australia, said: "They [SUHT] never made any contact... we would not have given him a good reference.

"It became apparent within a brief period that he was not able to do anything independently."

...

Hospital trust prosecuted for not supervising junior doctors - BMJ
Hospital fined £100,000 for patient death - The Times, 12 April 2006

Now, not to draw any parallels to the "Dr Death" business in Queensland (more info), but this is the outcome of the aggressive poaching of medical (and nursing) staff from one country to another. All sorts of things can go wrong.

1. The "donor" country loses its health workforce, after investing a great deal in their training.
   
2. The "recipient" country finds it very difficult to ensure that staff meet adequate standards.
   
3. A (very) small number of incompetent health-care workers make use of this back-and-forth poaching to hide their tainted history.
   

I am not opposed to doctors moving around the world - after all, we live in a world of global trading. Some form of international recognition goes a long way towards maintaining international standards and professional parity. Perhaps it is a shame, though, that doctors are being viewed as a commodity, rather than people. I am not suggesting that I know how to fix this, as I am sure that governments of many nations have extensive independent expert advisory panels to do so, but if anything, this is a symptom of our inability to adequately train medical staff.

Unfortunately, as I recently pointed out to some colleagues, there are no such things as Key Performance Indicators for medical education or training. Hospitals and Universities do not get penalised for turning out substandard doctors or specialists. Producing and training quality medical staff does not generate a profit. Screwing the system at every available opportunity is what improves the bottom line. Unfortunately, there is only so much of the system left to screw.