Australian policy on overseas-trained doctors

The rapid increase in use of overseas-trained doctors (OTDs) in Australia’s medical workforce is a consequence of a government decision in the early 1980s to cap the number of entrants to Australian medical schools. This decision flowed from projections of the medical workforce which indicated that, as a consequence of previous rises in medical training levels and continued high migration of OTDs to Australia, the doctor-to-population ratio in Australia was too high.1 Until recently,2 there have been no increases in medical students, despite a rapid increase in the nation’s population and the growth in per-capita demand for medical services.

There was a decline in the doctor-to-population ratio (from 485:1 to 413:1) over the decade 1986 to 1996.3 This, with the increased costs of Medicare, contributed to the stance of the Australian Medical Workforce Advisory Council (AMWAC) by the mid-1990s that any gaps in the supply of doctors in Australia were due to maldistribution of the medical workforce rather than an underlying shortage.4 This perception underpinned the government’s 1996 legislation requiring all future medical graduates who wished to practise as general practitioners to complete a postgraduate family medicine course first. The annual number of training places allocated for those wishing to enter the program was initially limited to 400.5

One outcome, which first led me to question AMWAC’s “maldistribution” thesis, was the finding that hundreds of permanent-resident OTDs, who were yet to complete or had failed the Australian Medical Council (AMC) examinations, were being employed in these junior public hospital positions in Victoria and other states.6 Furthermore, by the end of the 1990s there were not enough fully registered junior doctors to fill all the training places available in the various specialty programs. This, with federal government limits (based on AMWAC advice) on the number of training places being financed, resulted in some specialties having too few trainees to provide routine hospital-based services (eg, surgery) and insufficient fully trained fellows to meet patient demands.

These shortages have prompted increasing recourse to the recruitment of OTDs. The main pathways by which they have entered Australian medical practice are as temporary resident OTDs, occupational trainees or permanent resident OTDs. The conditions for these designations are described in Box 1.

By 2004 there were some 2000 visa category 422 OTDs and a further 1500–2000 visa category 442 OTDs working in medical positions in Australia (estimates based on unpublished Department of Immigration and Multicultural and Indigenous Affairs [DIMIA] stock counts for visa subclass 422 and numbers of occupational trainees registered with state medical boards). These numbers are likely to increase as a consequence of the federal government’s Strengthening Medicare initiatives to encourage recruitment of OTDs9 and pre-election promises of more doctors and nurses, including expansion of medical training in Australia. However, as the benefits from these training initiatives will not be experienced for another 8 to 10 years, it follows that dependence on OTDs will increase.

There is no national standard for the appointment of OTDs in Australia. By contrast, in Canada, the United States and the United Kingdom an OTD must pass a test of English, medical knowledge and clinical skills before being allowed to practise. In Canada and the United States, OTDs are also required to serve in a probationary hospital residency position.

In Australia, each state medical board has developed its own set of rules. In the case of occupational trainees, these vary according to whether the OTD is appointed to a training program within a medical specialty or to a general hospital position. In some specialties the relevant college assesses the applicants’ credentials. In others, this involvement is less evident. In the case of general hospital positions, the employing hospital makes the assessment, which is then accepted without further evaluation of the OTD’s skills by the relevant state medical board.

As regards “area-of-need” positions, the employer makes the final decision, although usually after an assessment by a professional recruiting intermediary. These generally base their judgements on a review of prospective candidates’ curricula vitae, sometimes accompanied by an international telephone interview. Only in a few cases is there any systematic evaluation of the medical knowledge and clinical skills of the appointees. Again, the state medical boards usually accept the judgement of employers without any direct involvement in assessment of the candidates. New South Wales is an exception. There are relatively few “area-of-need” appointments in NSW, but, where they are made, the NSW Medical Board assesses candidates by means of a face-to-face interview covering clinical skills and conducted by clinicians familiar with the relevant area of practice. The main task of medical boards is to check that the medical qualifications and experience of the appointees are as claimed. Until recently, most of the medical boards did not require OTDs to pass an English test. However, most now have instituted such a test, or will do so in the near future.