Nationally consistent assessment of international medical graduates

Australia, like many developed countries, relies on international medical graduates (IMGs) to supplement its locally trained workforce. In response to the growing realisation that the number of medical graduates being trained in Australia would have been inadequate to meet demand into the future, the previous federal government increased the number of places at Australian medical schools significantly, and established a number of new medical schools.1 However, the time between commencement at medical school and full and independent participation in the workforce ranges between 8 and 13 years, so Australia is likely to rely on IMGs to fill gaps for at least the next 10 years.

IMGs fill the spectrum from recently graduated doctors who come to Australia to take hospital or other positions for short periods, through to senior specialists working in metropolitan hospitals or academic institutions for the long haul. Although many come from countries in which English is the first or second language, many come from other countries, and an increasing number have undergone training in China and Eastern Europe (Ian Frank, Chief Executive Officer, Australian Medical Council, personal communication).

Assessment processes for IMGs have varied depending on the location and the nature of the positions for which they have applied. There are medical registration requirements set by the state or territory medical board, training and experience requirements set by the relevant college, and suitability requirements for the specific position set by the employing authority. Each body that sets requirements relies on some information or assessment by the other bodies. For IMGs who intend to practise privately, there is further assessment by the Australian Government Department of Health and Ageing for the purposes of obtaining a Medicare provider number so that their patients can access Medicare benefits for treatment. Although the Australian Medical Council (AMC) has had a defined role in assessing IMGs for a number of years, and has developed well regarded multiple choice question (MCQ) and clinical examinations that must be passed before unconditional or general registration, most IMGs currently registered to practise in Australia have not completed the AMC examinations.2 Their registration is conditional and they practise in areas of unmet workforce need.

Recent data indicate that around 31% of general practitioners in Australia are IMGs, although the proportion is greater in rural and remote areas (37%) than in urban areas (28%).3

The lack of a mandatory nationally consistent assessment process and local workforce requirements have, in some cases, led to unintended consequences; in the most notable case — that of Doctor Jayant Patel in Queensland — there have been adverse effects on patient outcomes.4

In their December 2005 research report, Australia’s health workforce,5 the Productivity Commission noted widespread support for national standards for assessing IMGs, while noting the concerns about the impact of any changes that might reduce the flexibility of current arrangements.

At its meeting in February 2006, the Council of Australian Governments (COAG) agreed “to a national assessment process for overseas qualified doctors to ensure appropriate standards in qualifications and training as well as increase the efficiency of the assessment process”.6 It was agreed in July 2006 that “health ministers will implement initiatives to establish by December 2006 a national process for the assessment of overseas-trained doctors”.7

As a general principle, the screening, assessment and supervision requirements for IMGs wishing to work in Australia should be based on the risk associated with the position for which they are seeking registration, and on the qualifications and experience of the IMG. The pre-existing AMC examination path leading to the AMC certificate will continue to be accessible, but the new approach to assessment provides a variety of pathways to registration depending on IMGs’ previous training and assessment, knowledge base, clinical skills, and the suitability of their skills and experience for the position for which they are applying.

An overview of the process, using the new standard pathway as an example, is given in Box 1. This shows how non-specialists with a range of training and experience can be matched against the intrinsic risk of the positions they are applying for, and how the assessments and supervision can be tailored appropriately. Similar matrices have been developed for specialists. The concept of this matrix was largely developed by Dr Alison Reid of the Medical Board of New South Wales and Deputy Chair of the AMC Expert Panel.

The term “competent authority” is used broadly in the area of international relations whereby countries mutually recognise the certification of goods or qualifications provided by agencies in other countries to facilitate free trade. The competent authority pathway allows IMGs who have completed prescribed examinations or accredited training in countries that have both a similar health care system, and similar training, assessment and registration systems to those in Australia to receive advanced standing towards the AMC certificate. This means they are not required to undertake the AMC examination, although they will need to undertake workplace-based performance assessment. Currently, registration by the competent authority pathway is possible for IMGs from the United Kingdom, Ireland, Canada, the United States and New Zealand, although other countries may be considered in the future.

In addition to the pre-existing AMC examination pathway (comprising MCQ and clinical examinations),8 which will continue to be available, a new standard pathway and a new competent authority pathway will be available for both non-specialists (including those who are applying for hospital non-specialist positions and those applying for general practice positions who are not trained and recognised as GPs in their country of origin) and specialists (including those who trained and are recognised as GPs in their country of origin).

Most of the specific developments relating to assessment of overseas-trained specialists (in this context, the term specialist excludes those who have undertaken general practice training) were undertaken by the AMC Joint Standing Committee on Overseas Trained Specialists. A recognised pathway for assessment of overseas-trained specialists existed previously, but there was variability in its application between colleges and between jurisdictions.

While many of the new processes for non-specialists will also apply to specialists, there are a number that are unique to specialists — some existed for some specialist colleges previously, but under the new arrangements there is a move towards a common approach for all colleges.

The processes for which there will be a common approach include:

• classifying overseas-trained specialists (in comparison with Australian-trained specialists) as “substantially comparable”, “partially comparable” or “not comparable” (previously, colleges had used different terminology);

• allowing those who are considered “substantially comparable” to gain fellowship without the need for further examination (some colleges previously required examination, even for substantially comparable specialists, but now most do not, and the remainder are moving in this direction); and

• allowing assessment of suitability for an area-of-need position and of additional requirements to gain college fellowship to occur simultaneously (previously, this would have required two similar assessments at different times, but now a single assessment can be done at the beginning of the process and any additional requirements highlighted).

Box 2 summarises important milestones, past and future, in the process of implementing nationally consistent procedures for assessing IMGs. As the implementation is a work in progress, some of the information in this article may have been superseded by the time of publication. Information will be made available publicly as it becomes available, and the AMC and jurisdictional websites will be regularly updated. Relevant websites are shown in Box 3.

1 Standard pathway for the assessment and registration of international medical graduates