Risks of complaints and adverse disciplinary findings against international medical graduates in Victoria and Western Australia

Australia has a shortage of doctors, particularly in rural areas.1,2 Like many other developed countries with this problem, its policy response has involved heavy reliance on the immigration of doctors whose primary medical qualification is from another country.3-5 Numbers of international medical graduates (IMGs) have grown to nearly 25% of doctors in Australia.1 The United States, United Kingdom, Switzerland, New Zealand, Sweden, Canada and Ireland have similar or larger proportions of IMGs in their medical workforces, and the prevalence of IMGs in Organisation for Economic Cooperation and Development countries has grown rapidly over the past decade.3

The effects on quality of care are unclear. Although some high-profile cases featuring incompetent IMGs have ignited public concerns,6,7 the evidence base is relatively thin and somewhat confusing. Previous international studies have compared IMGs to their domestically trained counterparts in relation to patient outcomes of care8,9 and risks of complaints and disciplinary action.10-17 Results from these studies run the gamut: most have found no association,9-14 but IMG status has also been found to be associated with higher15 and lower16 complaint-related risks. No research of this kind has been conducted in Australia.

Complaints to medical regulatory authorities are a useful, albeit imperfect, marker of quality.18-20 They capture both objective and subjective dimensions of patients’ care experiences and, unlike most outcome-based quality measures, can generally be examined at a “whole-of-population” level. In the IMG context, complaints to medical boards have the added advantage of being connected to the agencies that regulate doctors, which means that any heightened risks identified have immediate policy relevance.

We analysed a large sample of complaints lodged with medical boards in Victoria and Western Australia. Collectively, these two states account for about 37% of the nation’s registered doctors and 37% of IMGs.1 Our twin goals were to determine whether IMGs were disproportionately likely to attract complaints, and to analyse the extent to which that risk varied across countries of qualification. In addition, recognising that a variety of factors, including cultural misunderstandings and racism, may drive groundless complaints, we followed the complaints through the disciplinary process to test whether rates of adverse findings against IMGs and Australian-trained doctors differed.

While previous research has consistently shown that certain doctor characteristics, such as male sex,21 are positively associated with complaint risk, the international evidence regarding IMG status as a risk factor is less clear. Two studies10,11 have found no relationship between IMG status and complaint frequency, although one recent analysis from the UK found that IMGs had disproportionately high rates of referral to the National Clinical Assessment Service.22 Other studies have focused on the relationship between IMG status and the outcomes of complaints — specifically, the incidence of adverse findings — and the results from these studies are mixed.12-17 A recent study17 comparing UK-trained doctors with two groups of IMGs (those who qualified elsewhere in the European Union and those who qualified outside the European Union) found that inquiries made to the General Medical Council about both non-UK groups were more likely to attract “higher impact” decisions at each stage of the complaints and disciplinary process.

In finding higher risks among IMGs in Australia, our study extends previous analyses in two directions. First, we profile complaint risk by country of training. A noteworthy limitation of the international research into complaints against IMGs is that they consider IMG status crudely, comparing domestically trained doctors to IMGs en masse or in broad groupings. By this logic, Nigerian-trained and New Zealand-trained doctors working in Australia would both be classified as IMGs. The wide spectrum in risk we identified highlights the perils of considering IMG status in this unitary manner. Similar or lower risks among doctors trained in some foreign countries may attenuate or mask heightened risks among doctors trained in others. It seems plausible that this type of variation underlies the null effect found in most previous studies.

Second, rather than simply focusing on the beginning of the disciplinary process (the occurrence of a complaint), we examined outcomes of the process as well. We found that IMGs also had higher risks of adverse findings. This result is consistent with findings from the analysis of adjudications at successive stages within the UK’s General Medical Council.17 It was not feasible in our study to examine risks of adverse findings by country of training because, with only 373 adverse findings across the study sample as a whole, the analysis was underpowered to reliably detect significant differences.

Why is medical training in certain countries associated with higher risks of complaints? Unfortunately, our findings provide no clear answer. The “at risk” countries we identified share some similar features: English is not the primary language, and all have medical education and health systems that are quite different to Australia’s. However, this explanation is incomplete because the same can be said of several other countries (eg, Bangladesh, China) whose trainees did not exhibit higher risks of attracting complaints. Complainant factors may also play a role, with higher risks of complaints against doctors from some countries possibly reflecting cultural biases. More research is needed to elucidate the reasons for the inter-country differences.

Our study findings should be interpreted in light of the fact that multivariable models estimate the strength and significance of the association between IMG status and complaint risk, not the contribution of IMGs to the overall burden of complaints and adverse findings. Despite disproportionately high complaint rates among doctors trained in certain countries, their contribution to total complaints was small. For example, Nigerian-trained doctors were responsible for only 21 complaints and Polish-trained doctors for only 28 complaints. Consideration of total complaints spotlights India as especially important. Indian-trained doctors had 60% higher odds of attracting complaints than Australian-trained doctors and they accounted for 5% of total complaints lodged during the study period.

Our study had limitations. Complaints to medical boards are merely one marker of quality — they are a kind of sentinel-event surveillance system best suited to flagging problems with care that are both highly visible to patients and which provoke high levels of dissatisfaction.18,19 In addition, we did not have access to information on doctor specialty, complaint type and practice type (eg, sole versus group versus hospital). Inclusion of that information in future research may help shed light on why some IMGs are more complaint-prone than others.

The recent move to a national registration framework should expand opportunities for research in this area. Registration and notification data held by the Australian Health Practitioner Regulation Agency (AHPRA) include specialty and some information on complaint types, cover all states and territories, and capture analogous information on nurses and other types of health professionals. However, because national boards have been in operation for only 2 years, and state-level data from previous years is incomplete and difficult to merge, it will be several years before AHPRA data are ripe for such interrogation.

Findings from this study should provoke and inform discussion about more sophisticated approaches to regulating IMGs. Australia currently has a fast-track system of assessment — the “competent authority pathway” — for medical graduates from five countries (UK, Canada, US, New Zealand, Ireland) in which the quality and similarity of training is regarded as broadly equivalent to domestic programs. (Reassuringly, in our analysis New Zealand and the UK and Ireland had complaint rates that did not differ from those of Australian trainees.) Many other countries operate similar fast- and slow-track systems.

Which countries of training belong in fast-track groups, and on what basis? Should graduates from particular countries be singled out for especially rigorous registration and oversight, including start-up assistance with integration, and ongoing support, mentoring and monitoring? How many tracks are appropriate? By probing the relationship between the country of training and a quality measure, our study casts the spotlight on the logic of existing pathways and highlights the potential value of establishing new pathways. Any moves toward greater regulatory tiering should be evidence-based, both to defend against charges of parochialism and racial profiling and to maximise prospects of delivering real benefits to the health system in terms of improved safety and quality.