The evolving role of international doctors in the Australian emergency medicine workforce

BOX 1. The measures taken by the government to attempt to address national shortages of doctors and the uneven distribution of the workforce have not been without controversy. They have included increasing medical student numbers, active recruitment of IMGs and encouraging doctors to work in areas of need – either by providing incentives or placing restrictions on where some practitioners can work.1 From 2004–2013, the annual number of medical graduates has more than doubled, with a disproportionately small increase in the number of intern places.5 This surge in medical student numbers has been highly influential in Australia's relationship with IMGs, as prevocational training positions become saturated and bottlenecks of domestically trained medical staff seeking a limited supply of vocational training opportunities occur. In 2015, nearly 3700 applications were received for just over 3200 intern positions, with approximately 200 of the applications being from IMGs.6 The political complexities of the situation are considerable. Higher education was Australia's fourth largest export in 2014.6, 7 With the number of domestic graduates alone exceeding the number of intern positions, fee paying international students and IMGs are likely to be casualties in the race to secure a coveted intern job.8 Active recruitment strategies have also been subject to ethical scrutiny, particularly recruitment from developing countries. Social commentators have described a ‘brain drain’ of health professionals from struggling economies who have little opportunity to attract replacements from overseas.9 Section 19AB of the Health Insurance Act 1973 (otherwise known as the 10 year moratorium) requires IMGs to practice in government designated districts of workforce shortage, typically rural areas, for up to 10 years from the time of their first medical registration in Australia if they wish to provide services that attract a medicare rebate.10 These policies have translated to a rural medical workforce composed of 41% IMGs1 and likely play a part in the high IMG numbers within the FACEM community. Further, the limited applicability of these restrictions within emergency medicine means the 10 year moratorium fails to address rural workforce shortages within our speciality. As such, in 2015, only 20% of FACEMs and 16% of ACEM advanced trainees had a primary workplace considered to be rural or regional in location.4 The complexity of gaining medical registration in Australia as an IMG or OTS has long been subject to scrutiny. Despite a Commonwealth Code of Practice for the International Recruitment of Health Workers11 and an extensive parliamentary inquiry into registration processes and support for all overseas trained doctors in 2012,12 few of these bureaucratic barriers have lifted.13 The AMC acts as an external accreditation body for doctors seeking to apply for registration with the Medical Board of Australia, which is a requirement for employment in Australia.14, 15 Non-specialist doctors are able to undertake a complex but purely administrative verification process, if they have completed a medical education deemed similar to that gained in an Australian medical school and if they can demonstrate registration with a ‘competent authority’ – commonly, the UK General Medical Council (GMC) or with the respective bodies in the USA, Canada, New Zealand or Ireland.16 Those from other countries must embark on the time-consuming and expensive assessment process termed the standard pathway, comprising of both written and clinical examinations curated by the AMC. More recently, seven accredited providers have been given the opportunity to host work-based assessments as an alternative to the clinical examination.16, 17 The duration of the accreditation process as it stands is a significant source of emotional and financial stress for IMGs, who are often newly arrived in Australia and may be the primary income provider for their family. This is most notable for IMGs from developing countries since the majority of doctors who are accredited via the standard pathway are from India, Pakistan, Iran, Sri Lanka and Bangladesh.16 After the 2012 parliamentary inquiry, a streamlined process emerged for the accreditation of international doctors who had gained specialist qualifications overseas.12 These OTSs are now able to pursue verification of their specialist qualifications directly with the college with whom they seek fellowship, rather than via the AMC. Emergency medicine exists in a heterogeneous form as a speciality internationally, which presents challenges to ACEM in accrediting OTSs (Fig. 1). Although this assessment process has been somewhat streamlined in recent years, it likely adds to the difference seen in average age of election to fellowship between ACEM-trained FACEMs (37 years old) and OTSs elected to FACEM (41 years old).4 Across all specialities, approximately 25% of the medical workforce in Australia are IMGs11 and 22% are OTSs.19 Congruent with this, IMGs and OTSs form a substantial, but contracting, fraction of the Australian emergency medicine workforce – from FACEMs to trainees. Of the new FACEMs who completed the ACEM training programme in 2015, more than half – 55% – were IMGs who completed their primary medical degree overseas, where 29% were from the UK or Ireland.4 Eleven per cent of all new FACEMs were OTSs who achieved fellowship following recognition of their overseas specialist qualifications – a decrease on the average from the preceding 10 years, which stood at 14%. This change reflects a decrease in the actual numbers of OTSs seeking accreditation as FACEMs and a dilutional effect from an overall increase in the number of local graduates gaining FACEM status. The majority of the OTSs had completed their fellowship in the USA, UK or Ireland. Unsurprisingly, the large IMG fraction and dynamics of this fraction is similar within the training programme. Fifty per cent of all ACEM trainees were IMGs in 2015, and 25% obtained their undergraduate medical degree in the UK or Ireland. Both the percentage and the number of IMGs within the training programme are decreasing with time, which will ultimately make IMGs a minority in both the trainee and new FACEM numbers in the coming years. Only 32% of trainees entering the training programme in 2015 were IMGs – a fraction which has nearly halved since 2009. It is of note that ACEM does not currently have a selective application process to join its training programme, unlike many Australasian specialist colleges. Perceived and actual discrimination or selective discounting of professional credentials may deter IMGs from joining other training programmes.8 Although there is limited data on the numbers of IMGs working at a pre-vocational level, there are two key demographics of junior doctors that contribute significantly to the workforce. First is the IMG from a developing country who is working for the first time in Australia. Initial rotations are commonly in ED, owing to the level of senior supervision it offers when compared with ward work, particularly if English is not the doctor's first language. Second is the ‘working holiday’ doctor, typically from the UK. They may be looking to gain their first ED experience having been unable to secure such a rotation during their foundation training. Additionally, they enjoy the flexibility of shift work, to allow travel while in Australia. The current junior doctor contract crisis within the English National Health Service has added fuel to the fire. The GMC reportedly received 3468 requests for a certificate of current professional status – allowing doctors to demonstrate their registration to overseas medical boards – in the 10 days after the decision was announced to proceed with contractual changes, in contrast to the 20–25 they typically receive daily.20 IMGs and OTSs remain integral to the Australian emergency medicine workforce in 2016, although this role is currently in a state of flux. Limited data is available on the number of pre-vocational IMGs in emergency medicine, however, it is likely that the junior contract crisis in England will cause an increase in the number of British IMGs choosing to take an Australian ‘working holiday’. Although IMGs dominate the new FACEM and ACEM trainee cohorts currently, their numbers and fraction are declining. In the next few years, the incoming wave of new domestic medical school graduates will be seeking vocational training positions, and this will further dilute the IMG presence within ACEM. Despite recent attempts in a complicated political landscape to reform the system for accrediting international doctors, joining the Australian medical workforce remains difficult and drawn out – often at the professional and psychological expense of the doctor. SM is a member of the ACEM Council of Advocacy, Practice and Partnership. VT is Chair of the ACEM Trainee Committee and is trainee representative on the ACEM Council of Education, ACEM Council of Advocacy, Practice and Partnership and ACEM Discrimination, Bullying and Harassment working group. SM, LB and VT are section editors for Emergency Medicine Australasia.

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