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Injecting some real solutions into the debate about overseas doctors and rural workforce shortages

The AMA has been a critic of the Federal Government’s so-called “10-year moratorium”, which helps plug workforce gaps with overseas trained doctors, for some time.

Yesterday the AMA issued this statement, raising concerns about the outrageous problems these doctors and their families face in accessing healthcare and other services, amongst other things. It garnered this nice big splash in the SMH today, under the headline, AMA ends support for bush doctor rule.

But Dr Ian Cameron, CEO of the NSW Rural Doctors Network, says the issues are far more complex than the AMA is allowing, and has some other suggestions for tackling rural doctor shortages.  He writes (and please note the update at the bottom with some amendments):

“The AMA has joined RDAA in calling for an end to the 10 year moratorium. It is difficult from the press releases to see what they actually want.

Section 19AA is not discriminatory. It applies to all doctors, Australian trained or overseas trained who were registered after 1996, and denies them a provider number for ten years unless they achieve Fellowship of a College. This was strongly supported by the RACGP as enforcing training for General Practice as a specialty. This is the ten year moratorium – is this what AMA and RDAA wish to remove?

Or are they talking about the exemptions to the ten year moratorium that allow some doctors to work in rural areas, deputising services and as GP registrars. These exemptions were introduced in response to Democrat and AMA lobbying that young doctors would not be able to do rural locums, or get experience in General Practice before joining a training program. The RACGP has opposed the exemptions because they see what was an education issue being turned into a workforce issue.

Or is it only Section 19AB that the AMA and RDAA want rescinded? This is discriminatory, and applies only to temporary resident doctors and requires them to work in a district of workforce shortage. For more rural and remote places this ten years may be reduced to 3.5 to 5 years, as long as the doctor also achieves Fellowship.

For temporary resident doctors it has been a choice to come to Australia – instead of removing 19AB why do we not fund the provision of adequate assessment, orientation, clinical and education support that will change an overseas trained doctor into an Australian trained doctor?

The AMA and RDAA have focussed on the provider number issue, but there is also the issue of medical registration. Do the AMA and RDAA also want to remove conditional registration in an area of need? This also compels doctors to work in what are usually more rural or remote locations.

In NSW at least, the RACGP has been unable over two years to put in place processes for the Specialist Pathway (except FRACGP equivalence) and an end point to the Competent Authority Pathway. This means that there is no pathway for the more experienced or equivalent overseas doctors. While the NSW Medical Board has appropriate processes for assessment of doctors applying under area of need provisions, there needs again for there to be better orientation, professional, clinical and education support for these doctors

Both AMA and RDAA have called for better conditions to attract more rural doctors  – more carrot and less stick.

However they have largely focussed on more money, a simplistic approach that on its own is unlikely to change things. Government policy has been built around increasing education places at undergraduate, prevocational and vocational levels.

This has been highly welcomed, but as with better remuneration, is unlikely to lead to change unless accompanied by measures leading to a large increase in the number of new doctors choosing General Practice, rural General Practice and rural procedural General Practice. This means looking beyond outmoded cottage industry model of General Practice and moving towards offering alternatives that give GPs professional and clinical independence but relieve them of administrative burden.

There are a few things we could do for international medical graduates (IMGs) as well as providing that professional and education support. If IMGs who had passed both parts of the AMC exam were able to do their year of supervised practice in General Practice, it would both free up more intern positions in the hospitals and recognise that IMGs have prior hospital experience, but often need Australian General Practice experience.

Maybe we could require all IMGs to work as Physicians Assistants until they achieve General Registration or Fellowship. If contracted to an existing doctor this would ensure they received serious support and assessment, allow them to work within a clinical setting in the health system, and let the existing doctor make some money.

The ability to value add would mean an end to “you can’t make a bob if you work with your hands” mentality, help with workforce shortages and with appropriate support I am sure would have the support of the AMA and RDAA in recognising Physician Assistants as being part of the medical, rather than nursing or some other, system.”

Update: Dr Kim Webber, ceo of Rural Health Workforce Australia, has joined the debate, issuing this release, which says:

“Overseas-trained medical graduates are an essential way of addressing the doctor shortage in rural and remote Australia…The 10-year moratorium is vital for staffing remote and rural practices. Our workforce in the country would be decimated if you got rid of it and the AMA needs to be careful that it doesn’t throw the baby out with the bathwater on this issue..If that policy was unilaterally dropped, I don’t know how places like the Kimberley and Brewarrina would ever be staffed…”

Update on 21 Jan from Ian Cameron:

My Croakey bit needs some revision.

19AA does not include the moratorium. Basically you can’t get a provider number for General Practice unless you achieve FRACGP or FACCRM, or have one of the exemptions.

19AB applies to permanent resident OTDs (or Australian graduates who were not citizens or permanent residents when they were students) and they cannot get a provider number for ten years unless working in a District of Workforce Shortage (This may be reduced under the 5 year program for more remote places) For temporary residents the ten year moratorium only cuts in when they become permanent residents. It is discriminatory.

However I think my basic premise remains that there should be better support for all IMGs in orientation, clinical and professional support, and education. Having recruited temporary residents to Australia they should have access to Medicare and free schooling for their children in the public system. In this I agree totally with the AMA and RDAA. However we should separate the support issue from the moratorium issue and debate them separately.

Comments 4

  1. Doctor Whom says:

    If the AMA and the RDAA think that more cash will get doctors to rural areas then they have learnt nothing.

    Doctors don’t go to rural and remote areas because most of them don’t like the places, their wives husbands (and exes) and current lovers (and exes) don’t like the places, their teenagers don’t like the places and their friends don’t visit.

    Often the local clinic/hospital is run by a bunch of idiots, occasionally well intentioned, and sometimes sober, who exploit the doctors and penny pinch and frustrate.

    Far better to bring in a 10-year moratorium for ALL doctors, nurses and health workers trained on the public purse. Then we get rid of discrimination.

  2. Steve Sant says:

    The RDAA have for many years called for better supports for rural doctors. This includes better education and training support, professional support and financial support.

    RDAA workforce policy is based on evidence such as that in the viable models project (available on the RDAA website) which was undertaken about 6 years ago and more recent evidence in WHO Global Health Workforce Alliance publications and surveys which indicate over 80% of rural and remote doctors recently believe adding a significant rural and remote loading on Medicare items would assist in recruiting and retaining doctors in their communities.

    Clearly the policies of the previous and current govemnent, despite the best efforts of the rural communities and the rural workforce agencies have not provided rural communities with the services that they require as we still need at least 1800 more rural doctors across Australia.

    Financial incentives will not in themselves solve the problems but combined with better educational and professional supports they will go a long way towards improving the workforce numbers in rural australia and assist in ensuring that rural australians achieve the same health outcomes as their city counterparts. Rural practice is a great career choice and we should not be forcing doctors or health professionals to work in rural areas, instead we should support and reward them for taking on the rural practice.

    Steve Sant
    CEO
    RDAA

  3. chazzai says:

    I was lucky enough to spend my 5 year moratorium time in a large (8 doctor) medical centre with good peer support, interesting work, and excellent nursing support at the hospital where I was a VMO. But Dr Whom is right, I hated living in the place, my wife hated it and my friends didn’t visit. I survived it because I was paid well and got lots of holiday. I left within a week of my 5 years being up.

    In neighbouring towns, doctors who had to battle language barriers and enormously higher cultural changes on their move to Australia than I did, set up and tried their best to be a sole practitioner whilst also studying for the exams. They had no on-site medical support or supervision, and no business support. I doubt they were in accredited practices, so they would not have received all the remuneration available to other rural GPs. But they were desperate to work as doctors in Australia and thus tried their best to stick it out.

    Although I don’t think there’s anything discriminatory about asking IMGs to contribute to solving a workforce problem if they want to be able to work in the country, I do feel that making that request puts a responsibility on the govt to provide all the support necessary to allow those doctors to settle and enjoy practicing in what are often isolated and difficult conditions.

  4. parnold says:

    There are some hard facts about living in the country, up with which country people have to endure – facts which mean that I have never wished to live there.

    The smaller the town, the fewer the facilities – educational, cultural, commercial, financial, emergency services or health-care-related. I have chosen to be a city-slicker all my life because I want all of those facilities close at hand for myself and my family.

    A country town (with its surrounds) needs a certain-sized population to sustain general practitioners. The GPs need to be sufficiently numerous such that each can take time off for continuing education, for illness and for holidays. If, for the sake of argument, we agree that a GP can satisfactorily care for 1,000 patients (more or less), and if we agree that the minimum number of GPs needed to allow such time off is four (three at a pinch), then any town (and surrounds) with fewer than 4,000 people cannot expect to retain doctors over the long-haul – they will simply ‘burn out’.

    To insist that all of these small towns should have doctors is, in my view, unrealistic. Regrettably, the absence of a doctor is one of the many downsides of living in a small country town. The AMA has never been happy with my suggestion that the answer does not lie in bribing/coercing doctors into these towns.

    We need to be smarter about how we provide ‘health’ care (not necessarily ‘medical’ care) to small towns. There are ways that this can be done. Russia and China, with their vast open spaces and dispersed populations, have been training rural ‘felschers’ and ‘barefoot doctors’ for generations; a number of African countries are now belatedly following suit. Improved medical evacuations and flying doctors (for which Australia is renowned) are clearly part of the solution.

    But to harp on about supplying doctors to every small town is to fly in the face of reality. It’s well past time for a change in thinking.

    Peter Arnold, former Deputy President, NSW Medical Board; former Chairman AMA Federal Council

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