Updated post by Dr. LF Ng:
Medical internship in Australia and other educational matters
The world has not ended – so, let us look at some pieces of health care and education matters to pick up this New Year
By Dr Leong-Fook Ng, in private practice, Australia
Written 27 Dec 2012, revised in Jan 2013 and on 23 Jan 2013
Now that the world has not ended and that future Mayan prophesies may need much time to be rewritten on more stone, one may perhaps have a closer look at some ongoing challenges in the health landscape with political and other New Year resolutions.
To the optimists, it may be heralding the beginning of a new era – for example, an unofficial medical reformation movement in Australia. To those who are Christian (and Australia claims to have been founded on Christian tradition), the remembrance of being ultimately freed – for example, from psychological false imprisonment — by Christ, the Saviour – is the hope. With Advent, is timely that lux mundi is allowed to shine on the darkness. And with hope and light, evil, injustice and oppression will be eventually tackled in a transparent and systematic way.
Some days before Christmas, a Malaysia-based specialist colleague (a non citizen but permanent resident) who had sent his daughter to the Monash University (Malaysia) Medical School wrote to me about the difficulties she was facing in obtaining an internship posting in Australia after her recent graduation in Medicine.
My colleague had paid high University and tuition fees for his daughter to qualify with an “Australian” degree – albeit offshore. His family is now upset and disappointed and presumably mentally stressed. There will be many more.
It was stated that the Malaysian Monash school had distanced itself from this as had the Monash Australian School.
It is often said that newsworthy items will only attract attention in Australia (as anywhere else) if it is scandalous or if it affects the income or the tax of a voter.
- Australia is continuing to face a shortage of doctors and this is likely to be for some time to come. The ‘sell’ for the production of more “Australian trained” doctors remains intense, even rhetorical.
- The rapid and increased production of doctors over the past decade has produced a ‘tsunami’ of new graduates moving into internship and resident training positions. These newly qualified doctors will need close supervision and guidance despite that there will be some attrition.
- Australian public hospitals cannot cope with the demand for intern positions. The rural and remote ones may not have sufficient experienced doctors to supervise them.
- The Australian Medical Students’ Association appears to have taken the lead in an initiative to pressurise the creation more internship positions by the government and also offering solutions for exploring options overseas.
- Alternative ways of intern placements (including GP ones) are being thought out and implemented
What does all this mean?
The matter is complex and is one related and intertwined to funding, supply, demand, immigration policy, politics, turf protection and the law – and alleged irregular practices surrounding these.
From the simplistic view of an overseas parent who has spent much money in fees to empower a son or daughter to qualify with an “Australian degree” offshore, it appears to be very disappointing. Some may even feel misled and this has rippling implications across the whole education industry.
When Monash Medical School Malaysia was formed, it was promised that the degree conferred would be exactly the same as the one conferred in Australia. This sounds fair enough. Nothing more was disclosed about a labyrinth soon to be unravelled.
Many did not (and do not) know about the labyrinthine systems in Australian bureaucracy and law which lead to an outcome of whether an Australian medical graduate (whether on or offshore) is allowed to practise medicine in Australia – and with what discretionary or legal restrictions.
Recently, within the Australian medical landscape was the publication of a Report of a Lower House (Australian Federal Parliament) Inquiry into the Registration Processes and Support for Overseas trained doctors. The report was called “Lost in the Labyrinth”
This has opened the lid on a Pandora’s box suggesting a highly dysfunctional and inefficient system – even for Australians. Overseas medical students – whether they qualify from Australian medical schools inshore or offshore, will fall into the category of Overseas Trained Doctors for the purposes of Provider Number allocations as defined in the Health Insurance Act 1973 some of the woes of which had been thoroughly (but not completely) investigated in this Inquiry.
Initial scrutiny of this may not be important to parents who have invested millions in their children in an Australian medical degree – whether acquired inshore or offshore. They only wanted the letters after the names. But this is now different.
It does matter for several reasons:
- Australian law governing medical practice opportunities cover local and overseas born graduates if they have not registered to practise medicine prior to 1996. The instrument of law is called the Health Insurance Act 1973 and the section which applies is s19
- The law subtly forces those in the above group into rural and remote regions where doctors are needed most. It is a form of compulsory service and compared with say, the current Malaysian Government’s compulsory 3 year service for her citizens, the latter is nothing — with the 10 year moratorium in Oz. In reality it is involuntary civil conscription.
- Postgraduate training in an Australian metropolitan area does not count and the clock only starts when a legally defined rural posting commences. So, a young doctor commencing specialist practice may end up needing to work in the rural and remote regions for a long period – without much exposures to the peculiarities of the ‘sticks’ – unless a discretionary exemption is applied for (which could be revoked in a similar discretionary manner)
- The level of supervision in the rural areas is different from that in the metropolitan areas and the ‘high’ standards demanded of doctors are applied and expected. Disciplinary action can follow investigation of any case outcome or complaint irrespective of whether it is true or not, frivolous or not, malfeasant/mischievous or not – as have been described with ongoing and unresolved horror stories of allegedly competent Australian-trained doctors themselves! (Dr Tsigounis & Prof Dewan) and, the non disciplinary error-ridden (and denied) saga of an Australian doctor of Chinese origin, Dr Bo Jin.
- Not surprisingly some Australian states are offering internship positions to Australian medical graduates from overseas who are full fee paying. This subtle altruism is a subtle invitation to civil conscription at a later stage using s19AB of the Health Insurance Act 1973
- Naturally, Australian students, who are competing for these limited places are unhappy and a summit (National Intern Crisis Summit) took place on 22 Feb 2013 – this is likely to escalate.
Given this, (overseas) parents or those who already have children in the system should be alerted to what the real scenario may be as they continue to send their children (and money) to Australia.
A formal perspective could be viewed in the Official Report itself “Lost in the Labyrinth.” Disappointing as it may be, the Government (of Australia) is mandated to formally respond to this within 6 months – but it has not done so. It may be that it is in the ‘too hard’ basket.
Graduates of offshore “Australian” brand medical schools – whether citizens or permanent visa holders may now be in the same position as others anywhere else who are outside Australia. There is a world-wide shortage of doctors but economic, immigration policy and other matters impinge on their employability.
For example, in the UK, the scenario with available house jobs is bleak. UK graduates attempt to get their internships offshore (but, are they recognised later on for Full Registration?). The scenario with Australians who are Australian medical graduates is the same. They may secure internships offshore, but these are not recognised for Australian General Registration – and they will need to repeat these inshore if they wish to return – as the current law stands.
Other medical regulatory authorities remain less administratively obstructionist but the scenario may change. For the present time, Monash Malaysia medical graduates will likely be accepted for internship training and postings in Malaysia and Singapore – and, that would be good for these countries. Indeed my friend’s daughter mentioned above has secured a place in Sarawak. But, if it were their parents’ original intent for them to obtain overseas letters in order that they acquire an option to relocate to the country of their choice to practise their chosen profession, this will continue to be a disappointment.
There may be many Australian medical graduates who cannot find suitable internship placements which are recognised in their chosen country of practice because of administrative hurdles to be cleared.
Without this they cannot receive Full or General Registration and therefore cannot proceed with specialist or other postgraduate training.
This only applies to medical graduates but what about Australia’s offshore educational industry and the thousands of other graduates they have produced and are producing? Do they enjoy an equal rating? I doubt it for now, given what we have observed with offshore Australian Medical degrees.
There are some serious implications for education initiatives as the message sent would be that some Australian degrees may be more equal than others. There is also evidence that Overseas Trained Doctors, though apparently performing up to standard in the Rural and Remote Areas are generally unhappy people.*
These scenarios plunge some without their consent into alleged psychological false imprisonment and it allegedly breaches the various United Nations Covenants signed by Australia. There cannot be an easy domestic remedy in Australia because some of the aggrieved are offshore residents and have no right of residence – thus having no locus standii.
Any proposed class action in an Australian Court to seek justice may involve a demand by the respondents for a security for costs.
Other victims of the system, are the people of rural and remote Australia because they will continue to lack the opportunity of the services of those who may be able to serve them but who are prevented from doing so.
To the bureaucrats on both sides of the divide who had invented this scheme and who believe that they have “not got their nickers in a twist” they should think again.
Recent data shows that many doctors in the UK (and, by inference, bureaucrats working with or as doctors) have criminal records. Though the group is dominated by doctors trained outside the UK, it may also reflect a similar type of thinking by the Brits as the Ozzies – amongst bureaucrats at least – a racist bent that foreign trained doctors are automatically tainted (cf some Malaysian attitudes towards s 13.3 doctors in the old Medical Act)
By the virtue of the gene pool of the first “boat people” to Australia, the data here should not be too different, even on a speculative basis. And, it may be a surrogate of something further from the truth – that of discrimination and scapegoating.
To all tax payers (and parents) everywhere who fund the costly training of most doctors, where is the Government’s accountability in this bureaucratic fracas and wastage?
To the rural and remote residents (and the voters) of Australia – nothing appears to be changing significantly – the messy impediments remain – unless they send a strong message to the Australian and State Governments to get their act together soon. These matters not only hurt the people they are intended to hurt but also Australian tax payers. The root cause appears to the Australian Medical Colleges themselves!
Unlike the Australian PM, I do believe in God and in lux mundi to illuminate the darkness surrounding the dysfunctional – even corrupt — management of medical practice regulation. Accentuating the positive albeit with spin, is good but concealing or suppressing the truth is unacceptable and dishonest.
Perhaps one needs a mixture of adversarial and inquisitorial (reformed Napoleonic code stuff) to address these matters in a totally truthful and transparent manner as suggested by a legal historian, E Whitton in his suggestions about the probity of the recently announced terms of reference of an Australian Royal Commission on Child Sex Abuse.
*Matthew R. McGrail et al 2012 “International medical graduates mandated to practise in rural Australia are highly unsatisfied: Results from a national survey of doctors – the MABEL study” Health Policy in press
(the MABEL website)