It is pleasing to see the AMA take up the fight for probably the most disadvantaged and discriminated group of medical colleagues. International Medical Graduates (or IMGs) are doctors who are currently working here in Australia but have completed their basic specialty training in a country outside Oz. We know that IMGs make up at least 25% of our medical workforce and are over-represented in fields of psychiatry, general practice and obstetrics-gynaecology. IMGs and their families are unable to access our Medicare system for health and cannot access public education. A parliamentary report, entitled ‘Lost in the Labyrinth’ provided a concise and thorough understanding of the current predicament facing many IMGs, and reflects my thoughts 3 years on from the time of writing. The report, like myself, has no problem with regulatory and professional bodies having high standards for doctors wishing to practice in Australia. Both my thoughts and the recommendations tabled in 2012 reflect the ongoing issues of transparency, streamlining of accreditation requirements and substantiation of the costs associated with this. Another concern is the variable ways of appealing decisions made by these bodies. I speak after having extensive experience coaching and mentoring psychiatry IMG’s.
I have met many IMGs since I began coaching and training them for the RANZCP fellowship examinations. Over this time the way they are assessed has varied, but for about 10 years they have been assessed on requirements that are the same as local trainees, however their results are segregated from those of local trainees. When IMGs were segregated for their examinations, the premise was that they would receive extra time in the examinations due to linguistic challenges, and the standard expected on the day was much higher than of a local trainee, taking into account their experience and qualifications overseas. However, over this time, the pass rates for IMGs remain consistently lower that than of local trainees in the two types of clinical examinations set by the RANZCP, the OCI’s and the OSCEs.
Psychiatry IMG’s and local trainees are now following a 2012 training pathway with the RANZCP. Those who have not progressed in time on the 2003 pathway, which ended in October 2015, have moved into the 2012 pathway. Some trainees may be repeating requirements and some are waiting to hear what their requiremement wil be. I know this as I have spoken to many psychiatry IMGs and local trainees in this position.
A ‘bermuda triangle’ for many psychiatry IMG’s
After spending many hours with IMG trainees I conceptualise the problem to be one of “keepings off” between 3 main players; the Australian medical council/regulatory medical boards (AHPRA), the state hospital system that employs them, and the RANZCP (our college for accrediting psychiatrists). IMG’s must meet certain criteria to obtain residency status in Australia, state hospitals have their standards and fill vacancies with the IMG workforce, and the RANZCP administers it’s requirments and standards when it comes to deciding whether they can work as psychiatrists and obtain an Australian fellowship. All 3 organisations have their own set of criteria and benchmarks that IMG’s must fulfill, but they are raley streamlined, leading to confusion and misunderstanding.
Performance in RANZCP examinations
Many IMGs facing repeated attempts at the examinations. It is not unusual for me to coach an IMG who has failed 5 times. they find themselves in the category of ‘failure to progress’ through to the Fellowship as the RANZCP moves onto a new training pathway. many are waiting to hear what their pathway will look like as of 2016, and whether they will indeed be able to make it to fellowship.
Psychiatry IMGs have endured low pass rates despite being provided an exam with extra time to help with linguistic difficulties. Many have attempted the examinations more than three times. In October 2015, the last round of the ‘old style’ clinical examinations or ‘OCIs’ the pass rate for local trainees was 55%, and IMGs 20%. In July 2015, the pass rate for local trainees was 60%, and IMGs 29%. Similarly, the pass rates for the July 2015 OSCE clinical examinations, which will continue under the new fellowship pathway were 80% for local trainees and 48% for IMGs.
Many of these IMGs who are failing repeatedly are working as psychiatrists in regional, rural and remote areas of Australia, with limited access to training and supervision.
There appears to be wide disparity between the fee structure for local trainees and IMGs. An IMG will spend over $15,000 in fees to the RANZCP in order to practice in an area of need. They must pay $5030 for an assessment, including an interview. Their placement fee is $9370. This is over and above the fees imposed by the Medical Board of Australia, and on top of other administration fees imposed by the college.
Of recent times as I continue to coach and mentor IMG’s I have noticed a drop in morale amongst them. I know that for cultural reasons they find it very hard to speak up if struggling, and I have seen them crumble when they tell me how difficult it has been for themselves and their family. Many have been practicing psychiatry for years before coming to Australia, and moved their family here as part of a requirement to achieve fellowship in India or Sri Lanka, only to find they cannot get through the training program. Many that I have come to know over the years are now at a stage where their children are older and they are facing decisions of splitting the family so a parent can return home with the children for education, or whether they all go home.
AIHW data shows that in Australia there are roughly 13 psychiatrists available for every 100,000 of population. In rural and remote areas, where I have spent some time working as a locum psychiatrist, the figure drops to 2 or 3. Because of restrictions on where IMGs can work, most of these spaces are filled with IMG’s or locums. If IMG’s choose to leave Australia there will be a dearth of service and care of those with serious mental illness. Many regional centres exist solely on a locum workforce, with very few or no permanent psychiatrists. I have been a locum in FNQ and then diagonally across to Lower Great Southern WA. I know we are facing a huge problem already that is only going to get worse.
Summary and recommendations
I am not singling out RANZCP by writing this article but this is the experience I have after working with many psychiatry trainees, whether they be local trainees or IMG’s. “Lost in the Labyrinth’ made recommendations, and provided evidence of similar situations occurring within RACP and RANZCGP. I write to support all IMG’s in general, as the AMA has recently done as well. But I think it really is time for action, the recommendations have been made and the IMG’s won’t stay forever to help our workforce if we don’t get it correct. The recommendations outlined in the 2012 report “Lost in the Labyrinth” are really worth a read as they speak to simple strategies that would go a long way to removing a bermuda triangle on our sunny shores.