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National registration and accreditation scheme for doctors and other health care workers

CHAIR —Good afternoon and welcome. You have information on parliamentary privilege and the protection of witnesses. We have received the submission from the Committee of Presidents of Medical Colleges, which we have numbered 15, which means that it came to us very early—that is very impressive! I invite any or all of you to make some opening comments and then we will go to questions. This particular session is scheduled to go until 2.15 pm, so that gives us some idea of the time available to us. Professor Stitz, would you like to start?

Prof. Stitz —Thank you very much. I will. Thank you for the opportunity to present to you. We understand that this is a very complex process. Things that we take for granted may in fact not be entirely plain to the Senate committee.

CHAIR —You are not wrong.

Prof. Stitz —Just to give you a brief overview of what our organisations are, the Committee of Presidents of Medical Colleges is a committee, as the name suggests, which acts as a forum to coordinate all the common themes of the medical colleges. The medical colleges are basically there to develop standards and to educate and train young people to those standards so our respective specialities graduate specialists in those areas. Contrary to a lot of the other health professions, the progression—the continuum—of learning goes from the university medical courses through to postgraduate years 1 and 2, the so-called intern years, where there is a formalised training program now, into vocational speciality training, which is run as I said by the colleges. We then continue into a lifelong learning mode where the colleges have very strict and prescribed rules about continuing professional development and the maintenance of skills.

In essence, the colleges are about standards and training young people to those standards. We are not effectively a political body. Because of that, we believe that the drivers for all this should be standards of care and safety and quality. By and large, the Committee of Presidents of Medical Colleges and all the medical colleges support national registration as a process. That means that you should be able to be registered in any state and allowed to practice elsewhere in the country. But that registration needs to be underpinned by standards of qualifications.

As a result of that, the current process, which is by mutual recognition, is not uniform. So the proposal that we have a uniform regulation across the whole of the country such that doctors can move throughout the country is very sensible. However, it is important because of the knowledge generated by the medical boards in each particular jurisdiction that the complaints processes—the regulatory and disciplinary components of that—should be done at a state or territory level. Obviously, that is where the doctors are known better. But it must be with uniform regulations and an IT system which allows all states to know exactly what the status of any particular medical practitioner is. That will get over some of the problems that we have, such as Dr Patel and so on.

Largely, we support uniform regulation. We believe that it is the right thing to do. In my own case, I do some preceptoring in surgery around Australia. Currently, I have to be registered in the states that I go to. I am now registered in Queensland, New South Wales and Victoria, and every year I have to be re-registered and pay a fee. Because it is sponsored I do not personally pay it, but the way it is at the moment is ridiculous. We support uniform regulation. That is not our area of concern, because it is a statutory requirement for the registration process to protect the public, which is obviously what we are very concerned about.

However, we believe that the accreditation process as proposed has significant flaws. You have to ask why you would change something in medicine, which has an international reputation? We graduate specialists of very high quality in this country. We are tampering with that quality with this proposal. What I mean by that is that currently the way it is proposed there will be national boards in all the health professions, as you know, and in our case the medical board. That medical board will in fact be responsible for the standards and the accreditation of bodies that deliver training. This is unacceptable to the medical profession and also, I have to say, to all the other health professions—that is what comes out of all the stakeholder meetings. Why a government would try to introduce something that all the professions object to begs the question.

What we believe is that as it is now the Australian Medical Council, which has an international reputation in this area, should still be able to make its decisions on the standards and the accreditation of university medical courses and specialty training programs independent of government and independent of the medical profession. Obviously, they will have representatives of that—the current Australian Medical Council has experts in medicine on it. But it also has consumer representatives and currently all the presidents of the state medical boards automatically sit on the council. It is a very well-tried program. The colleges of surgeons of physicians have now been doing this for nearly 80 years, so there is a huge amount of experience in that. You can see that any attempt to erode that independence will potentially allow, for example, work force issues to denigrate the standards, as happened with Dr Patel. He was never referred to the College of Surgeons. He was promoted internally by the system and was never monitored in any way, so nobody knew that he was not fully registerable. What we are saying is that we need to be very careful in this process.

I know that governments are always interested in solutions. Let me tell you what we have recommended. This had a reasonably good ear just before the Queensland election. We understand that the IGA is going through and the next bill is about to be progressed. It is unlikely that that will be radically changed. But we can modify it to negate some of the concerns that the profession has. Bear in mind that the medical colleges represent 97 per cent of the medical practitioners in this country.

What we propose is that the National Medical Board delegates the responsibility for standards and for accrediting the university courses and the college programs, as it does now. Those decisions cannot be influenced by government or the medical profession, but their report is delivered to the National Medical Board. The National Medical Board is not compelled to accept that in the IGA. But, on the other hand, to fly in the face of what is the most expert body would be unusual. They obviously would have to be a very good example.

The second thing that we propose is that all deliberations of the Australian Medical Council should be published in government circles so that they are documented for everybody to see, including the rationale for doing things, for example. There are concerns that the Australian Medical Council is a separate corporate body and not a statutory authority.

One of the recommendations that we have made is that we can get over that by having a review process, which is what happens to universities. There would be every five years, say, a review committee, which would include representatives of government and the profession and international representatives—patently, it is an international process. The World Health Organisation and the International Federation of Medical Education Bodies say unequivocally that this process should be independent. By doing that, we get over the problem of credibility, if you like, or the government worrying that this might go off at a tangent. We propose, and it seemed that we had reasonable acceptance of this—although not in writing, I might add—that this might in fact mitigate some of those concerns. The Australian Medical Council, with its credibility internationally, has already been advising the other health professions, which obviously do not have that degree of experience.

There are work force issues, and we would be pleased to talk to you about those. But we have to emphasise that if we are talking about standards and protecting the community then we must not colour that with work force problems. In other words, just to get somebody on the ground should not be an excuse for having less of a standard. That is not acceptable to the public. On that note, I should stop and allow you to ask questions. I will also ask my colleagues if they would like to make any other comments at this stage.

Prof. Metz —Perhaps I could supplement that briefly. Quite often people say, ‘You are resisting change. You are old hat. You are fuddy-duddies.’ We are in no way opposing change. We certainly are interested in continuous improvement—that is what we do at the college. We keep revising our curricula; we keep revising our examinations—the way we teach and the way we examine. If you say, ‘Okay, this is a proposal that we think is a sensible one, a good one. Let’s just take accreditation away from the colleges and give to this body that thinks it can do it better,’ there is precedence that I would like to tell you about.

In the UK they have been doing this in the last 10 years. They set up a committee called PMETB, the Postgraduate Medical Education Training Board. PMETB took away a lot of the accreditation standards from the colleges and set it up as a government body with 25 per cent doctors and 75 per cent jurisdictional and laypeople. I had to go to London and Philadelphia in the last two weeks and whilst at a college meeting in London I took the opportunity to have breakfast with the chairman of PMETB and with the president of our equivalent, the Academy of Medical Colleges. The president of the PMETB confessed that they have completely ruined their accreditation processes. They are scrambling now to get back to the colleges to try to fix it.

They took the colleges away from the process and they refused to discuss with the colleges the changes that the jurisdictional people in London and in the provinces had decided was a better way of doing things. They have had doctors marching in the streets—you may have read about that about 12 months ago. They have quite unequivocally lowered the standards of medical assessment and accreditation in England and they are now asking the colleges to come back onto the PMETB. The chairman of PMETB has resigned and PMETB is actually being dissolved. Having been in the process only for five years, it is being folded up into the General Medical Council.

This is a process that we see as almost identical to the one that is potentially going to come out of the process we are talking about now. All they have done over there is say, ‘We think that we can do it better than the colleges. The colleges have been there a long time; they are probably a bit dusty, a bit tired. We will do it differently and better,’ and they have now confessed and agreed that they cannot. The chairman of the academy is Dame Carol Black, a very feisty woman whom I had lunch with, who said that she is very happy to come and talk to you to tell you, ‘Please do not make the same mistakes.’

So we are saying that we have a history. We have a record. We are interested in change and we are interested in continuous improvement. We are also interested in people who know what they are doing being in a position to do what they are doing.

CHAIR —Thank you. Dr Wood, do you want to add anything at this stage?

Dr Wood —No, I think that they have both said it all, thank you.

CHAIR —Professor Stitz, you are the current chair and, Dr Wood, you have become one. Is that an elected position?

Prof. Stitz —It is elected by the Committee of Presidents of Medical Colleges—

CHAIR —Presidents of all the colleges get together. How many colleges are there?

Prof. Stitz —Twelve. The college positions are all elected—the presidents—and by and large they are two-year appointments. The appointment as chair of CPMC is a two-year appointment, so I finish in November and Glenda takes over at that time.

CHAIR —I was just interested. You gave the information about your group in the submission but not in that degree of detail. It is the way my brain works!

Senator BOYCE —As I said, things that might seem standard information to you may not be to us. I just want to confirm a few things before Senator Humphries asks questions. Postgraduate education, which the colleges oversee, who delivers that? Is that primarily the universities?

Prof. Stitz —No.

Senator BOYCE —So who delivers postgraduate—

Prof. Metz —The colleges.

Dr Wood —People are appointed to hospitals as visiting medical officers and as part of their appointment they also train the postgraduate students. But there are also people who were not part of the hospital who will also train. So a lot of the training is done in our own time or controlled—

Senator BOYCE —And examinations?

Dr Wood —Colleges have their own examinations and the process is all very well controlled.

Prof. Metz —I can supplement that. For the examinations we do we always have visiting examiners from the US or Canada or the UK. So standards around the world within the colleges are very clearly watched and changed, if changes are required. Examinations are very carefully overseen.

Prof. Stitz —It is probably worth mentioning as well that virtually all of that is done pro bono. We are employed by the public hospitals, and an obligation is that we have to teach. But, for example, the emergency management of severe trauma course is a three-day program over a weekend, so the instructors do that free of charge. So it is a fairly critical thing, because if it were taken completely out of the hands of the colleges it would be a huge cost to the community—not that that is the major driver.

The other thing is that we are often accused of being closed shops—and I think that is the reality—but over the last decade there have been significant moves. We have consumers on all our major boards; we have been through an ACCC process where all of our processes have been looked at. It is all open and transparent. All appointments to our training positions and our examinations are open for everyone to see, so we get somewhat irritated when people say that we are now a closed shop, because all these guys worked their insides out and it has all been through these rather costly processes. But we are comfortable that what we are doing is of a very high educational standard which really gives the community very high quality specialists. Obviously we do not want to see that change, but we believe that the community does not want to see that changed either.

Senator BOYCE —Do the colleges as a collective group have any input into the standards for undergraduate medical education?

Prof. Metz —At the Royal Australasian College of Physicians we are cardiologists or respiratory physicians or oncologists—whatever—all under the one hat. In our appointments we teach and train the next generation of specialists coming through and, as Russell implied, the vast majority of our teaching is seven till eight o’clock in the morning and five till six o’clock in the evening because nobody has time in between that. There is such a heavy service load in all of our hospitals. But we also, at the same time, are teaching the undergraduates because it is the same setting, the same hospitals, where universities send their students to be trained as doctors, so we all have a load of students as well as trainees within the college.

Senator BOYCE —What about the curriculum itself, though, that is used for undergraduates? Is there input?

Prof. Metz —That is a very good question. The answer to that is that previously they have been independently designed, but we are now working with the committee of deans. You are going to see them from 2.15 till three o’clock. The chairman, Allan Carmichael, is a fellow of my college. He is dean at the University of Tasmania. We are working now with them to make sure that there is continuity and congruity between the curricula of the undergraduates and the curricula of the specialist training. That has not happened previously but it is happening now.

Prof. Stitz —To further that, in the two hours at the beginning of the quarterly forum of the CPMC there are various representatives, including the committee, the medical deans and also the Confederation of Postgraduate Medical Education Councils, which look after the education of PGY—postgraduate year—1 and 2, so there is a continuum. For example, my current position at Royal Brisbane is as professor of clinical surgery and head of the surgery discipline for the University of Queensland, so I have a primary responsibility for undergraduate teaching in the medical course.

Senator BOYCE —Thank you.

Senator HUMPHRIES —The Australian college presently sets accreditation arrangements for the education and training course you have just been describing to Senator Boyce. It also prescribes the assessment processes for international medical graduates or doctors seeking to migrate to Australia who want to practise in Australia. Does it deal individually with those doctors who want to come from another country, or does someone else take your standards and apply them to an individual and say, ‘Yes, you can come in,’ or, ‘No, you can’t’?

Dr Wood —The people who are applying are initially assessed by the AMC and then, if it is thought that they are suitable, they are referred to the appropriate college where they are interviewed. I know our college and all colleges have a special committee that interviews IMGs, and then they are assessed as to whether they are comparable, not comparable or need further training, and then that information is given back to the AMC. So they do oversee it but they seek our expert opinion on the details of that person’s abilities.

Senator HUMPHRIES —So an overseas trained doctor would front both a committee of the AMC and a committee of the individual college.

Dr Wood —Yes.

Prof. Stitz —It is fair to say that only orthopaedic surgeons can tell whether another orthopaedic surgeon is up to speed. But the principles are governed by the Australian Medical Council standards and the process itself.

Prof. Metz —It is an area which there has obviously been a lot of discussion about and which has received a lot of flak—is it restrictive trade, and do we want them or do we not want them? We encourage IMGs. We need them because we have not got enough doctors in Australia at the moment. At the same time we see our responsibility as protecting the community, so we believe that we need to first of all assess IMGs. If they have what we see as a comparable training then we are very happy to give them the tick. If we think that it is good training but not comparable we will often put them into the field working, but under supervision and peer review over 12 months, and they may or may not have to sit an exam after that. We are trying to get them through because we know we need more doctors, but we are also trying to protect the public, so it is a double-edged sword.

Prof. Stitz —You may not be aware that in the five years to 2012 we will have doubled, with the federal initiatives and those of COAG, the number of medical graduates. That is obviously a good thing, in view of what Geoff said. But the reality is we have to find clinical places for them, because you cannot train a doctor just out of a textbook or on the web. Patently, they have to learn how to look after patients, get rapport with them and learn judgment. It is not a question of whether you can do the operation; it is whether you should be doing it, and you can only learn that in a clinical environment.

Senator HUMPHRIES —We have had a succession of witnesses who have drawn attention to the problem with the accreditation arrangements which appear to be part of the new national registration and accreditation scheme. We have not seen some of the detail of the scheme yet, so we cannot be sure that the scheme will not pick up suggestions like the one that you have just made, where AMC would become contracted to the boards to deliver the accreditation services. But is it your impression that there was an argument being put by the proponents of the national scheme as to why a general separation of the accreditation arrangements from the registration arrangement should be part of this scheme?

Prof. Stitz —We have not been given a cogent reason why that is the case. When the Productivity Commission introduced this initiative, right at the beginning they suggested that the two should be separated because they were separate issues and one informed the other. For whatever reason, the architects of the NRAS proposal decided to lump them together. Their argument was that this would be more cost effective, but the current complexity of the national registration process alone will take considerable effort and resources, both human and financial. For example, $19 million has been allocated for this process. That will hardly cover the cost of the IT programs that everyone is going to have to introduce. It would be much better to get the national registration proposal in place, because in medicine, anyhow, there is no cogent reason why we need to change significantly. Let’s get the registration done—and we will probably have the resources to do that—but the complexity of the accreditation process is going to defeat the whole thing. It would be a shame if national registration fell over because they tampered with accreditation and it failed.

Senator HUMPHRIES —While you have heard no cogent reason, have you been given any reason as to why?

Prof. Stitz —The reason that is argued is that it will be more cost effective in terms of the bureaucratic support processes if you combine the two. We are very concerned about the cost because it has been indicated that it is going to be taken up by the professions. Some would argue that doctors can afford it, but certainly some of the other health professional groups cannot afford significant fees. It is very important that we do not create a huge bureaucracy where it is not necessary, because those costs will have to be transferred.

Senator HUMPHRIES —It is meant to be self funding so that the professions some way or other will have to meet those costs, which will be very large.

Prof. Stitz —Correct.

Senator HUMPHRIES —You are still confident, though, that you could have this national scheme—you could even have the boards as the key drivers of each of the standard-setting exercises across each of these particular areas of practice, but your proposal for some offshoring of the accreditation process would be cost effective and would not disrupt the integrity of the scheme that has been basically announced today.

Prof. Stitz —Absolutely. The facts are that this has already been well tried and there does not seem to be any contraindication to doing that. It is a perfectly reasonable approach, to change the registration, because that has had significant flaws in it. It has been an initiative of the medical boards for up to 10 years to try to improve the standardisation across all the jurisdictions. But in fact that has not been able to be implemented, whereas this proposal will be. And that will be a major advance in this country. Just as, for example, in the UK you have the General Medical Council for everyone, so too do we need to have a national board in medicine and the other health professions. It seems so obvious that everyone should be agreeing to that.

But the accreditation process is much more complicated because that is about developing and setting standards and making sure that bodies train to those standards. And if that is not independently assessed—if it can be influenced by a whim—by governments, doctors, whatever, then that is in appropriate. We need to have processes which actually define how we arrive at those standards.

Senator HUMPHRIES —I suspect that it may well be that this idea of separating accreditation and registration is not going to be part of the national scheme. You will appreciate that this committee does not have the power to change that, even if it believed it should be changed, because this is not national legislation; it is state legislation. Do you regard the issue as a deal breaker? If it is lumped in together with the national boards what would the view of the medical profession be?

Prof. Stitz —It is absolutely against it. There is almost universal support for national registration. There is virtually no support for this accreditation proposal. So you will effectively, in medicine anyhow—and we understand from the stakeholder meetings that the other health professional groups feel the same way—have an uncooperative profession, because we believe that the standards are going to be denigrated by that. And colleges are not about allowing that to happen. So we will, in fact, still train to the standards we have now, because we believe it is absolutely right to do that. Why would we decrease the standards of care in this country, which are second to none in the world? Obviously, it does not seem to be answerable.

You commented that we cannot change the IGA. We cannot, but the bills can change the way we do it. We are not saying that there should not be national board. We agree with that. And we are not saying that there should not be an accreditation body. What we are talking about is the nexus of control between that accreditation process and the national board. The national board is appointed by the ministerial council. If it then controls the accreditation process then that is open to interference, whereas if the delegated authority is given, in our case, to the Australian Medical Council, it would do the job and report back to the national board. As I said, the national board is not compelled to accept that recommendation but you would have to say that if they did not they would have to have very good reasons, because this is going to be published. The Australian Medical Council is where the expertise lies.

Prof. Metz —The difficulty, as Russell was saying before, is that the devil is in the detail, and we have not seen the detail. I had an hour and a half yesterday afternoon with Daniel Andrews, the Minister for Health in Victoria, who I think is driving it for the states. His comment when I had finished talking to him was, ‘I can’t really tell you anything more, but don’t you worry about that.’ I can remember a Queensland premier saying that once!

CHAIR —And it worked.

Prof. Metz —Well, we looked from outside. We weren’t sure.

CHAIR —It was in place for 20 years.

Prof. Metz —That is why we are worried.

Senator HUMPHRIES —Talking of Queensland, you mentioned before that the Dr Patel case was an example of where the system broke down because it did not conform to those principles of rigorous college based assessment of a doctor’s qualifications. Why did it break down exactly? I am not clear from what you had to say.

CHAIR —It is subject to legal process.

Senator HUMPHRIES —Yes, it probably is sub judice, come to think of it.

Prof. Stitz —Would you like me to answer that? I think I can answer it quite simply because I was president of the college of surgeons at the time. The normal process with the AMC is that overseas graduates have to apply to the Australian Medical Council and then their qualifications are looked at to see if they are legitimate and the references are looked at. The processes of the Medical Board of Queensland were somewhat flawed because they did not actually look in detail at his qualifications in the States, because he had conditions on his registration in Oregon. However, he got through that. But he was never referred to the Australian Medical Council for that process, because, if he had been, he would have been further investigated to see if he was legitimate and then he would have been referred—in his case, because he was a surgeon—to the college of surgeons.

The college then goes through a process with expert committees and people are assessed—as Glenda said—as ‘substantially comparable’, ‘partially comparable’ or ‘not comparable’. If they are ‘substantially comparable’—for example, a UK graduate—then they are basically allowed to practise, usually with oversight for one or two years just to make sure that their performance matches their so-called competence level. If they are ‘partially comparable’, they have to go back and do one or two years and sit for the Australasian exams. If they are ‘not comparable’, they have to do the full training course. So we feel that that process, through the AMC, has legitimised the protection for the community.

Senator HUMPHRIES —That would have picked up the Dr Patel situation?

Prof. Stitz —It did not happen with Dr Patel. He was employed as a senior medical officer at Bundaberg and he was promoted unilaterally by the administrators to become director of surgery without ever having gone through that process.

Senator BOYCE —So how many surgeons might be practising right now in Australia who have not been assessed by the college of surgeons?

Prof. Stitz —We do not actually know that. We do know from the Australian Medical Council that there are still a significant number of people out there who have not gone through the AMC process. I think you would have to ask the Australian Medical Council, because even their figures are not entirely accurate. There is also this arrangement called ‘area of need’ where if in fact an area, for example in Queensland—

Senator BOYCE —But that, at least, is a known risk, isn’t it?

Prof. Stitz —Yes. But, in theory, those people going into areas of need should still be assessed. Think about it. If you have an ‘area of need’ surgeon coming in, as in my case, they do not get any enculturation. What we have been arguing is that for three months they should go into one of the public hospitals near where they are going to practise so they at least learn their networks, they learn to know where they can phone and they learn about Medicare before they go out into the sticks, as it were. These people are sent directly out into that environment without any enculturing or any local assessment of what they are supposed to do. That is very threatening.

Senator FURNER —I am familiar with these ‘areas of need’ in Queensland. Are there any other locations interstate where that applies where examples like Patel slipped under the radar and got through that you can enlighten us about?

Prof. Stitz —Would you like to comment on that in New South Wales?

Dr Wood —I do not know that much about it, but the so-called ‘Butcher of Bega’ was the same process, yes.

—I will just make another brief point about Senator Humphries’s comment to Russell. Again, bringing back a reality check, when asked why the English had introduced PMETB they said that Dr Shipman, who killed so many of his patients, was a demonstration of the failure of the college of general practice in the UK, in that their standards should have stopped Dr Shipman. Subsequently to PMETB being set up, the House of Lords had an inquiry into the Dr Shipman affair, and the inquiry—which as a House of Lords inquiry is obviously independent of the medical profession—very clearly said that it had nothing to do with the college standards of accreditation: he was a murderer and he would have murdered people anyway. So PMETB was set up ostensibly because of the Shipman thing, and that is the outcome.

Prof. Stitz —It is also fair to say, in the UK, that Bristol was a major issue and where the public lost faith in the medical profession. But because that came to the fore, our colleges and our processes have really jumped ahead considerably. So there have been stimuli for us to improve and change, but you just need to be aware of the fact that these proposals, if anything, are going to break that level down and not promote them. It is absolutely imperative that at this level senators know that all elected people will take some responsibility for this, because we are publicly noting that this could be a recipe for a decrease in standards. I tell you that we are not going to be part of that.

CHAIR —Professor, who is on the Australian Medical Council? I have been trying to get them on the website to find out how they get to be on the Australian Medical Council and it does not tell me.

Prof. Stitz —How it is appointed, you mean?

CHAIR —Is it appointed? By whom?

Prof. Stitz —I am surprised that it is not available on the website. Basically it has got an eclectic representation. All of the presidents of the jurisdictional medical boards are automatically members of the Australian Medical Council.

CHAIR —And they are all appointed by state ministers?

Prof. Stitz —The state medical boards are appointed, finally, by the ministers. They are statutory bodies. The positions vary a bit, but although some of them are recommended positions the minister finally decides.

CHAIR —Signs off on them.

Prof. Stitz —Correct.

CHAIR —All the states and territories have their rep. I just ask because it is so much a core of your submission that that body is the one that is best placed—and that is fine. They have requested a short extension in providing their submission, so I could not check it on the submission. I have learned some splendid things on the net about what they are doing, but I have not learned how they get there. I can ask them, but it was just interesting as they are such a core part of your example of them being independent and at arm’s length. I just wanted to find out how they get there.

Prof. Stitz —They are there and the committee of presidents, for example, nominates two people and they have four-year terms. There are two consumer representatives. I am not absolutely sure how they get appointed but they do get appointed for I think also a period of four years. The chairman of the educational assessment committee is automatically on the council. It is a fairly broadly represented group, but certainly the majority—over 50 per cent—of those people have got educational qualifications in medicine.

CHAIR —Okay. We may well have questions on notice for you because the occupational hazard is that we run out of time. We have three minutes if anyone wants to dive in with a question in that time.

Senator FURNER —Your submissions give a UK example. We heard earlier this morning from the Osteopathic Association about different standards across the world. Would you be familiar with any countries that may have the same issues that you have identified so well in your submissions?

Prof. Metz —The UK is the standout one because it is so hot in the UK right now. What I would say is that we work very closely with Canada as well. Canada actually is doing it well. We interact about their education as well as their standards of assessment. They actually have been to the brink a couple of times and come back, and we think they are doing it well. If you look at the curricula development, the assessment development and the continuing professional development after you graduate, Canada and Australia are very closely linked, with the UK and the USA just behind us. The four of us work a lot together. I think the UK is the danger—the red flag—and the others seem to be keeping their heads above water by, I think, very productive exchanges.

CHAIR —I have a question which you will probably need to take on notice.  I know there has been a massive increase in the number of medical students. This committee has a lot of specialised hearings about medical needs and there seems to be an element of competition between the professions in that there is a pool of graduates and they have a massive choice in front of them when they finish their basic training—I suppose that is the wrong term—and they make a choice at that stage. Sometimes they come back many years later and make a choice, but there is that option. There has been a perception that there has been a degree of competition in that certain specialties have at different times peaked in their attraction and their ability to recruit. I am interested to see, when you bond together in a professional capacity, how you deal with issues of, for example, whether there are not enough psychiatrists as opposed to orthopaedic surgeons. There is that kind of thing. How do you then step away from that speciality focus, which you would have in your positions, towards working in a cooperative way, which is in general? That is a very difficult question. We on this committee hear evidence very often about doctors making choices for different reasons and then perhaps not going where they want to. I suppose dermatology has been one that has been very attractive.

Dr Wood —Dermatology has been a very popular specialty for some time and for certain reasons. It does enable you to have a life—and that is true—so it has been very popular. We do not compete for the students. Medical students make their own choices and they decide what they would like to do. I do not think between the colleges it is really an issue. All medical graduates are of an extremely high standard. They are all these kids who have been dux of their school and they have all got honours. They have all done very well. There is not a competition between colleges as to whom they choose to go on their scheme. It is not a particular issue for us.

Prof. Stitz —It is not. I think, as with all professions, you could never really stick at medicine unless you really wanted to do the area that you were doing. You just could not be a psychiatrist if your real interest was in surgery.

Prof. Metz —The other thing is that it is all generation wide and they do not know how to make a bed or to clean the dishes but apart from that they are fantastic.

Senator BOYCE —Doesn’t that in itself raise workforce issues if there is no outstreaming or no encouragement to stream? Does it all balance itself out or is it simply that we are so short in every area that it does not matter?

Prof. Stitz —That last point is a very real consideration. Some people make up their minds early.

CHAIR —Yes, that they want to be.

Prof. Stitz —In fact, you find that in their third or fourth year of the medical course they have already decided they want to be a psychiatrist or a dermatologist. But I think most young people do not get enough broad exposure to make their final decision. For example, somebody might like to be a surgeon but which particular branch of surgery they go into develops as they become interns. Some people go away and tour Europe and then come back and decide they want to specialise. So it is not one size fits all, but it does seem to work out and I think by and large we—

CHAIR —Do you all have your full complement at the moment in each of your specialties?

Dr Wood —Do you mean if there are enough dermatologists in Australia?

CHAIR —No, in terms of going for the training. That is a question that we ask often.

Dr Wood —We have far more applicants than there are positions. The number of positions is determined by the number of paid positions.

CHAIR —Sure, so you have more than enough students going for them.

Dr Wood —We have more than enough applicants.

CHAIR —What about positions?

Prof. Metz —You have just opened another two-hour discussion.

CHAIR —I know. I knew the answer before I started. I should not have gone there.

Prof. Metz —I spent six years on the relative value study from 1994 to 2000. We thought we would fix up this problem because of differential payment. Consultative areas are undervalued and procedural areas are relatively overvalued—I am a proceduralist, and that is okay—but that is the truth. Within consultant physician practice we have trouble at the moment. The previous health minister under the Liberal government was very interested in this, and had discussions with me, because we have trouble getting registrars in certain areas—paediatrics, rheumatology, nephrology and neurology—because they are mainly consultative; they sit down talking.

CHAIR —And the specialists in ageing as well, whose name—

Prof. Metz —Geriatrics—absolutely.

CHAIR —And gerontologists.

Prof. Metz —Yes. Whereas we never have problems getting people who want to do gastroenterology and cardiology. I am a gastroenterologist. I was in there with Louise Morauta, whom you saw this morning, saying, ‘You’ve got to get the balance better to fill the gaps.’ It did not happen.

CHAIR —Thank you very much. When bill B is public there could well be some further comments that you would like to make. We are waiting on that process as well. As Senator Humphries says, we are in a situation that is in fact mainly to do with state legislation, but I think people may want to make further comments when that is public.

Prof. Stitz —Thank you for allowing us to present. I need to say to you, though, that we are continuing to have discussions with the architects of this to try to get some of the detail as practical as we can. It is not our intention to walk away from this. You heard our motives.

CHAIR —Thank you very much. I am sure we are going to continue to hear about that when we speak with Medical Deans Australia and New Zealand.

[2.20 pm]