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Standing Committee on Health and Ageing
12/08/2011
Registration processes and support for overseas trained doctors

STOKES, Prof. John, Private capacity

[10:30]

CHAIR: I now call on Associate Professor John Stokes. Although the committee does not require you to speak under oath you should understand that these hearings are formal proceedings of the Commonwealth parliament. Giving false or misleading evidence is a serious matter and may be regarded as a contempt of parliament. Would you like to make a brief introductory statement and then we will open up for questions. The more questions we get to ask, the better information we get. So I will hand over to you for a brief introductory statement.

Prof. Stokes : I will not repeat the details of my submission, you have that. Let me say that I would just like to talk as a person that is an Australian trained doctor who has worked overseas. On the basis of being an Australian, I am deeply disappointed at what I have seen happen over the years to overseas trained doctors. I hark back to my training days and my professors were Steinbeck and Gonski. They were the Jews from the Second World War; they were overseas trained doctors. That is where my knowledge came from in the majority of cases. I have watched over the years what has happened to people who have come from overseas, in my capacity as a resident, registrar, consultant, teacher, and I have heard statements about quality and I think it is hogwash. I do not believe at all that it is about maintaining standards. For every overseas trained doctor that you can name who has created a problem in Australia, I can name an Australian doctor with the same training I had who has created the same troubles. I do not believe it is an issue of standards, as the colleges say. That is an observation, I do not have any science or numbers to back that up. The Patel problem was not a problem with Patel's training, Patel's problem was a problem within Queensland health for appointing him. His friends were not in Queensland health, his friends were the doctors and the nurses who realised something was going wrong and were suppressed from doing anything about it. His true friends actually brought it to the attention of the public; his enemies were those people in Queensland health who are not now in jail as he is.

I think it is very important to speak truthfully about standards. Standards in Australia are exceptionally good, as they are in Germany, France, Britain, Canada, the United States and many other countries, and these doctors face exactly the same problems. I gave you the example of my professors; I will give you the example of doctors who have won Australian of the year. Three of them in recent years would not get registration at the moment. Professor Hollows would struggle, as would the others who have been Australians of the year.

I am not as benign about the colleges as Professor Rane would be. My belief is that no-one can set aside their interests in their income or their wanting to actually keep it all Australian. I see that and I have seen it over the years. I do believe there is a prejudice against overseas trained doctors and they have a harder row to hoe than we do. You make excuses for your friends. You say, 'Isn't it sad that Dr Smith had the problem'; when it is Dr Rane from India who has just come here, we say, 'not well trained'. It is a very unfair way of looking at things.

My recent experience is with trying to help people come to Australia as anaesthetists. It is the most torrid, horrid, complex, difficult, frustrating thing to do, particularly when you know you are being white-anted. These things do not appear in hearings, they do not get recorded in minutes, they are hearsay. Let us stop this happening, boys. That is the way it works, and I am afraid that I truly believe that there is a difficulty for overseas trained doctors. I would challenge the colleges to nominate those places in the world where doctors are trained to the same standards as we train people so that they could come easily into our service. I asked a former Chairman of the College of Surgeons Queensland what country he could name where surgeons are trained as well as Australian doctors, and I nearly fell over laughing because he said none. I just do not believe that would be true. If I got ill in Germany, if I got ill in the United States or in Canada or the UK, I am sure I would get a very good standard of care. Those doctors would easily transfer to caring for patients in Australia. Having said that, I would like to answer your questions.

CHAIR: Thank you and I will start off with a very brief one. Are there any countries where the standard is not the same as Australia, that you are aware of?

Prof. Stokes : There are, and we should be honest enough to actually nominate them. There are countries where you are trained well. If you have good parents who are wealthy you can go to a good university and get good training. But there are other universities in those countries where we know that the standards are not particularly good. It really upsets me that we feel so constrained, why we are unwilling to say that, and why we cannot say that somebody trained in Ireland or England or France or Sweden or Germany who has gone to a relatively good university, who has got a good CV and good references, cannot practise. It may appear to be racist but there are some places in the subcontinent where the training is not good enough and we know that, and I am sure Professor Rane and others would equally admit it, but not publicly.

CHAIR: The other question I have is similar to the question I asked the previous witness: how can the accreditation, the registration system, be improved to suit the requirements, especially for regional Australia where there is a high need?

Prof. Stokes : I faced that; we were told that we would never get people directly into private practice, that it would be impossible, there would be so many people against us. And we did it. I run a private practice. We made nothing out of it; every doctor who came into our practice earned the same as the ones that worked there. So we decided that we would bring doctors from overseas and interview them here at our expense.

CHAIR: So you flew them out here at your expense?

Prof. Stokes : We flew them out here, interviewed them, made sure that we were happy with them, made sure that they were what they said they were and then we guaranteed that if we offered them a job we would support them through the system. Then we battled with the colleges to get them recognised. Colleges are interesting groups of people, and it is not quite as easy as they say. I have 10 years of experience dealing with colleges; they are not a benign group about this. They use the argument of standards all the time. They were the most difficult group we dealt with. The next group that was difficult was getting the doctors a provider number because it is a private practice. It is not popular to bring overseas trained doctors straight into private practice. All the doctors we have brought in have stayed in Australia. Unfortunately, one died; one is now a neonatal anaesthetist in Adelaide; several are working at the Townsville Hospital; all the rest are functioning, extremely good doctors. We helped them through their exams. I would like to mention that the exams they have to sit are exit exams; they are not exams about your competence to practise. They are designed for Australian registrars, for Australian trainees and they are designed to determine that at a particular time you had that knowledge. I would fail both the exams in intensive care and anaesthesia now, but I am fit to practise.

CHAIR: You would say you have been successful with these doctors because you have assisted them to navigate through the system, and there has been someone there for them at all times to assist, to help?

Prof. Stokes : Correct.

CHAIR: I suppose what you are saying is that if we mirrored that across the whole system—

Prof. Stokes : I could reiterate what Professor Rane said. Dealing with multiple organisations is hopeless. Just for interest sake I obtained the notes from the recent meeting from the Queensland State Health Department at which they presented a paper of policy and procedures for areas of need. It is a nine-page document and I cannot make sense of it. Admittedly, I am getting on and I have trouble with these things, but I cannot make sense of it. I have the PowerPoint slides. It is designed to stop you getting there! It is designed to make it harder, particularly if you are in private practice.

Mr WYATT: In your view, why do IMGs fail?

Prof. Stokes : It is a different construct. They do not fail. They are put through an exam they cannot pass. I put it to you that if Australian athletes lined up at the Olympics looked across and saw a really streaky Nigerian who was going to win, and they said, 'He didn't do the same training as we did so you'd better get him out of here,' we would be a bit suspicious. They would not want him there because he is actually good. So these people fail because they are not taught as we are taught. They face an exit exam, not a fitness-for-practice exam, which is completely different. We spent most of our time in the two or three years that people had to prepare for the exams in teaching them how to pass the exam. We did not have to do anything with regard to their knowledge or skills. All we had to do was teach them the tricks of how to pass an Australian exam.

Mr WYATT: If somebody is from a country that we do not accept, would it be appropriate to suggest they do a 12-month refresher or an intensive training course at university to bring them to a level that sits within the Australian construct?

Prof. Stokes : :Yes, there needs to be an alternative. A bit of uncertainty for organisations is quite good. It keeps them up to speed. The colleges have absolute control over who gets registered as a specialist. If there were something that overseas trained doctors could have as an alternative to the colleges, I think you would find the colleges would sort it out pretty quickly.

Mr WYATT: The third part to that is supervision. How adequate is it?

Prof. Stokes : I can only speak for what we did. We gave constant supervision. We were always available and made quite sure they knew that there was another specialist to turn to to ask questions—and a sympathetic person.

Mr WYATT: That was also intensive in terms of providing support for the practical element of application of skill to patient diagnostic work and patient treatment?

Prof. Stokes : No, it was not the issue of negotiating the system. Because we had to interview them, because we knew them, because we knew the universities they had trained at—it was a piece of cake in terms of having them care for patients. You might like to ask some of the doctors who appear here today who have had those people give anaesthetics for them whether they were happy with them. There will be no complaint.

Mr IRONS: Are there any bodies involved with the process of obtaining registration and getting a provider number that you would describe as being proactive and positive in the process?

Prof. Stokes : Yes. It is not a popular thing to say but the best people to help have been the local members of parliament, and I cannot speak highly enough for their attitude to this, their openness to try to solve the problem. Some particular people in the departments have been very helpful. Our college was writing two different letters, one for private practice and one for the public hospital. The letters for private practice submitted the word 'specialist'; the letters for the public sector had the word 'specialist' in so they could get their people through. A clerk in the department of health told me that. Once I mentioned to the college that there was a difference, the word started to appear. So, yes, there have been a few people, but I say, absolutely, that politicians have been the most helpful in this, and when we go to bulwarks in actually getting—

Mr Irons interjecting

Prof. Stokes : Peter Lindsay—

Mr IRONS: Ewen Jones. If Ewen is listening—

Prof. Stokes : Bob Katter and Senator Ian Macdonald. When you get to someone senior in the departments of health, both at state and federal level, they are extremely helpful. The people I found most difficult were when negotiating with the colleges. I am completely different from Professor Rane and I am happy to stand by it for the rest of my life about the treatment they gave us.

Mr IRONS: Do you feel there is a level of protectionism?

Prof. Stokes : Absolutely—nothing else.

Mr IRONS: So it is not safety; it is protectionism?

Prof. Stokes : It is a bad thing. As I say, a tiny touch of insecurity makes you perform better. I had much rather people check that I actually did my job properly. The remit to the colleges should be: find a way to get these people to practice to a standard that is reasonable and that you would expect for yourself. I have a great admiration for the people we brought through and their willingness to put up with some terrible situations which basically are discrimination.

Mr IRONS: So with our current system, the way it is set up, how many good overseas doctors are we probably losing for Australia?

Prof. Stokes : Several. There was an oncologist who was professor in Adelaide who has just left our country because he could not practise. The professor of paediatrics at James Cook University, our first professor, was from South Africa he could not practise for two years but he could teach our students. It is insanity; it defies logic that we actually do this. Why do we think Australia is the only country that can produce specialists such as airline pilots, engineers and lawyers? One of the previous state premiers came from Dannevirke in New Zealand. To me it is a matter of openness. When I think back to my days as a child in Daceyville, in my class at school we had 65 people. Only about ten or twelve were Australians; the rest were from Lebanon, Greece and Italy. We are a nation of immigrants.

Ms HALL: I find the idea that you put forward of a certificate of standing, or, to put it a different way, accreditation of training and experience in certain countries, very interesting; and the fact that if a person trained and worked in a country that had very much like training and like work experience then they should basically be automatically accepted as a doctor with equal standing to an Australian doctor. I would like you to expand on that, and maybe in doing so look at the recent change that has taken place between Australia and New Zealand. New Zealand trained doctors can now basically come into Australia and work straight away.

Prof. Stokes : I will speak to that with one example. A chap from Britain, accepted as an anaesthetist in Britain, who had done his proper training, English, came to Australia. He was white, with nice teeth and white hair. He went to Sydney to do intensive care work. They made him do his intensive care training and pass the exam even though he is a qualified anaesthetist. So after doing that and passing the exam, exceptionally well, they told him he needed to do 12 months training in anaesthesia. This chap had been working at St Thomas' for a long time. You cannot ask for better than that. He could not actually get a job like that. They wanted him to go back and be a registrar.

Somebody rang us up and asked if we could help. So we offered him work in our practice for 12 months. We also had a German anaesthetist who was in that position. He went to Royal Brisbane. So that area of need disappeared and we had to spend nine months reapplying so that that doctor, already practising in Sydney, could practise in Queensland. He had to get his 12 months to become a specialist anaesthetist. He just finished last year. It would be really obvious to Joe Blow that he can practise. Firstly, he can speak English; secondly, he can practise medicine; and thirdly he is recognised as a good doctor because he was working at the Prince of Wales Hospital in Sydney. Yet we had to go through all of that again. So there has to be a way of recognising these people. It defies logic that you cannot actually do something which is bleedingly obvious. Part of the problem is, and there is a saying about this up here, 'it's hard to drain the swamp when you're up to your neck in crocodiles'. That is what it is like trying to get these people through: there are all these things to do. They are sniping at you and holding you back. It is just near impossible to do and actually carry on doing work.

Ms HALL: So maybe that is something we should be looking at when we are putting together our recommendations. I was wondering if you might like to expand a little on the statement you made about people being white anted.

Prof. Stokes : I brought over a doctor from Europe—Germany—who was trained in intensive care and anaesthesia. Letters saying that we were bringing untrained doctors into the town were written to the local hospital and to the Medical Board of Queensland. I know this happened specifically at meetings of the college—I know someone who was there—that it was claimed we were bringing untrained people into the country. It is basically not true. They ought not say things like that. That is what I mean by 'white-anting'. Those things do not get recorded in minutes; you say that to your mates.

Ms HALL: I have one final question. When you have IMGs working here, do they get support—I do not mean support from people such as yourself—from our society? They are not given medical cover. They are providing medical treatment to Australian people, yet they have to pay for it themselves. If they have young children who go to state school, they have to pay for their education.

Prof. Stokes : Do you mean associated problems other than those in medicine?

Ms HALL: I am talking about the personal level. Can you comment on that?

Prof. Stokes : You just have to come to an organisation willing to make the effort to help you with those things. Fortunately we did. I think Queensland Health tries to do things such as that with housing. That is probably the most important thing—happy wife, happy life; that sort of thing—if they are made welcome. Generally, in the regions, people are made to feel extremely welcome.

Ms HALL: Whilst they do not have eligibility to access health treatment through Medicare, the local practice, or wherever they are working, picks up the treatment for the family?

Prof. Stokes : That is very important. We made it quite clear to people that came that they would earn as much as I did.

Ms HALL: Is there anything that the government should be looking at in those areas?

Prof. Stokes : I am always very suspicious of subsidy. It tends to increase the cost of things and not provide an outcome. People should be encouraged to do that in the workplace. Those people supporting them there should do it and take the responsibility. Maybe they should get some kudos and some tax deductibility. But I would not be supporting—

Ms HALL: You would not support them being eligible for Medicare?

Prof. Stokes : They should be eligible for Medicare.

Ms HALL: That is what I am saying.

Prof. Stokes : That seems grossly wrong: that they can be working in a health care system and having to pay extra to Medibank Private.

Ms HALL: If their children attend the state school, should they have to pay excessive fees?

Prof. Stokes : No. We in Australia pride ourselves on free education and free health. And that should be available them.

Ms HALL: That is what I was getting at.

Mr WYATT: In terms of visiting rates to hospitals, yesterday I asked a question of a GP who was part of a private practice. One of the challenges he faced was the visiting rights to hospitals, particularly when his went into a period of being null and void because of registration requirements. Did any of your doctors face that experience in the state system?

Prof. Stokes : Yes; they cannot work until that is all sorted out. That creates problems. In particular, one of our doctors forgot to re-register for a Medicare number. We did not find out about that for six months. That cost a lot of money. There are issues associated with registration and accreditation. It has to be exactly right or you do not get accredited. The simplest thing can stop you.

Mr WYATT: When they are in the framework, do they have difficulty meeting all the obligations? Are there any challenges in terms of the interface with the public hospital and continuity of care?

Prof. Stokes : I cannot comment. Fortunately, I have little to do with public hospitals.

Mr WYATT: I assumed that, given the other citing of the hospital.

CHAIR: Thank you very much for your evidence. If we require anything else, we will be in touch with you. And vice versa: if there is anything else that you feel that the committee should know and, for whatever reason, has not been said here today, feel free to get in touch with the secretariat.