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

QUIGLEY, Dr Frank, Private capacity

[11:04]

CHAIR: We now welcome Dr Frank Quigley. Although the committee does not require you to speak under oath you should understand that these hearings are formal hearings of the Commonwealth parliament. Giving false or misleading evidence is a serious matter and may be regarded as a contempt of parliament. I ask you to make a brief introductory statement and then we can open up for some very informal questions and answers. Over to you.

Dr Quigley : I do not think my statement needs to be as long as the others. They have covered most of it. The theme, as you know, is fairly similar in all submissions. My main purpose in the submission was to make an observation as someone acting as a proponent or supporter of IMGs and an assessor of IMGs. My concern is that the process is not always as transparent or as fair as it should be. I think one of the issues has been outlined pretty well by Professor Rane in that there are a large number of committees and departments—the colleges, various state government departments and federal government departments—and they all have their own issues with overseas trained doctors. There are issues in making sure that doctors jump through the hoops of each one of the departments. No-one is acting for the overseas trained doctor. Professor Rane's recommendation of a case manager is a good one. Whether or not anyone can get a number of departments to cooperate remains to be seen, but that definitely has to be a better option than what we have got at the moment.

It amazes me that people get through the process as they do. If you looked at a person coming from overseas with a family and trying to settle in a new country you would see that it puts a fairly big strain on their life. If they then have to deal with 15 different government departments and supply the same paperwork to them repeatedly and at odd intervals, while trying to study for an exam that they do not really think they need to do, it is a pretty hard process. If you look at stresses in your life, it would have to be worse than divorce or marriage.

CHAIR: Either one of them!

Dr Quigley : Yes. They are the great stresses in life, and I think that is up there. My main concern is with transparency in the process and the amount of support that the overseas trained doctor gets.

CHAIR: Why is it that you believe that the registration and accreditation for an IMG is much harder than that of an Australian counterpart?

Dr Quigley : For an Australian person who wants to apply for a speciality there is a fairly clear process. He applies to the training program, goes to an interview, gets a reference and gets on the program and there is a very structured system through five years or so of training. He gets repeatedly assessed, he is mentored the whole way and he knows exactly what the exam is going to be at the end of it. An overseas doctor coming into the country has no idea what is going to happen to him. He does not know how he is going to be assessed and when he is assessed it is not at all clear what is going to happen. He might be told he needs some further assessment and then an exam but he does not know what the exam is like because he has never done it and is not trained for it. To expect an overseas trained doctor to pass the exam without the five years of training is pretty hard work.

CHAIR: How can we improve the levels of training that are available to the IMGs in rural and regional areas? What is the best way to improve the training that is given to them?

Dr Quigley : Part of it goes back to the fact that people often are not given registration when they are from overseas because the colleges are too scared, for whatever reason, to give someone registration without proving they have done the exam because the other option is too hard for them. The other option—it is recognised by the colleges and by most other people that it is the best way to assess someone's learning—is direct observation. The trainees have that happen to them for five years in a row. They are directly observed and assessed all the way along. If an overseas trained doctor works in your department for a year it is pretty clear whether or not he is just as good as you are. There is no need for an exam.

CHAIR: You also noted in your submission that you were aware of an IMG who had received conflicting advice or evidence from their college. We are hearing that quite a bit. How can we address that? What would you say could fix that?

Dr Quigley : Ajay's proposition of a case manager is best. It is a little bit like John Stokes's example about area of need. I tried to clarify for that trainee what his options were for doing the exam or applying for reassessment, and I still could not give him any advice at the end of it because I could not understand the advice from the college. And I told them that. So a case manager is probably the only way to go.

CHAIR: That would be very disheartening. If it is difficult for you to understand then it would be impossible for someone from—

Dr Quigley : Yes, I agree. The only clear way forward I can see is to use an assessment process. Most people agree that that is a reasonable way of looking at people's training. The colleges actually have very good assessment processes in place, but they are not readily available to use for the IMGs.

CHAIR: We heard earlier that the colleges claim that all these steps along the way are there because we have very high standards—higher than those of most other countries. Would you agree with that?

Dr Quigley : I do not think there is anything wrong with the training program or standards in Australia. I also agree with the proposition that we are not the only country in the world that trains good specialists.

Mr WYATT: Dr Quigley, one of the things I liked in your paper—and I have raised this previously—was the information about online inreach into other countries. Would it be possible, and I ask this of your university, to have a point of connection whereby overseas doctors thinking of coming to Australia could go to one point to look at the processes required and the various structures that exist to help them before they make the decision to come here? Would that be possible rather than them spending 12 months after they get here going through the process a number of times because they do not have that information and paying additional money each time they fail to go through it again? If they had a taste of that prior to coming here, it may be a different proposition for them.

Dr Quigley : I am not sure I said that in my submission.

Mr WYATT: No, you just alluded to the online element and the global—

Dr Quigley : I agree entirely with what you are proposing. I am not quite sure how easy it would be. It ties in with what everyone else has said: the process is so complicated to look at from the outside that it is almost impossible to understand and the process needs to be made more transparent.

Mr WYATT: That is part of the challenge. They are uprooting their whole family and coming to a new country where they are not sure of the standards and not sure whether the university course they have done will be acceptable to the colleges or to the workforces they want to go into. Certainly they are sold the notion that they are coming to a region that has plenty of opportunities; therefore, they make the judgement to uproot the whole family, lock stock and barrel, and come out here, where they often find, after some time, that their visa is under threat and they may have to return home.

Dr Quigley : From my experience, most people's experience is that, when they get here, the work is what they expected; it is just that the process they have to go through is far more complicated than they expected. It is a process problem rather than the work when they get here.

Mr WYATT: There are countries we deem not to be suitable in this context. People do train and become doctors within their own countries and do leave their homelands for a range of reasons. Is it feasible to look at the proposition of a university refresher program that would bring them to the level required? I am thinking of the EFSU that you will have to deal with and the whole construct of Commonwealth funding in the medical schools.

Dr Quigley : I do not know whether a university program for a year is really what you are looking for. I think a supervised position in a teaching hospital is probably closer to what you want. They are at a stage where they are past sitting in front of a lecturer and learning things; they are doing practical things. An observation of their procedural skills and interaction with people is what you are after, rather than working out whether or not they understand A plus B.

Mr WYATT: Or, better still, an RPL process, recognising prior learning, and then being accredited for that learning.

Ms HALL: I think there has been a common theme this morning in the presentations we have heard. I want to take a bit of a different tack here. We have talked about the process of assessment and registration. What about when a problem becomes apparent? Do you think the review process that is in place at the moment is adequate?

Dr Quigley : You mean with an overseas trained doctor that is being assessed?

Ms HALL: Yes—a problem with the assessment or the paperwork, or any of the areas that have been identified, or a problem in which the person's performance in a medical practice has been questioned. In any step along the way, do you think that the review process to examine the problem is adequate?

Dr Quigley : From my own personal experience with trainees, both Australian and overseas, I think the review process is pretty good, as far as their medical practice is concerned. They are closely supervised and if there is an issue with their medical practice it will be picked up.

Ms HALL: Do you think that there is a need for a dispute review body, like an ombudsman—for example, to deal with a problem relating to process or medical supervision? We have received a number of complaints through this committee from doctors who feel that they have been unfairly treated. They feel that the way problems have been dealt with has been inadequate. Do you think there should be a very different body that could assess their particular case, something very transparent and apart from the system that exists now? Quite often the people that are assessing the complaint can at the same time be the people that have made the complaint.

Dr Quigley : I think there are a number of processes in place to look at medical practice. Sometimes various bodies do not actually follow them. We can talk about Patel if you want to; that was a process fault. But, by and large, there are processes in place and if they are followed they will allow good management supervision of medical practice and any problems that arise. They are not always followed and sometimes you get problems because of that.

Ms HALL: Could that justify having a body where—

Dr Quigley : I think there are already bodies there. If people do not follow the rules, you will still get problems.

Ms HALL: What do you say to my comment that quite often the people with the problem are the people assessing the problems?

Dr Quigley : I think the other side to that is that overseas trained doctors are assessed a lot more than just their medical practice. As you know, they have to jump all those hoops. I agree entirely that they often stumble in that system due to no fault of their own and no-one is looking after their interests. I agree with you that there should be someone doing that, as we have already said, such as a case manager or some other body.

Ms HALL: Maybe I should give you an example.

Dr Quigley : If you wait for an ombudsman, you are waiting for the problem to occur. You are a lot better off trying to prevent the problem from occurring in the first place if you set in place a process that is easy.

Ms HALL: Absolutely. But I am moving to a different direction here. Say Dr A has been practising in a hospital somewhere. His supervisors say that his medical knowledge and techniques are not up to par, but this doctor has been doing it for a very long time in this hospital, he is just about to go out and open a practice on his own and then the doctors say that he should no longer be allowed to practise. His medical expertise is reviewed by the same doctors who are making the complaint. My question is: in those sorts of circumstances, do you think that a separate review body—

CHAIR: An appeals body.

Dr Quigley : I have recently been involved in just such a thing. The Queensland health department, for all its sins, actually has a very good process of that in place at the moment, and I recently took part in one of its reviews. It has an independent review panel, if you like, that has to be approved by the doctor being assessed. I thought it was a very good process and quite fair.

Ms HALL: So you feel the current system is adequate?

Dr Quigley : Well there is one available through Queensland Health which I am quite impressed with.

Mr IRONS: Dr Quigley, when you were involved in the actual processes, did you in any way attempt to change that process at all when you saw that it was not working? If you did try, what difficulties did you face?

Dr Quigley : I wrote a number of letters to the college and in the end the college's view, to me, was that, although direct observation of practice would be a good idea, the exam is what we have at the moment so that is what they will have to do. Their view was that it was a fair exam because it assessed just competency, but my view was that that was not true. I have made my views known to the college and there are a number of people within the colleges who would agree with my views. I think it is a job in progress.

Mr IRONS: It sounds like it is set in stone and that, even if you come up with what you perceive as a better process, they still would not have been prepared to—

Dr Quigley : At the time. They now say that there is a process in the College of Surgeons where you do not have to do the exam. If you have been observed for a year and the unit you are on has assessed you as not needing an exam then you do not need to do the exam. But it is still not clear to a person coming from overseas and looking on the website that that is going to happen to him. It is all up in a cloud and you do not know where you are going to come out.

Mr IRONS: In our report we make recommendations. As someone who has been through the system and knows the system, what would be your suggestion for the best way to implement those changes? If you had people who do not know the system trying to implement the changes the government will make on the basis of the recommendations of our report, what would you see? Would you see a body that is set up purely for those changes by people who have been through the system?

Dr Quigley : Firstly, you would have to sort out the process. We have already been through that. Trying to jump the hurdles of five different departments each month is difficult. But there are already processes available within all the colleges for assessing people by observation on a unit with set standards—the direct observation of procedures, observation of history taking, observation on a ward. It is all done for the trainees already. And the simple way we assess a hospital when we go to inspect it is to interview various people in the hospital—for example, the nurses they have worked with, the radiology department they have worked with and various people throughout the hospital. You get a pretty good idea after two days whether or not that hospital and that doctor is up to scratch. You do not have to do an exam.

Mr IRONS: I am trying to get at what sort of body would need to be put together to make changes.

Dr Quigley : The colleges have already got the ability to do that in place, but it is not funded. They will not fund it; the state governments have to fund it.

Mr IRONS: If the government made legislation to change to processes—to say to the College of Surgeons 'This is how you do it under legislation'—what sort of people would need to be on that body to make sure those processes were put into place?

Dr Quigley : You are going to have to have some cooperation from the colleges because they are the only ones who could implement it.

Ms HALL: This morning the three of you have mentioned that the examination overseas trained doctors undertake is really an exit examination as opposed to an examination that you would expect overseas trained doctors to undertake. Can you expand on that a little and provide information on the type of examination and assessment that is more relevant?

Dr Quigley : I think I have said most of it. At the end of a training program you want a competent person, whether it be a doctor, lawyer or engineer. At the end of a training program and in university education, the traditional way of assessing that is an exam. There are different sorts of exams. The various colleges in Australia have their own exit exams, which everyone agrees are pretty good exams for the training program done by those people. That does not necessarily mean that that is the best exam for assessing someone who is trained in engineering or medicine at a different university or in a different system. It does not mean that he is not a good engineer, lawyer or doctor; it is just that he has studied a slightly different technique and has been examined in a different way. At the stage where someone has been through a program and has been working, your best way of assessing whether he is suitable is to see what he does in his work as an engineer, doctor or lawyer.

Ms HALL: What would you replace it with? How should it be done?

Dr Quigley : They would be in a supervised position—a post preferably in a teaching hospital. It is the same with anaesthetics, O and G, and surgery: we observe our trainees. They have to have an objective, standardised assessment at least every three months where we watch them do a procedure and mark it with an objective scoring system. We look at them every day on the ward. We see them in theatre. We see how they manage patients. It is just observation of their practice. That is what it comes down to.

CHAIR: Thank you, Dr Quigley for your evidence today. If there is anything else we need to know, we will be in touch with you, and vice versa.