Better health and ageing for all Australians

Medical Training Review Panel: thirteenth report

Requirements for Practising Medicine in Australia

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Although national examinations for non-specialist IMGs have existed in Australia since 1978, states and territories had adopted different approaches to the assessment of some categories of Area of Need practitioners and specialists. In July 2006 the Council of Australian Governments (COAG) agreed to the introduction of a nationally consistent assessment process for IMGs and overseas trained specialists. COAG gave Health Ministers the responsibility for implementation of this decision and a model for a national process was developed and submitted to Health Ministers on 12 December 2006. The final report on the agreed pathways was presented to the Australian Health Ministers’ Advisory Committee in October 2008.

This model outlines three main assessment pathways:

  • Competent Authority (CA) pathway;
  • Standard pathway (including the current AMC examination and a new workplace-based assessment pathway); and
  • Specialist pathways for all specialties including general practice
    • Standard specialist assessment
    • Area of Need assessment
    • Overseas trained specialist in specified training position.
The Competent Authority pathway was implemented from 1 July 2007 and the first stage of the Standard pathway (workplace-based assessment) for general practitioners and non-specialist hospital doctors was implemented the following year, from 1 July 2008.

The Australian Medical Council (AMC) is responsible for processing all initial inquiries regarding assessment of international medical graduates and overseas trained specialists.

Further details on assessment requirements that are common to each of the pathways and the specific requirements of each are provided below.

Common Assessment Requirements

Each of the pathways includes some (or all) of the following steps:
  • assessment of English language proficiency at a nationally agreed level;
  • primary source verification of qualifications;
  • assessment against a position description with the level of assessment according to level of risk (for Area of Need positions);
  • orientation within three months of starting employment and evidence of satisfactory completion of this submitted to the relevant medical board with the supervisor's three-month report; and
  • access to continuing professional development.

Competent Authority Pathway

Competent Authorities are designated overseas accredited medical training and licensing examination authorities that have been reviewed and approved against criteria developed by the AMC as competent to undertake a basic assessment of medical knowledge and clinical skills for the purposes of registration in Australia. One of the criteria used to recognise a Competent Authority is the extent to which the clinical context is consistent with the Australian context of health care. This is defined in terms of the pattern of disease, level of medical technology, delivery of medical education and professional ethics. The AMC has approved four examination authorities in the United Kingdom (PLAB examination), the United States of America (the USMLE examination), Canada (the MCC Licensing Examination) and New Zealand (the NZREX examination). The AMC has also approved medical school accreditation programs in the United Kingdom and the Republic of Ireland as Competent Authorities.

IMGs undergo a pre-employment assessment of suitability for a position if required by the state or territory medical board. Where the medical board determines a pre-employment structured clinical interview (PESCI) is required, it is carried out by an AMC-accredited provider against the position description. This may be carried out if required for more senior hospital based positions and is included as a matter of course for general practice positions.

Doctors eligible for the Competent Authority pathway are granted advanced standing toward the AMC Certificate and undergo up to 12 months workplace-based assessment to ensure satisfactory adjustment to the Australian health care system before they are eligible to receive the AMC Certificate and apply for general registration.

Data on IMGs who applied and were assessed through the Competent Authority pathway in 2009 are covered in Table 5.4. This shows that a total of 1,599 applicants were assessed through this pathway in 2009. Of these, 1,297 applicants qualified for Advanced Standing. While these are primarily applicants who applied in 2009, the figure also includes a number of 2008 applicants who were required to submit additional documentation to confirm their eligibility. In 2009 a total of 843 AMC certificates were granted, making the applicants eligible to apply for general registration. AMC Certificates were granted to a large number of applicants who qualified for Advanced Standing in 2008 and then completed their 12-month performance assessment in 2009.

Table 5.4: International medical graduates: Applications assessed through Competent Authority Pathway, 2009(a)

Country of training

(b)PLAB

(c)MCC

(d)USMLE

(e)NREX

(f)GMCUK

(g)MCI

Total

Advanced standing Issued

Certificate issued

Canada024100027272
India1093341014181168
Ireland0000023326323282
South Africa230000754
United Kingdom01008650944810448
United States of America003000036252
Other(h)10016111721171117137

Total

211

47

45

21

867

234

1,599

1,297

843

(a) Data covers the period 1 January 2009 to 14 December 2009.
(b) Professional Linguistic Assessments Board Exam.
(c) Medical Council of Canada Exam.
(d) United States Licensing Exam.
(e) New Zealand Registration Exam.
(f) General Medical Council of the United Kingdom Accreditation.
(g) Medical Council of Ireland Accreditation.
(h) Other includes: Afghanistan, Albania, Armenia, Austria, Bahrain, Bangladesh, Belarus, Hungary, Indonesia, Iran, Iraq, Italy, Jamaica, Jordan, Latvia, Lebanon, Libya, Lithuania, Macedonia, Malaysia, Myanmar, Nepal, Netherlands, Nigeria, Pakistan, Peru, Philippines, Poland, Romania, Russia, Sant Lucia, Saudi Arabia, Serbia, Singapore, Slovak Republic, Somalia, South Korea, Sweden, Syria, Tanzania, Trinidad and Tobago, Turkey, Uganda, Ukraine, Venezuela, Zambia, Zimbabwe.

Source: Australian Medical Council administrative data, December 2009



AMC Standard Pathway

Doctors who are not eligible for either the Competent Authority or Specialist pathways are assessed through the AMC Standard pathway. In addition to the common assessment requirements, this consists of two mandatory examinations or assessments:
  • AMC Multiple Choice Questionnaire examination (MCQ); and
  • AMC clinical examination.
A PESCI is required for all IMGs applying for general practice positions and for some IMGs in hospital positions. Success in the AMC clinical examination leads to the awarding of the AMC Certificate.

Data on IMGs who applied and were assessed through the AMC Standard pathway in 2009 are covered in Table 5.5. This shows that 2,464 IMGs passed the Multiple Choice Questionnaire examination (50.8% of attempts) in 2009. A total of 650 IMGs passed the clinical examinations (51.5% of attempts). Applicants came from over 100 countries with over two thirds of those who completed both the necessary examinations required under the Standard pathway coming from Asia.

Table 5.5: International medical graduates: Applications assessed through Standard Pathway, 2009(a)

Country of training

MCQ exam attempts

MCQ exam passes

Clinical exam attempts

Clinical exam passes

Bangladesh226859845
China183797351
Columbia361885
Egypt142763817
Fiji391793
India974511284137
Indonesia361630
Iran26915410352
Iraq87462315
Jordan453241
Malaysia643131
Myanmar1771174529
Nepal6837116
Nigeria13254179
Pakistan4972949739
Papua New Guinea19511
Philippines3901186723
Romania37796
Russia168572714
Saudi Arabia321000
South Africa1611303832
Sri Lanka36826912574
Ukraine8222156
Vietnam19763
Zimbabwe281995
Other57225314876

Total

4,851

2,464

1,261

650

(a) Data covers the period 1 January 2009 to 10 November 2009.

Source: Australian Medical Council administrative data, December 2009



Assessment of Overseas Trained Specialists

Prior to 1990, all overseas trained specialists seeking registration in Australia, who did not hold a recognised (registrable) primary medical qualification, were obliged to pass the Australian Medical Council (AMC) examination and obtain general registration before they could be registered to practise as a specialist. Also, before 1990 only two states (Queensland and South Australia) had separate specialist registers.

In 1991 the Australian Health Ministers Conference (AHMC), in anticipation of the implementation of the mutual recognition scheme, approved a process for overseas trained specialists to be assessed by the relevant specialist medical college in Australia against the standards for an Australian trained specialist in the same field of specialist practice. If the qualifications and relevant experience of the applicant were assessed is substantially comparable to an Australian trained specialist, he/she could apply for registration limited to the field of specialty.

In consultation with the medical boards and colleges, it was subsequently agreed that the specialist assessment process should not be seen as a 'backdoor' to specialist training in Australia. For this reason it was resolved that any overseas trained specialist who required more than two years of further supervised training to meet the required standard for substantial comparability (equivalence to an Australian trained specialist) would be assessed as ‘not comparable’ and would be required to sit the AMC examination and obtain general registration.

A national assessment process for Area of Need specialists was not resolved until 2002, when agreement was reached on a separate pathway for the assessment and registration of overseas trained specialists in Area of Need positions. This involves an assessment against a position description that defines the levels of clinical responsibility, supervision and specific clinical skills required for a particular position. The relevant specialist college assesses the individual against the position description, rather than against the standards required by the medical college for a (fully recognised) specialist.

Recently, at the request of the medical boards, a number of colleges have agreed to combine their Area of Need and full comparability assessments, so that the applicant (and the medical boards) can be advised of the additional steps required to achieve substantial comparability at the same time as they are being assessed for the Area of Need position. To date some five colleges (RANZCOG, RACP, RCPA, ACD and RACS) have agreed to undertake the combined assessments of overseas trained specialists.

All specialist applications are administered through the AMC and assessment of comparability to Australian standards is carried out by the relevant specialist college. Applicants who do not meet the requirements for specialist assessment are required to undergo assessment through one of the non-specialist pathways.

Standard Specialist Assessment

Overseas trained specialists applying for comparability to an Australian trained specialist must have completed all training requirements and be recognised as a specialist in their country of training before applying under the specialist pathway for assessment of comparability.

There are three possible outcomes of assessment:
  • Substantially comparable;
  • Partially comparable, requiring up to 2 years upskilling to reach comparability; and
  • Not comparable.
The majority of medical colleges will allow applicants who are considered substantially comparable to Australian trained specialists to gain fellowship without requiring an additional examination.

IMGs with specialist qualifications or specialists-in-training are eligible to apply for general registration under the Competent Authority pathway (if eligible), in addition to applying for specialist registration through the specialist assessment pathway.

The following tables (Tables 5.6 and 5.7) present various data on overseas trained specialists (OTS) being assessed under the Specialist pathway in 2008.

Table 5.6 shows that in 2008 212 overseas trained specialists had their applications approved and a further 440 were deemed as requiring further training and/or examinations. In total there were 1,760 overseas trained specialists whose applications to be recognised as a specialist in Australia were being processed. While these are primarily applicants who applied in 2008, this figure also includes a number of applicants who were required to submit additional documentation or undergo further training to confirm their eligibility.

Tables 5.7 present data on the countries in which approved applicants were trained.

Two-fifths of all OTS (90 or 42.5%), who have had their applications approved, were trained in the United Kingdom and Ireland.
A further two-fifths were trained in just five other countries, with most coming from South Africa and India (285 or 16.8% and 212 or 12.5% of all approved applicants respectively).

Table 5.6 Specialist assessment by medical specialty, 2008

Medical specialty

Initial processing

Application deferred

Further training and/or examinations

Application lapsed

Rejected by College

Approved

Withdrawn

Total

Adult medicine15383317387301
Anaesthesia11870119365249
Pain medicine11
Dermatology11829232
Emergency medicine111210226
General practice1711230
Intensive care13176128
Medical administration11
Obstetrics and Gynaecology971121185152
Occupational and Environmental medicine11
Ophthalmology308410254
Paediatrics873068185154
Palliative care11
Pathology524411161115
Psychiatry7476301181
Public health medicine718
Radiation oncology/Radiodiagnosis 4337989
Rehabilitation medicine114217
Surgery19560538913320

Total

923

1

440

16

122

212

46

1,760

Source: Australian Medical Council administrative data, December 2009


Table 5.7 Approved specialist applications by country of training and medical specialty, 2008

Medical specialty

Canada

India

New Zealand

South Africa

United Kingdom and Ireland

United States of America

Unknown

(a)Other

Total

Adult medicine1124131738
Anaesthesia104111136
Dermatology6129
Emergency medicine253010
General practice110011
Intensive care medicine1236
Obstetrics and Gynaecology3382218
Occupational and Environmental medicine00
Ophthalmology126110
Paediatrics4310118
Pain medicine00
Palliative Care00
Pathology122106
Psychiatry9215430
Public health medicine00
Radiology/Radiodiagnosis51219
Rehabilitation medicine1102
Surgery3429

Total

4

48

1

27

90

7

1

34

212

(a) Other includes Argentina, Austria, Bangladesh, Belgium, Czech Republic, Egypt, Fiji, Finland, Germany, Hungary, Iraq, Ireland, Italy, Netherlands, Philippines, Spain, Sri Lanka, Sweden, Switzerland.

Source: Australian Medical Council administrative data, December 2009


Area of Need Specialist Assessment

Overseas-trained specialists applying for an Area of Need assessment must have completed all training requirements and be recognised as a specialist in their country of training. When assessing applicants for suitability for Area of Need positions, medical colleges will determine at the same time (or soon thereafter) what is required to meet standards for fellowship.

An Area of Need applicant is always assessed against a position description. The position description together with the qualifications, training and experience of the applicant will determine the level of risk and the level of supervision or further assessment required.

Specified Specialist Training

Applicants who wish to enter Australia for specified specialist training will require registration by the relevant medical board following advice from the relevant specialist medical college. This allows applicants to undertake training or to obtain experience in Australia not available in their country of training for a short period (normally up to one year), but can in exceptional circumstances be extended to three years.

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