Overseas doctors addressing rural doctor shortage?


A man sits in front of Parliament House, his stomach rumbling. A stranger walks by and yells abuse, but it rolls off his back. The man is well dressed, even in the 35 degree heat. All he wants is some attention from the Government, some help to find a job. He’s not homeless, he’s a doctor.

In November 1997, 39 overseas trained doctors declared a hunger strike in front of Parliament House, protesting against the Federal Government’s accreditation process for them to practice in Australia. A few days later, 50 more doctors in Melbourne and Canberra joined the fast.

The national president of the Australian Doctors Trained Overseas Association, Asaad Razaghi, told Time magazine he was the one who called for the hunger strike and swore to be the first to die unless he saw the Government take action.

The overseas trained doctors had been encouraged to come to Australia to address the shortage of doctors in rural and remote areas of Australia. However, once in the country, they faced more problems than they helped to solve.

On 20th November 1997, Labor Party MLP Franca Arena addressed the New South Wales Parliament on behalf of the striking doctors:

“They go to an Australian embassy overseas, they pass an exam on a points system; they are told that they will be recognised, then they come here and it is a completely different ball game… When they arrived in Australia, in some cases they were able to work for a few years, but in other cases not at all; they were told that they should sit exams, and all sorts of impediments were placed in their way to prevent them from working as doctors.”

17 years later has anything changed?

Ghaleb Jaber, who was born in Kuwait and received his medical qualifications in Egypt and now practices in Australia, doesn’t think so.

“In 1997, [overseas trained doctors] held a hunger strike in front of the Parliament to attract the attention of the politicians and the media. That was the time when they considered things need[ed] to be done for those doctors. I think the issues are the same now.”

Dr Jaber said it’s a complicated and expensive process for the International Medical Graduates to become accredited.

Firstly, the Australian Medical Council assesses the clinical skills and professional attitude of those interested in working in Australia, followed by a test which is equivalent to a medical student graduating from university. If the first tests are passed, the overseas trained doctors are required to complete an English proficiency exam. The next step is to register with the Australian Health Practitioner Regulation Agency which performs a Pre-Employment Structured Clinic Interview for further assessment. Once all these tests are passed, the Department of Immigration and Citizenship is contacted for a permanent Visa.

The progression costs $6000 if all tests are passed on the first attempt. If any step is unsuccessful, the sequence has to be restarted. Doctors are then required to work for twelve months in a hospital to gain Australian experience as a General Practitioner. Dr Jarber said they complete the whole expensive process before they find out there are no jobs available.

“They pay for the exam, they pass the exam, but there are no jobs after that,” Dr Jarber said.

Yet rural areas are in desperate need of doctors.

Studies by Rural Health Australia have found rural and regional areas have a higher mortality rate than in the metropolis. Between 2004 and 2006, the death rate in regional Australia was 4600 deaths above the normal mortality levels. In 2011, the mortality rate remained 10% higher in rural areas. Rural patients are also more likely to have to be ill, more likely to travel over an hour for healthcare and more likely to have increased doctor and hospital waiting times.

 Graph ABS

Source: ABS 2011 Census of Population and Housing


Despite these statistics, the ratio of General Practitioners in the country is half of the ratio in the city. Major cities have 228 GPs per 100,000 people compared to 113 per 100,000 in remote areas such as Broken Hill. Specialists are also scarcer in regional towns – only 25% of Australian specialists are located in regional areas.

It appears to be an easy solution. There are doctors in need of jobs, and towns in need of doctors. However, the reality is more complicated.

Colleen Best, the Practice Manager at the Mudgee Medical Centre, said despite the Medical Centre’s struggles to maintain enough doctors to meet the community’s needs, rural areas are often not ideal for the International Medical Graduates.

“Most GPs want to work in city regions, close to private schools and where their partner can pursue their own career,” Ms Best said.

Gil-Soo Han and John S. Humphreys in their article ‘Overseas-trained doctors in Australia: Community integration and their intention to stay in a rural community,’ pinpoint integration as one of the most important factors contributing to International Medical Graduates remaining at rural practices.

“Integrational issues associated with cultivating relationships with locals assist in ‘anchoring’ migrants in the new community and forming their identity as part of that community.”

However, the authors agreed with Ms Best that the limited opportunities for children’s education and “spouse adjustment” hindered the desire for overseas trained doctors to practice away from the city. The associate professors added preparation for exams, professional isolation, heavy workload, unrealistic expectations, lack of access to specialists and frequent moves for training all increase the reluctance.

Ms Best said discrimination is another problem. While not treated differently by the staff, the Practice Manager found patients may refuse to see doctors from overseas if they “look different” or are difficult to communicate with.

Two years ago, a Parliamentary report into the registration process and support for overseas trained doctors, titled ‘Lost in the Labyrinth’ highlighted the same problem, not only from patients, but from the accreditation process itself.

In the report, Steve Georganas, chair of the Committee on Health and Ageing, said many doctors felt they had been the subject of discrimination, and anti-competitive practices which had adversely affected their success in registering for medical practice in their chosen speciality.

“One particularly illustrative example of the problems faced by International Medical Graduates was a specialist who despite being highly regarded overseas was forced to sit a basic exam for his field. There was a textbook listed as a study guide – he was the author!” Mr Georganas said.

To combat these problems, the 5-year Overseas Trained Doctor Scheme was introduced in 1999 to provide an incentive for the OTD’s to temporarily re-locate to the bush.

According to the NSW Rural Doctor Network, after working in one of the Government-designated ‘areas of need’, for either three or five years, depending on the remoteness of the area, eligible doctors are awarded a non-location-specific Medicare provider number, which enables them to practice Australia-wide.

There are over 100 towns on the Eligible Location list, including Mudgee, Cobar and Lightning Ridge.

Ms Best said at the Mudgee Medical Centre, most Registrars who partake in the Five-Year Scheme only stay to complete their compulsory training in rural areas, and leave as soon as they receive their Medicare provider number.

The Mudgee Medical Centre’s experience with overseas doctors is contradictory to the research done by the Australian Department of Health and Ageing when the Five-Year Scheme was first introduced.

According the Department, 60% of Overseas Trained Doctors who participated in the first syndicate of the Scheme – which finished in 2004 – indicated they would remain in rural areas, with 51% signalling they would stay at their current rural practice.

In the ten years since, the scheme’s rate of retention seems to have dramatically declined.

Despite this, the numbers of overseas trained doctors are steadily increasing. The ABS study identified 56% of GPs in 2011 were born overseas, compared to 46% in 2001; while the Immigration Department granted 1,260 visa for doctors in 2012, with the number growing to over 2000 in 2013.


ABS Graph2

Source: ABS 2011 Census of Population and Housing


Dr Jaber said more research is needed to identify the impact these doctors are having.

“The problem is we don’t know how many doctors are in the country. How many employed? How many unemployed? What they are doing? What jobs they are doing? We have a problem and we need to accept this information. Because unless we have the figures you know, how can we deal with the situation?”

There have been no studies into the number of International Medical Graduates who move to Australia but are unable to find employment, and there is little information on the current retention rates from the Five Year Overseas Trained Doctors Scheme.

Gin-Soo Han and John S. Humphreys agree it is an area which needs more study.

“Most rural studies have focused on youth, older or retired persons and refugee workers… however, few studies have explored the integration of foreign-born medical practitioners into rural communities.”

17 years ago, International Medical Graduates felt forced to go on a hunger strike out of frustration at a Government which had enticed them to Australia, then refused to address the associated issues. Now, overseas trained doctors such as Dr Jaber are facing similar issues and are still feeling ignored, while rural practices remain understaffed.

“We don’t want to go to that stage of a hunger strike. I can’t speak on behalf of all doctors to commentate the situation, but many people because of their frustration – there’s no response they’re not getting anywhere, there’s no operation- they might just be talking about it.”


Thumbnail image: Courtesy of the National Photo Archives

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