Australia

overseas trained doctors – explanation of workplace location determinators in australia.

bobby-hendry-305614

This article is about both the Area of Need (AoN) and District of Workforce (DWS) systems for overseas trained doctors (OTDs) Consultant/Specialist/GPs who are migrating to Australia. Overseas trained doctors (OTDs) are doctors who have completed their specialist training in country other then Australia.

In the 1990s Australia began to introduce policies to encourage more IMGs to migrate here. Now, approximately 40% of its medical practitioner workforce are IMGs. These systems and – more significantly – theOTDs themselves are essential to Australia’s current and future well being.

If the systems in place are vital to ensuring the provision of health care to Australia’s population why are they so misunderstood and complex? So complex that even the odd workforce manager, clinical director and international recruiter can’t understand the distinctions between AoN and DWS, let alone doctors exploring the idea of moving to Australia.

Lets step back to understand to try to peer behind the curtain and acknowledge that everything is not what it seems. For example, to work as an overseas  trained Consultant/Specialist or GP in Australia doesn’t mean you have to work in a tiny outback town, thousands of kilometres from a decent flat white with a toothless beer swilling, vest wearing, pig hunting neighbour for company and little employment prospects for your partner or hooling for your kids. The truth is you actually don’t have to work in a remote environment in your first job. But this is the common perception.

There are more location options for you or your family then you probably think.

The fact these exist and you don’t know about them reflects the complexity of the systems in place determining OTD workforce provision and the way these systems have been communicated to international medical graduates over the years and how they have been perceived. 

Dependent on your specialism and subjective workforce requirements at any given time, there are cities with 300k populations where you can theorectically work. Even major metro (Sydney or Melbourne) suburban opportunities, like these smaller cities become available from time to time, for certain specialties and dependent on workforce requirements.

 I’ll come to AoN and DWS shortly but let’s consider a subtle but important variation in the meaning of a couple of words used to describe geography and the sense of space in Australia. In particular, lets consider the word ‘regional’ within an Australian context. This word is often misinterpreted by OTDs at the stage of initial research or job application. A ‘regional area’ or ‘regional town’ does not mean the stereotypical remote Australian outback town I referred to earlier.

In fact, Australians tend to use this term “regional city” or “regional hospital”  to describe an area or place which tends to be a drivable distance from a state or territory capital. The term regional can also describe a city I mentioned before with a population of up to 300k people. I believe there is a subtle but clear distinction between a regional location and what is termed a remote location within an Aussie context which is important to understand from an international job applicant perspective. If you’re a truck driver or lawyer living in Australia it doesn’t matter but if you are starting this process with little knowledge of the country please bear this in mind. An example I often think to is a UK Surgeon I dealt with in the past who aplied for a remote job vacancy I was managing. The surgeon insisted to me they had remote medicine experience because they drove to and delivered care in communities just 20 minutes outside of Manchester, England! I almost fell off my chair. 

I believe in an Aussie context, a ‘remote’ location means at least an hour flight or at least a six hour drive from a state or territory capital. Remote means a loooong drive between petrol stations – who do great business in CD audio books keeping road train drivers awake through the night. So please consider this in the future and make sure not to be put off by the term ‘Regional’.

Now, to the systems. The systems for determining where OTDs can work is extremely confusing. Combine this with the infamous levels of bureaucracy during the college assessment and medical registration processes and you get a sense of the big pile of knots that need untangling.

Critics and those doctors who’ve had bad experiences have called the Area Of Need (AoN) and District of Workforce Shortage (DWS) systems of workforce distribution discriminatory and divisive. The impacts for OTDs and their families whose futures and experiences are determined by these systems should not be underestimated.

Therefore, it is important that you understand the following differentials. I have tried to make this as clear as the legislation allows.

Moving to Australia, as an OTD either at Consultant/Specialist/GP level you do have to work in a position that is categorised as  “District of Workforce Shortage (DWS)” or in a job given the status of “Area of Need (AoN)”. 

Area of Need (AoN).

Area of Need status is administered by the relevant state or territory government. Each actually has a separate policy regarding definition but they are more or less the same for the purpose of this explanation. Despite its wording, AoN reflects the status of a specific open vacancy for an employer (either a public health organisation or private employer). How this is defined and administered varies between each state and territory but the outcome status remains the same. AoN status mean an employer’s vacant position has been granted suitable status for an OTD to work in this particular position. AoN is a term in which a medical position  remains unfilled despite recruitment efforts to source an Australian trained applicant. Importantly, AoNs are not confined to regional, rural or remote locations but can also encompass metropolitan and outer metropolitan locales as it is the job not the location which qualifies for the status. Therefore, because of an identified need, the accreditation process can be fast tracked along the long and windy road ahead.

An AoN position has implications for your respective college application process and pathway. For example, you may be planning to go on Specialist Pathway for Area of Need but you can only be assessed on the AoN pathway by your college if you have been offered an AoN position. However, most colleges allow you to be assessed without a job offer. Also, it may be a condition of your medical registration that you practice within an AoN position under supervision. Remember, AoN status is not permanent it is dependent on a specific job and must be applied for. More on pathways in a later post.

To secure AoN status for a job the employer must apply and prove they have tried but cannot source a local Australian candidate for the position. They must do this by advertising the position – sometimes more than once – then applying to the state or territory government for AoN status.

Often a clinical hiring manager at a hospital will proactively source and identify a candidate for a critical post independent of the medical workforce team and therefore not be aware of the AoN process. Once their knuckles get rapped by HR they are then instructed in the correct recruitment process and either secure a local (unlikely) or the original IMG candidate sourced.

District of Workforce Shortage (DWS) or Section 19AB of The Health Insurance Act 1973.

DWS is an Australian Federal (as opposed to AoN’s state or territory regulation) Government tool which analyses population based doctor and patient ratios on an annual basis. DWS status is fluid – status is determined each year as the availability of medical services in any district can change as demographics do. Medicare date is reviewed annually to measure these. DWS is the term given to a geographical area. The reference to The Health Insurance Act 1973 is that Section 19AB restricts an IOTD’s access to Medicare ensuring they work in a “district of workforce shortage” for a minimum of 10 years from initial medical registration in Australia.

As an OTD, you must work in a DWS to get your medicare provider number enabling the patient population to claim rebates from the Australian Government for accessing your services. If you have not secured your Australian permanent residency or citizenship by the end of this 10 years, you will require a section 19AB exemption in order to access Medicare benefits arrangements.

You can change jobs within the 10 year moratorium as long as your new job is also within a DWS for your specialism There are exemptions – for example , allowing you to work in private practise in an out of hours context (evenings, weekends etc) or where you have an exemption due to your spouse’s own medical specialty.

It is important to remember – DWS does not always imply a remote location and DWS suburbs can often be found in metropolitan areas – for both GPs and Consultant/Specialists.

For GPs or District Specialists (mobile rural and remote medical specialists, often called different things dependent in which state or territory you are in) this 10 year period can be reduced by up to 5 years if OTDs work in eligible rural and remote zones. The nature of this work means that only those with or working towards their Fellowship of the Australian College of Rural and Remote Medicine (ACRRM) or of the  Royal Australian College of General Practitioners (RACGP) would be appropriate for this exemption.

It goes without saying that the 10 year moratorium is controversial. When you think about it, it is a system which forbids free movement to work and as such has been labelled discriminatory and unfair. A further inequity exists: an OTD who becomes either a permanent resident (PR) or Australian citizen within these 10 years will still have to work within the boundaries of the 10 year moratorium. Thus, continuing to restrict their ability to move freely within their own adopted country despite their  PR or Australian citizenship status. These doctors pay tax like their fellow citizens yet do not have the same rights to work unrestricted in Australia. Further, those who become PR or Citizens within the 10 year moratorium must have become Fellows of their respective college or undertake an approved postgraduate course or workforce placement to continue to access the medicare benefit.

Any other Australian PR or Australian Citizen has the right to work anywhere they want – why not senior medical professionals? Is it right to restrict anyone’s freedom of movement when they pay taxes (including the Medicare Levy that supports the very system that limits their work opportunities), vote and whose children were born in Australia? Arguably, this is a human rights issue and clearly discriminates in favour of locally trained doctors. Some claim that OTDs arrive simply to free up local doctors to go off and earn lucrative money in private practise.

The DWS system can also impact patients as it can place OTDs into extreme and isolating environments. These can be with limited or no access to professional support in challenging clinical environments impacting care and increasing the isolation for the IMG with subsequent implications on a personal and professional level.

Clearly, the ongoing need for the Australian government to direct medical services to skill short areas still outweighs the state’s concerns for OTD’s individual rights within the context of 10 year moratorium. It is an impossible balancing act: population needs with an individual’s rights.

Many thought that an increase in Australian Medical Graduates between 2005-2015 would naturally phase out the 10 year moratorium. This has not proved to be the case.

There continues to be strong demand for OTD’s in the following specialisms: GPs,Anaesthesia, General Surgeons, Psychiatrists, Medical Oncologists, Obs & Gyn, Cardiologists, General (Diagnostic) Radiologists.

Is there an overlap between AoN and DWS? Yes, as many OTDs subject to working in a DWS will also be working in an AoN position. While there is no formal regulation, it tends to work out that AoN jobs within States and territories require that a vacant job be within a DWS for certain specialty.

Confused? So are most people. Everyone in the system is confused. There is no reason why the powers that be may make it so.

A parliamentary committee formed to discuss these systems acknowledged that key stakeholders within the recruitment and implementation stages of these processes did not know the difference between AoN and DWS.  Or they thought they were one and the same. The parliament finally concluded – after a great deal of parliamentary time, expenses, pastries and coffee – that  it was indeed a very confusing system.

When decisions are made in separate institutions at Federal government level for DWS and at state or territory level for AoN it isn’t a recipe for success to make things easier.

AoN positions were designed to fill gaps in health services where local Aussie graduates could not be recruited. However, harsher critics say that all the system does is create a secondary tier of specialist care by allowing health services to avoid the issue of ensuring that the right support, incentives and working conditions are in place to attract locally trained specialists.

Many overseas trained doctors who moved to a DWS were extremely satisfied with their new lives. Happiness comes in many shapes and sizes and often in the most unexpected places. New professional challenges can inspire. A new health service, culture and geography can make Doctors and their families thrive. Others may struggle for a myriad of reasons. Is it hard to generalise when something like this is so subjective to the human experience? During my time working with OTDs, those who thrive tend to have the long game in mind – well beyond the 10 year moratorium. They will come to terms with the situation and counterbalance an arguably unfair restriction by choosing to direct energy towards spending more time with family, or pursuing more personal interests, perhaps more professional development or additional administrative responsibilities.

I’ll be writing again about the experiences of OTDs working in DWS. But if you have any corrections, thoughts or experiences on this controversial topic please contact me via the site, twitter, facebook or post a comment on this site.

Picture credit:
bobby hendry

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