I Introduction
Australia is experiencing major shortages of health practitioners to meet demand.Footnote 1 These deficiencies can result in impediments to and delays in patients accessing healthcare, as well as health practitioners shouldering onerous workloads, which potentially compromise health outcomes.Footnote 2 Australia has long depended on internationally qualified health practitioners (‘IQHPs’) to fill gaps in health services, particularly in regional and rural areas.Footnote 3 It is thus unsurprising that, to address the present crisis, National Cabinet has sought to entice more IQHPs to work in Australia.Footnote 4 Yet the World Health Organization has stated that ‘Member States [of which Australia is one] should discourage active recruitment of health personnel from developing countries facing critical shortages of health workers’.Footnote 5 High-income nations – including the United Kingdom (‘UK’) and the United States of America (‘US’) – are presently suffering from a dearth of health services, too,Footnote 6 so it may also be unethical to encourage their health practitioners to emigrate. In any event, in the case of medical practitioners, Australia already has a pool of international medical graduates (‘IMGs’) who wish to continue their medical careers, but are not yet doing so: doctors to whom Australia has granted refuge. Media reports have profiled several of these practitioners who are currently employed in low-skilled jobs.Footnote 7
In 2022, National Cabinet confirmed its intention to ensure that ‘regulatory settings … signal Australia as an attractive destination for [IQHPs] and not discourage recruitment and retention of global talent’.Footnote 8 To that end, it commissioned Robyn Kruk to undertake a ‘review of Australia’s regulatory settings for the registration of overseas health practitioners and recognition of their skills and qualifications’.Footnote 9 Kruk identified obstacles confronting IQHPs who wish to obtain legal entitlement to practise their profession in Australia.Footnote 10 Her findings are consistent with previous academic research regarding, and government initiated inquiries into, IMGs’ experiences in this country.Footnote 11 It is possible that, in addition to barriers that all IMGs may encounter in seeking to pursue a medical career in Australia, IMGs from a refugee or asylum seeker background (‘refugee doctors’) will face hurdles that are unique to their refugee experience, including having fled – often with scant or no pre-planning – from countries that have suffered upheavals such as wars and political unrest. Yet, to date, specific challenges for this cohort of medical practitioners in Australia have not been the subject of inquiry, though overseas research has identified impediments to refugee doctors’ medical practice in other countries.
Kruk recommended important reforms.Footnote 12 As she recognised, it should be relatively straightforward and expeditious to facilitate the practice in Australia of IQHPs who ‘obtained’ their ‘skills and experience’ in countries with ‘comparable health systems with similar regulatory settings’ to Australia, and IQHPs who are ‘accredited and registered … by trusted overseas authorities’.Footnote 13 Nevertheless, refugee doctors might often not fall within those categories of IQHPs, and could require additional support in their progress towards obtaining the right to practise medicine in Australia. Current Australian health workforce policy does not, however, take into account particular difficulties that refugee doctors, as distinct from IMGs generally, might face in attempting to attain medical registration. Moreover, Australia’s humanitarian settlement policy does not at present provide significant incentives for assistance to be provided to refugee doctors to pursue a medical career here.
Facilitating refugee doctors’ advancement towards medical registration can potentially produce the same benefits as helping IMGs who have immigrated to Australia in other circumstances. Those advantages include: alleviating shortages of medical practitioners; giving patients opportunities to obtain medical care from doctors who share their linguistic and cultural background, who they can trust and to whom they feel comfortable disclosing their health information; enabling IMGs to obtain employment in their areas of expertise and financial security; and, as Kruk observed, ‘enriching the diversity of skills, experience, and knowledge of the … healthcare workforce’.Footnote 14 In addition, it is ethically responsible to give doctors who have obtained sanctuary in Australia the chance to practise the vocation for which they trained.Footnote 15 They can thereby support themselves and their families, and recover the professional identity they relinquished when fear of persecution compelled them to leave their country of origin.Footnote 16 Further, refugee doctors will be able to provide empathic support to patients from a refugee or asylum seeker background who have suffered similar trauma.Footnote 17 It might therefore be imperative to implement reforms that are tailored to refugee doctors’ experiences and needs.
To address the abovementioned gaps in knowledge, we conducted semi-structured interviews with ten refugee doctors about their experiences in seeking to obtain legal entitlement to practise medicine in Australia. This research confirmed the proposition that refugee doctors can face substantial challenges in attempting to resume their medical careers in Australia, some of which earlier Australian studies of IMGs had not identified. Several of our findings are consistent with the results of international investigations into barriers to medical practice that refugee doctors have confronted in other countries.
The next part of the article outlines laws and policies regarding IMGs’ medical practice in Australia, and findings of previous relevant research undertaken in Australia and overseas. Part III discusses the methodology of our research, the participants’ demographic characteristics and progress towards attaining the right to practise medicine, and the study’s key findings. In Part IV, we make recommendations for reforms that could assist refugee doctors who are safe and competent to practise medicine to secure legal entitlement to do so in Australia. Part V outlines the limitations of our study and makes suggestions for future research on this subject.
II Background to this Study
A. Laws and Policies Relevant to IMGs’ Medical Practice in Australia
The medical profession is among sixteen health professions that are regulated throughout Australia under the National Registration and Accreditation Scheme (‘NRAS’).Footnote 18 The Health Practitioner Regulation National Law (‘National Law’), enacted in each Australian state and territory, established the NRAS, which commenced in 2010.Footnote 19 National Health Practitioner Boards (‘Boards’) were created for each profession, including ‘to register suitably qualified and competent persons’ to practise them.Footnote 20 The National Law specifies categories of registration and preconditions to obtaining them, and requires the Boards to stipulate details of those preconditions.Footnote 21 We now set out these laws and policies developed by the Medical Board of Australia (‘MBA’) – the Board for the medical professionFootnote 22 – and explain how they apply to IMGs. Notably, the laws and policies pertain equally to all IMGs, regardless of whether they have a refugee or asylum seeker background or have immigrated to Australia under other circumstances. Although refugee doctors may confront difficulties in meeting these laws and policies that are not faced by other IMGs, the entities that apply them do not provide any specific guidance for, or additional support or assistance to, refugee doctors.
An individual is eligible for ‘general registration’ (and thus to practise their profession without supervision)Footnote 23 if they are ‘qualified’ for it.Footnote 24 A person is so qualified in the medical profession if they hold: ‘an approved qualification’ (as they completed an ‘accredited program of study approved’ by the MBA);Footnote 25 a qualification the MBA ‘considers to be substantially equivalent, or based on similar competencies, to an approved qualification’;Footnote 26 or a qualification ‘relevant to’ the medical profession and they have ‘successfully completed an examination or other assessment’ the MBA requires.Footnote 27 To determine if IMGs hold these qualifications, the MBA relies on evaluations by the Australian Medical Council (‘AMC’) of overseas study programs, education providers, and authorities that examine applicants for registration and accredit study programs relevant to registration.Footnote 28 The AMC also assesses the knowledge and skills of IMGs who lack ‘approved qualifications’.Footnote 29
An individual is qualified and thus eligible for ‘specialist registration’ to practise in a medical specialty approved by the Ministerial Council if they hold: ‘an approved qualification for the specialty’; ‘another qualification the’ MBA ‘considers to be substantially equivalent, or based on similar competencies, to an approved qualification for the specialty’; or a qualification ‘relevant to the specialty’ and have ‘successfully completed an examination or other assessment’ the MBA requires.Footnote 30 The AMC accredits specialist medical colleges, which evaluate IMGs’ qualifications – a college’s determination that an IMG is eligible for fellowship of it constitutes an ‘approved qualification’ – and the colleges also conduct assessments of IMGs’ skills and knowledge.Footnote 31
Also to be eligible for general or specialist registration, an applicant must have ‘successfully completed’ a ‘period of supervised practice’ or ‘examination or assessment’ required by a ‘registration standard’ approved by the MBA.Footnote 32 These requirements are incorporated into ‘assessment pathways’ for IMGs that the MBA has created.Footnote 33
IMGs can pursue the ‘Competent Authority pathway’ to general registration if they have completed: a medical degree and training or assessment approved by an overseas authority that the MBA considers competent to assess their knowledge and skills; and post-training or post-examination experience prescribed by such an authority.Footnote 34 These IMGs are eligible for ‘provisional registration’, which enables them to ‘complete’ the ‘period of supervised practice’ they require to become ‘eligible for general registration’.Footnote 35 Most refugee doctors would not have undergone assessments by the international authorities that the MBA has approved, as those entities are based in the UK, US, Canada, New Zealand and Ireland.Footnote 36
Refugee doctors may nonetheless be able to pursue the ‘Standard pathway’ to general registration if they ‘have a primary qualification in medicine and surgery awarded by a training institution’ that the AMC and World Directory of Medical Schools (‘WDOMS’) recognise.Footnote 37 IMGs must apply to the AMC to verify their qualifications (which in turn relies on the Educational Commission for Foreign Medical Graduates’ (‘ECFMG’) Electronic Portfolio of International Credentials (‘EPIC’)),Footnote 38 and then pass the AMC’s Computer Adaptive Test Multiple Choice Question Examination (‘MCQ’).Footnote 39 IMGs who subsequently pass the AMC’s Clinical Examination can apply for provisional registration, but only once they have obtained an employment offer.Footnote 40 If they have been offered employment, but not passed the Clinical Examination, IMGs can apply for ‘limited registration’ to enable them to: ‘undertake a period of postgraduate training or supervised practice’ or ‘undertake assessment or sit an examination, approved by the [MBA]’; or ‘practise [medicine] in an area of need decided by the responsible Minister’.Footnote 41 While holding provisional or limited registration, IMGs must complete 12 months’ supervised practice in general practice or hospital-based approved positions, with a minimum of 47 weeks’ full-time service.Footnote 42 IMGs with limited registration need also to pass the Clinical Examination or successfully complete a workplace-based assessment (‘WBA’) undertaken by an authority accredited by the AMC.Footnote 43 IMGs may only be placed in general practice positions if they have passed a pre-employment structured clinical interview (‘PESCI’) conducted by an AMC-accredited organisation.Footnote 44
IMGs can pursue the ‘Specialist pathway’ if they ‘have a primary qualification in medicine and surgery awarded by a training institution recognised by’ the AMC and WDOMS, and ‘have satisfied all the training and examination requirements to practise in their field of specialty in their country of training’.Footnote 45 This pathway comprises sub-pathways.Footnote 46 In the ‘Specialist pathway - specialist recognition’, which leads to specialist registration, IMGs must apply to the AMC to verify their qualifications, and to the relevant specialist medical college to assess their ‘level of comparability to an Australian trained specialist in the same field of specialist practice’.Footnote 47 An IMG who a college assesses as ‘not comparable’ may instead pursue the Competent Authority pathway or Standard pathway to general registration.Footnote 48 An IMG who a college assesses as ‘partially or substantially comparable’ must secure an employment offer and then apply for limited or provisional registration, so they can complete ‘a period of supervised practice’ of a length between 3 and 24 months and ‘upskilling and assessments specified by the specialist college’.Footnote 49 An applicant on the ‘area of need’ sub-pathway must apply to the AMC to verify their qualifications, ‘secure a position in an area of need’, and then ‘apply to the relevant specialist medical college for an area of need assessment’.Footnote 50 If the college assesses the applicant as suitable for the position, they can apply for limited or provisional registration, and potentially complete the requirements of the ‘Specialist pathway - specialist recognition’ while working in that position.Footnote 51
Also to be eligible for the abovementioned categories of registration, IMGs must satisfy requirements of the MBA’s ‘registration standards’,Footnote 52 two of which will be particularly relevant for many IMGs. To meet the ‘English Language Skills Registration Standard’ (‘English Standard’), IMGs whose primary language is not English or who have not completed specified education taught and assessed in English, must undertake one of the English language tests listed in this standard.Footnote 53 These include the International English Language Testing System (‘IELTS’), PTE Academic (‘PTE’), and Occupational English Test (‘OET’); applicants must attain prescribed results in one of those tests and, subject to some exceptions, complete it within the two years before they apply for registration.Footnote 54 To meet the ‘Registration standard: Recency of practice’ (‘Recency of Practice Standard’), immediately before applying for registration, IMGs must have practised for a minimum of 152 hours in the previous year or 456 hours across the preceding three consecutive years.Footnote 55
Several ‘objectives’ and ‘guiding principles’ of the NRAS, to which entities that have functions under the National Law must have ‘regard’ in exercising them, are pertinent to their application of the abovementioned laws and policies to IMGs who seek registration.Footnote 56 Those entities include the MBA and the Australian Health Practitioner Regulation Agency (‘Ahpra’), which is required ‘to provide administrative assistance and support’ to the Boards, including by developing ‘an efficient procedure’ for managing registration applications.Footnote 57 The NRAS aims: ‘to provide for the protection of the public by ensuring that only health practitioners who are suitably trained and qualified to practise in a competent and ethical manner are registered’; and ‘to facilitate’ ‘the provision of high quality education and training of health practitioners’, ‘the rigorous and responsive assessment of overseas-trained health practitioners’, and ‘access to services provided by health practitioners in accordance with the public interest’.Footnote 58 The NRAS’s ‘main guiding principle’ is that ‘protection of the public’ and ‘public confidence in the safety of services provided by registered health practitioners’ are ‘paramount’.Footnote 59 Another ‘guiding principle’ is that the NRAS ‘operate in a transparent, accountable, efficient, effective and fair way’.Footnote 60
B. Previous Research Regarding IMGs’ Experiences in Seeking to Practise Medicine in Australia
We now analyse key findings of studies of and inquiries into IMGs’ experiences in seeking to obtain legal entitlement to practise medicine in Australia that have been undertaken since the NRAS commenced. None of those investigations focused on refugee doctors. It may be attributable to this research gap that Australian health workforce policy does not address difficulties that refugee doctors in particular, as distinct from IMGs generally, can face in attempting to resume their medical careers. Indeed, the Commonwealth Department of Health and Aged Care’s (‘DHAC’) National Medical Workforce Strategy 2021-2031 merely recommends that Australia reduce its reliance on IMGs.Footnote 61 The strategy makes no mention of refugee doctors who are already in Australia, despite recognising the undersupply of doctors in certain geographical locations and medical specialties.Footnote 62 Likewise, recent modelling by DHAC predicted that there will be an insufficient number of general practitioners in Australia to meet demand in the next 25 years,Footnote 63 but did not refer to the potential for refugee doctors to help reduce this shortage if they receive necessary support.
1. Access to Relevant Information
A finding common to several studies was IMGs’ difficulty in obtaining clear, accurate and detailed information about the steps towards and processes involved in securing registration.Footnote 64 IMGs relied on information on websites, which some considered insufficient, discussions with other IMGs, friends and relatives, and social media.Footnote 65 Prior to Kruk’s review, the House of Representatives Standing Committee on Health and Ageing (‘Committee’) undertook the deepest inquiry into ‘registration processes and support’ for IMGs in the NRAS.Footnote 66 Its report, Lost in the Labyrinth, recommended improvements to the information that entities including the AMC and specialist colleges provide to IMGs.Footnote 67 In response, the AMC and Ahpra made more comprehensive information available,Footnote 68 but Kruk still received submissions that ‘[i]nformation about how to navigate the process is difficult to find and interpret’.Footnote 69
2. Challenges in Pursuing the Pathways to Registration
Some IMGs considered that they had been subject to discrimination and/or bullying by individuals who administer the accreditation, assessment and registration processes that IMGs need to go through to obtain legal entitlement to practise medicine.Footnote 70 As discussed further below, much of the research identified the significant financial expenses incurred by IMGs in those processes, including fees for verifying their qualifications, sitting the AMC’s and specialist colleges’ exams and English tests, and applying for registration.Footnote 71 Studies also observed inefficiencies and hindrances in these processes, though without speculating that bias or malicious intent underlay them.
For instance, the Committee found that relevant entities did not communicate effectively or coordinate with one another.Footnote 72 It received submissions that Ahpra and the AMC did not respond promptly to IMGs’ queries,Footnote 73 and the AMC took a long time to verify IMGs’ qualifications and did not provide updates or assistance to them regarding that process.Footnote 74 After the release of Lost in the Labyrinth, the MBA, Ahpra, the AMC and specialist colleges made changes to ‘streamline’ processes.Footnote 75 Nevertheless, IMGs still reportedly experienced delays including in the management of their registration applications.Footnote 76 Further, Kruk found that IMGs face difficulties in ascertaining ‘the progress of their [registration] application’, and obtaining ‘timely advice if supporting documentation is missing’, and ‘real time support … in navigating the discrete components of the process’ and ‘compiling documentation’.Footnote 77 The Committee and Kruk observed that the various authorities often require IMGs to provide the same or similar documentation to each of them and ‘on multiple occasions’.Footnote 78
3. The Standard Pathway and the AMC’s Exams
Much of the research highlighted difficulties that IMGs encountered in pursuing the Standard pathway. Indeed, certain employers were apparently reluctant to hire IMGs on this pathway owing to lags and other obstacles associated with it, which IMGs in the Competent Authority pathway seemingly did not confront.Footnote 79 Many of those studies raised concerns about the AMC’s exams in particular.
The AMC has enhanced the fairness of its exams (including by publishing annotated practice questions for the MCQ, which candidates find helpful),Footnote 80 and increased opportunities to undertake the Clinical Examination.Footnote 81 However, while the pass rate of the exams has grown, it is not high.Footnote 82 The AMC’s exams are pitched at a level that recent graduates of Australian medical schools would be expected to pass, and the MCQ evaluates candidates’ knowledge in all areas of medicine.Footnote 83 IMGs who trained years earlier, and especially those who had practised in a specialty or sub-specialty, often found the exams difficult.Footnote 84 It has been hypothesised that evaluation of the competence of IMGs with significant experience through WBA would yield better results.Footnote 85 Some considered that IMGs who failed the Clinical Examination received insufficient feedback on their performance,Footnote 86 and the Committee recommended giving IMGs opportunities to appeal their results.Footnote 87 Candidates who narrowly fail the Clinical Examination can now appeal the result and watch a recording of their exam with an examiner.Footnote 88 Research emphasised that the costs for IMGs (and sometimes their employers) to sit, and for some to re-sit, the AMC’s exams are very high.Footnote 89
Several researchers noted the likely correlation between IMGs’ success in passing the AMC’s exams and their study and receipt of assistance and training in preparing for them.Footnote 90 IMGs reportedly benefited particularly from participating in preparatory or bridging educational courses and study groups with other IMGs, which offered educational and personal support, and chances to engage with peers and receive mentoring.Footnote 91 Nevertheless, studies indicated that there were not enough educational and training programs for IMGs, existing ones were inaccessible to IMGs in certain jurisdictions and locations, and some courses lacked sufficient resources to continue.Footnote 92 Some preparatory courses were expensive, and IMGs often lacked sufficient time to study (presumably because they were working to support themselves).Footnote 93
Concerns were expressed about the PESCI, too. Some IMGs needed to wait a long time to undertake it, did not understand why it was a requirement, received insufficient feedback on their performance, and noted that requirements for its use differed between jurisdictions, and it was another significant expense for IMGs or their employers.Footnote 94
4. The Specialist Pathway
Researchers also exposed obstacles that IMGs confronted in pursuing the Specialist pathway. Kruk emphasised that there was no expedited pathway for IMGs who are specialists to obtain registration and it takes most of them years to attain registration (the MBA has since then introduced an ‘Expedited Specialist pathway’ for some IMGs).Footnote 95 In response to the Committee’s concerns and recommendations, specialist colleges improved the transparency of their assessment and introduced appeal processes.Footnote 96 Nevertheless, subsequent inquiries indicated that some colleges’ assessment processes remained opaque.Footnote 97 In addition, there were inconsistencies between the assessment undertaken and standards expected by different colleges; some stipulated that IMGs needed to pass exams and undergo substantial training (including where they had extensive experience in practice), whereas others did not impose such requirements.Footnote 98 In order to pass the colleges’ exams, IMGs who were experienced in a sub-specialty often needed to demonstrate, and thus reacquire knowledge and skills of, the overarching specialty that they had not needed to draw upon in practice.Footnote 99 The Committee therefore suggested that the colleges use WBA rather than exams to assess those IMGs’ competence.Footnote 100 It also found that the costs of undertaking specialist colleges’ assessment and training can be high, and varied between them seemingly without justification.Footnote 101
5. Registration Requirements of MBA Policies and the National Law
The examined studies highlighted problems that some IMGs faced in fulfilling requirements of MBA policies and provisions of the National Law relating to registration that applied to all the pathways. The MBA’s stipulation that IMGs need to obtain offers of employment before Ahpra will process their applications for limited or provisional registration caused difficulties for some.Footnote 102 Hospitals and teaching general practices were found to be reluctant to employ IMGs who were not yet registered.Footnote 103 Issues concerning the period of supervised practice that IMGs need to complete were also identified. Studies noted shortages of supervisors and supervised placements, their high cost, and limited available funding for them.Footnote 104 It was observed that supervision approaches were not always adapted to take into account IMGs’ experience, so some may have been required to undergo supervision for longer than they needed or work in roles that were too ‘junior’ for them.Footnote 105 Further, when IMGs were offered employment and supervised positions, Ahpra’s tardiness in processing their registration applications or approving their roles delayed their commencement of them.Footnote 106
Previous research illuminated difficulties for IMGs in meeting some registration standards and queried justifications for them. The Committee received submissions expressing concerns that the English Standard required IMGs to sit tests that assess ‘academic English language skills rather than general communication’ in a ‘clinical setting’, and the providers did not give ‘qualitative feedback’ to candidates who failed them.Footnote 107 Some questioned the reasonableness of the MBA’s policy only to accept results of IMGs’ English tests if they are obtained within two years of their application for registration, and recommended that this period be extended,Footnote 108 or more exemptions from the rule introduced.Footnote 109 The cost of the English tests was noted to be another financial burden for IMGs seeking to obtain registration.Footnote 110 Owing to the interruption to their careers from having children and preparing for the AMC’s exams, some female IMGs were found to have struggled to meet the Recency of Practice Standard.Footnote 111 It was emphasised that there is insufficient evidence to support the presumed reasoning behind this standard, namely, that medical skills decline when unused.Footnote 112
6. Assistance for IMGs
Studies identified that IMGs need personal and professional support and guidance in progressing through the accreditation, assessment and registration processes to obtain legal entitlement to practise medicine.Footnote 113 IMGs valued opportunities for clinical observation,Footnote 114 and there is seemingly a demand for more observership positions and also bridging courses.Footnote 115 IMGs who are specialists benefited from supervision and mentoring.Footnote 116 IMGs’ peer networks were found to be similarly helpful.Footnote 117 Much of the research emphasised the importance of IMGs receiving assistance and training to understand Australia’s healthcare system, culture (including communication styles), and laws.Footnote 118
C. International Research Regarding Refugee Doctors’ Experiences in Seeking to Practise Medicine
The present study is the first substantial research into the experiences of refugee doctors specifically, as distinct from IMGs generally, in seeking to attain legal entitlement to practise medicine in Australia. By contrast, several overseas investigations have identified barriers to medical practice that refugee doctors have confronted in other countries due to their distinctive background, and especially having been forced to emigrate, rather than planned and chosen to do so like many other IMGs.Footnote 119 Indeed, studies indicate that IMGs who have immigrated in other circumstances tend either not to face or to struggle less to overcome those challenges.Footnote 120 That research also highlighted factors that refugee doctors believed had helped or would help to make their path to medical registration and employment less arduous. We now outline the main findings of those studies, which involved doctors who had obtained refuge in various countries, including the UK, Germany, South Korea, Sweden and Canada.
Many refugee doctors face obstacles to obtaining a licence to practise medicine and medical work in their host country because they did not prepare in advance to apply for them.Footnote 121 Particularly where they have fled their country of origin clandestinely and hastily, they will not have taken with them, and subsequently can have difficulty extracting from their home country, documentation and references that attest to their educational qualifications, training and experience, which they need to provide to registration authorities and employers.Footnote 122 Refugee doctors frequently have left behind assets and funds, and therefore struggle greatly to afford the costs associated with progressing through the steps to medical practice.Footnote 123 Having not intended to immigrate to their host country, some refugee doctors are not proficient in communicating in its dominant language and have difficulty passing a language test, which is a precondition to medical registration.Footnote 124 Further, few language training courses would teach refugee doctors the medical terminology they need to learn.Footnote 125 Refugee organisations do not always provide sufficient support or current, relevant information for those refugee doctors who wish to resume their medical career, but prior to arriving in their host country did not investigate its pathways to registration.Footnote 126 Refugee doctors can have difficulty obtaining those details from other sources.Footnote 127
Interruptions to many refugee doctors’ medical training and/or practice, due to their experiences of persecution and/or detention, and their refugee status, can also inhibit their progress towards medical registration and practice in their host country.Footnote 128 As a consequence of this interval and their need to work in unskilled employment, some refugee doctors’ technical medical skills regress, they forget medical knowledge and their professional development is arrested.Footnote 129 Retraining in their host country, which can be time-consuming and expensive, is not feasible for some refugee doctors owing to their age and/or poverty.Footnote 130
Refugee doctors can struggle to undertake and pass clinical exams, which is another precondition to registration in their host country due to: their inability to find and/or afford relevant textbooks and preparatory courses; differences between the medical training in their home and host countries; the cost of sitting the exams; and, in the case of specialists, their deficient generalist medical knowledge.Footnote 131 Refugee doctors’ unfamiliarity with their host country’s healthcare system (including its technical equipment and record keeping, and the duties and hierarchy of staff members) and culture (such as its values, social norms and communication styles) can significantly diminish their likelihood of passing these exams and also obtaining employment in the health sector.Footnote 132
Many studies observed that the deleterious psychological impact on doctors of their experiences as an asylum seeker and refugee hindered their progress towards medical practice in their host country.Footnote 133 These experiences may include their: persecution (doctors in particular can be targeted by repressive regimes, for instance, if they have treated patients who are perceived to be enemies of the state);Footnote 134 escape from their home country; dislocation; uncertain legal status; loss of their respected professional role; sense of insufficient recognition of and inability to use their expertise; and unemployment or employment in low-skilled, poorly reimbursed jobs.Footnote 135
Refugee doctors’ lack of personal and professional networks in their host country can also affect their mental health and impede their integration.Footnote 136 Compounding this problem, many refugee doctors believe they have experienced discrimination, which they consider has manifested in the requirement for them to retrain and pass difficult language tests and clinical skills exams, and the heightened difficulty for them in securing medical work compared with local candidates.Footnote 137
Nevertheless, opportunities overseas that have been available to some refugee doctors to improve their knowledge of their host country’s main language and healthcare system, and create new professional networks, advanced their progress towards medical practice.Footnote 138 Refugee doctors have particularly valued undertaking medical training courses, clinical attachments and internships in hospitals and medical practices, and other roles in the health sector, even if voluntary,Footnote 139 and support from relatives, friends, other refugee doctors, colleagues and teachers.Footnote 140
III Australian Refugee Doctors Study
A. Methodology
The data for this study derive from semi-structured interviews we conducted with ten people from refugee and asylum-seeking backgrounds during a nine-month period in 2023 and 2024. The participants discussed their experiences of navigating the pathways for IMGs to attain registration to practise medicine from the MBA. We applied the following criteria for selecting participants for this study. Participants must have: obtained medical qualifications outside Australia; arrived in Australia within the previous five years (however, at the time of interview, one participant had been in Australia for almost six years and another for five and a half years); received a visa on humanitarian or refugee grounds (all of the participants had rights to work and study in Australia); aspired to pursue a career as a medical practitioner in Australia; and investigated or begun going through the steps towards and processes involved in obtaining registration to practise medicine.
Participants were identified and/or recruited in several ways. We placed an advertisement about the study on the career clinic platform of the Deakin Centre for Refugee Employment, Advocacy, Training and Education (‘CREATE’), sent messages via email to mentors and people from a refugee or asylum seeker background who had participated in events and initiatives organised by CREATE, and obtained referrals from people in the refugee community and the administrative assistants who worked on the project. We sent doctors who indicated their interest in participating in an interview a copy of a ‘Plain Language Statement and Consent Form’ to complete. This form emphasises that participants’ involvement in the interviews is voluntary and they can withdraw from the study at any time without penalty. It explains the aims of the project, the nature of the proposed interviews, risks and potential benefits of involvement in the project, and how we will maintain the confidentiality of participants’ identities and data. All of the participants consented to their involvement in the project.
Two of the three project investigators conducted each interview, with the exception of one interview, which one of the investigators conducted. The duration of the interviews was usually between one and two hours. All of the interviews were conducted online using the ‘Zoom’ platform and audio recorded. Participants were asked open-ended questions about the following matters: their cultural and linguistic background; their education; qualifications they obtained; their employment history; their professional networks; reasons why they left their country of origin; their knowledge of medical practice in Australia before they arrived; the circumstances of their arrival in Australia; their initial experiences in Australia; support they have received and agencies with which they have dealt; work they have undertaken in Australia; any professional networks they have developed in Australia; steps they have taken towards obtaining legal entitlement to practise medicine in Australia; assessments they have had of their English language skills; assessments they have had in Australia of their qualifications, skills and experience, including exams administered by the AMC and specialist colleges; further study or training they have undertaken in Australia; their goals regarding their employment and career; and any interruptions to their employment in Australia and career development. Participants were invited to recommend reforms they considered would assist them in progressing towards obtaining legal entitlement to practise medicine in Australia. One participant provided further information via email to the project investigators.
An external transcription service transcribed the interviews. As the project investigators, we conducted a qualitative thematic analysis of the interview data contained in the transcripts.Footnote 141 We used NVivo 14 software to facilitate this analysis. We uploaded the transcripts into NVivo and developed a broad coding framework, initially by drawing on the main categories of questions asked in the interviews and then through an inductive process while reviewing the data. One of the project investigators first coded the data and then, to ensure the validity of the coding, a second project investigator reviewed it. During this process, participants were de-identified. The project investigators identified challenges participants faced in seeking to obtain legal entitlement to practise medicine, and factors that had assisted, or the participants believed would assist them in progressing through the steps to registration. Following multiple readings of the transcripts, extracts of the interviews reflecting those themes were chosen.
B. Participants’ Demographic Characteristics and Progress Towards Obtaining Registration
The age of participants ranged between 31 and 48, and the average age was 41. Five of the participants identified as female and five identified as male. All the participants had completed undergraduate medical degrees overseas. Four of the participants had also completed postgraduate training in a specialty (P1 in surgery, P7 in radiology, P6 as a physician in internal medicine and P10 in obstetrics and gynaecology), and two had commenced specialisation training when they left their country of origin (P8 and P9). One participant had completed a Master’s degree in Public Health (P3) and another participant had commenced that degree (P2) in their country of origin. All the participants except one (P5) had worked as a doctor in hospitals overseas, and three had worked in rural or regional areas (P4, P7 and P9). Five of the participants had worked in public health roles in their country of origin (P2, P3, P4, P5 and P10). In their country of origin, five of the participants had belonged to doctors’ professional organisations that represented their members’ interests and offered them support (P3, P6, P7, P8 and P9), and one (P4) had belonged to an informal organisation of doctors.
Eight of the participants came from Afghanistan, one came from Colombia, and another came from Iraq. Each had left their country of origin in response to political unrest and/or internal conflict. Four participants had been working with an international organisation or entity operated by another country and three of those participants believed they were consequently targeted by the political regime. Two of the participants’ family members had been killed, two participants’ lives had been threatened, and one of them was physically attacked and seriously injured. One of the participants, who identifies as female, explained that the new government in her country of origin had restricted the medical practice of female doctors.
At the time of interview, the participants had resided in Australia for between six months and six years. Eight had arrived in Australia with relatives, though the family members of one of the two participants who arrived alone subsequently joined them. As noted above, all the participants had been granted visas that gave them work and study rights in Australia. None of the participants had worked as a medical practitioner in Australia, though one had accepted an offer of employment as a medical officer in a hospital and was intending to commence that role shortly (P9). Three of the participants had worked in Australia in public health roles (P5, P7 and P9), and two had worked in the health sector (P4 and P6). Four participants had been employed in non-medical roles in Australia (P3, P5, P7 and P9) and one had undertaken voluntary community work (P3). Three participants had undertaken further study in Australia: P4 undertook a course to work as a technician in an operating theatre; P6 undertook a course to become a pathologist and studied a short course on gender and human rights; and P7 completed a Master’s of Public Health.
All the participants had embarked, to varying extents, on the Standard pathway. None was eligible to pursue the Competent Authority pathway and the participants with specialist training had not considered the Specialist pathway. P9 was the only participant to have obtained registration. The AMC had verified the qualifications of seven of the participants (P1, P2, P5, P6, P7, P8 and P9). Three participants had passed the MCQ (P1, P7 and P9), and five participants were preparing to sit it (P2, P4, P5, P6 and P8). Only P9 had attempted and passed the Clinical Examination (P9), but P1 was preparing for it. P9 was also the only participant to have passed an English test. P1 and P7 were preparing to sit the PTE.
C. Findings
1. Access to Relevant Information
Most of the participants, having not intended to emigrate, had no prior knowledge of Australia’s healthcare system or medical practice before they arrived. Since being granted refuge, several participants had learned, to differing degrees, about the steps they needed to complete to obtain registration. Their main source of information was conversations with friends, other doctors and health practitioners, some of whom came from their country of origin (P1, P3, P5, P6, P7 and P10), but not all those individuals had comprehensive knowledge to share. Agencies that assist refugees (HOST International, Asylum Seeker Resource Centre and CREATE) had conveyed some useful information to three participants (P3, P4 and P9). Four participants (P5, P7, P9 and P10) found information on the Internet, two by using the online search engine ‘Google’ (P5 and P9), though before P9’s English skills improved, they could not understand some of it. P10 found some of that information ‘difficult to follow’ and relied more on details provided to them by their partner, also a refugee doctor, who had already embarked on the pathway to registration. P5, P8 and P9 had accessed the AMC’s website and found the information on it to be clear and helpful, and P9 had the same view of Ahpra’s website.
Despite acquiring some relevant knowledge, there were notable gaps in some participants’ understanding about IMGs’ pathways to registration. A doctor had told P1, a surgeon, in a cursory way about the Specialist pathway, but P1 was still confused and uncertain about where to start. At the time of interview, P1, P7, a radiologist, P6, who had trained as a physician in internal medicine, and P10, an obstetrician and gynaecologist, had not heard about Australia’s specialist colleges. P7 had not heard of Ahpra. P5 considered there was no clear advice, for instance from a government website, about how to proceed after passing the MCQ.
Five participants (P5, P6, P7, P8 and P9) believed they had not received formal, informed ‘guidance’ about the steps to obtaining legal entitlement to practise medicine, which was a significant barrier to progressing smoothly through them. P5 confirmed that they knew ‘no one to clearly instruct and share their experiences’ with them, and P9 stated, ‘we don’t have help to go through this process’. Case managers, resettlement and refugee agencies, and in P9’s case a mentor introduced to them by a refugee agency, had tried to help P7, P8 and P9, but they lacked sufficient knowledge of IMGs’ pathways to registration to be of substantial assistance.
2. Challenges in Pursuing the Pathways to Registration
Participants referred to various factors that made their progress through the stages to obtaining registration especially ‘stressful’ (as P7 and P9 described the process). These included their need to work in paid employment to support themselves and their families, and difficulty finding time to prepare for the AMC’s exams and English test owing to their work commitments and caring responsibilities for relatives (P1, P3, P4, P7, P9 and P10). For P3, working in roles outside the health sector eroded their impetus to seek registration. P9 referred to pressures associated with having relocated from their country of origin (P9). P6, who had no family members in Australia, felt isolated. P1 was still dealing with mental and physical health issues attributable to their refugee experience, which had delayed their progress towards obtaining registration, and they were supporting a relative who was also suffering from mental health problems. P7, P9 and P10 noted the many, high costs involved in attempting to obtain registration (including sitting the AMC exams and English test and undertaking preparatory courses for them), which they struggled to afford. P9 estimated that they spent close to $50,000 on relevant exams, tests and preparatory courses. P4 was aware the process could be lengthy and aimed to sit the MCQ in three years’ time. As noted above, it took P9 five and a half years to complete the steps to registration. P9 observed that, during that time, ‘you don’t use your knowledge’, so there is a risk of ‘losing’ it.
3. Assistance for Participants
Participants recognised the benefits of becoming acquainted with Australia’s healthcare system while progressing through the steps to registration. P6 had worked as an administrative officer in a hospital and, as noted above, undertook a course in pathology, though they had not yet secured a role in that field. Also as mentioned above, after completing a relevant course, P4 was offered a job as a technician in a hospital operating theatre, which gave them an opportunity to observe the ‘health facilities’ and ‘systems’, ‘connect’ with Australian doctors, and ask them questions about their practice. CREATE arranged an interview for P2 for a position as a clinical assistant under supervision in a hospital, which they secured. In that role, P2 had been learning ‘a lot’ from a ‘supportive’ team about the healthcare system and had ‘access’ to ‘diagnostic measures’, technology and administrative systems that differed from those in their country of origin. P2’s colleagues advised them about steps to registration and offered them support. P2 believed this experience would prepare them for working in remote areas after obtaining registration.
Although P1, P3, P5, P7 and P8 wanted to volunteer or obtain an internship or observership in an Australian hospital, they had not had opportunities to do so. P1 and P3 did not know how to find such roles, and P7 and P8 had been advised they did not exist. Further, some participants were discouraged from obtaining work in the health sector, though P3 believed such employment would have motivated them to proceed further along the pathway to registration. P2 had previously been advised, ‘if you can just remove your medical qualification from your CV then we can find a job elsewhere for you maybe in a factory … and then you can prepare for your AMC examination’. One resettlement agency offered P7 low-skilled jobs, and a resettlement agency encouraged P10 to undertake an English language course so they could pursue the agency’s recommendation to obtain employment in a supermarket.
Participants valued personal and professional support they had received. The Commonwealth Department of Home Affairs issues tenders for providers to bid to deliver settlement services to refugees and asylum seekers under the ‘Humanitarian Integration and Settlement Program’.Footnote 142 Agencies that have been engaged by the Government for this purpose (including AMES Australia) helped the participants find accommodation, set up bank accounts, enrol in Medicare, use public transport, enrol their children in school, obtain vaccinations and medical care, and provided white goods, furniture and food to them. P6 had met ‘helpful, supportive’, ‘very kind’ and ‘patient’ people. P3 and P5 benefited from participating in CREATE’s careers clinics, which introduced them to other doctors and prepared them for job applications and interviews. MSCWA similarly helped P7 draft their resume. HOST International connected P5 with other doctors from their country of origin. The Asylum Seeker Resource Centre assisted P9 in applying for a visa and ran a program through which a retired Australian doctor was appointed as P9’s mentor.
4. Verification of Qualifications
Several participants highlighted obstacles they confronted in applying for verification of their qualifications. P2 described the process as ‘lengthy and complicated’. As the university where P2 obtained their medical diploma had not responded to EPIC’s email for several weeks, EPIC suggested that P2 contact the university. When P2 did so, the university informed them that ‘they are under pressure from the new government in verifying medical credentials of those doctors who left the country’. The university did, nonetheless, eventually respond to EPIC’s email. Likewise, another IMG told P5 that they believed their university refused to confirm their graduation due to government pressure to try and keep doctors working in their country. P5 and other IMGs they knew also found the process of seeking verification of their qualifications ‘very complicated’ and, for P5, it took three and a half months. Delays were attributable to the recording of a different date of birth for P5 in their passport, and their graduation certificate and diploma, respectively,Footnote 143 and a change to their university’s email address (so the university did not receive the initial email request to confirm their graduation).
P4 had not yet had their qualifications verified because they needed assistance with the process, they were struggling to obtain required documents due to the repressive government in their country of origin, and P4’s life would be at risk if they returned to retrieve them. (By contrast, P9 had relatives in their country of origin who could send them documents they needed and, though P10 had not yet attempted to have their qualifications verified, they believed they possessed all relevant documents for this process). P8 had difficulty arranging an appointment to have their documents notarised prior to submitting them to the AMC, and found the process ‘time consuming’. P1, P5 and P8 commented on the significant costs involved in this process, including the expenses of having the documentation of their degrees verified and creating an account with the AMC. Notwithstanding these issues, P1 considered the process ‘straightforward’ and ‘very easy’, P7 also thought it was not unduly complicated, and P8 commented that the people involved in administering it ‘were doing their job really good on time’, and the ultimate verification of their documents was ‘quite easy’.
5. The Standard Pathway and the AMC’s Exams
Participants identified factors they believed had assisted them in undertaking and, for some, passing the MCQ. P1 and P8 learned about the MCQ and strategies for preparing to sit it from other IMGs. P2 had studied English and worked in an international organisation in their country of origin, so quickly became familiar with medical terminology used in Australia. Similarly, in their country of origin, P10 had studied medicine in English and communicated in English while practising medicine in an international organisation. In addition, P2 and P5 considered there was substantial overlap between the medical terminology used in and curricula of the medical courses in their country of origin and Australia. In preparing for the MCQ, P2, P5, P6 and P8 relied on the AMC’s publication, which it posts on its website and includes sample questions and suggestions for further reading.Footnote 144 P1, P3, P4, P5, P6, P8 and P10 referred to books, including Australian medical textbooks. P1, P2, P4, P5 and P7 spent time studying alone to prepare for the MCQ, which they found useful.
P1, P2, P3, P5, P6 and P8 studied online with groups of IMGs, located in Australia and/or overseas, who were preparing for the MCQ. P3 formed a study group with friends; P1, P6 and P8 were introduced to their groups through friends; and P5 and P8 had found groups through social media. Some participants considered the groups helpful, as the members shared information, asked questions, and answered practice questions together. Nevertheless, P5’s study group had not assisted them much, as it was informal and inconsistent, and none of the members of P6’s study group knew how to proceed and needed a mentor.
P7 and P9 attended online courses to prepare for the MCQ, which both subsequently passed. P7 found the course and its provision of video recordings and other material ‘very helpful’. P9 similarly considered that the six-month course they attended for four nights a week (to which they had been directed through social media) prepared them well and was reasonably priced. However, while P8 knew two other IMGs who had attended such courses and passed the MCQ, and recognised that they helpfully collate relevant material and present it concisely, P8 could not afford to pay for them. P2, P5, P6 and P10 also observed the high cost of such courses and that they were prohibitively expensive for some refugee doctors.
Participants mentioned other hurdles that they and other IMGs faced in preparing for and sitting the MCQ. P2 noted that they had not received any ‘formal support’ to prepare for the MCQ from the AMC or any other organisation. P7 knew some IMGs who had not sat for the MCQ as they were ‘very scared because they don’t know how to’ and considered the necessary preparation for it a ‘very long process’. Due to their work and/or family commitments, P3, P4, P5, P9 and P10 struggled to find time for intensive study and attendance at study groups’ sessions to prepare for the MCQ. P8 found living in a home with seven people (and sometimes guests) ‘distracting’, and they had no ‘specific study room’. P3 lacked inspiration to prepare for the MCQ while working in a job outside the health sector. P5 considered the limitations of their English language skills a significant challenge in preparing for the MCQ. Further, P5 emphasised that, due to their unplanned arrival in Australia, refugee doctors were in a ‘different’ ‘situation’ from other IMGs who were preparing for the MCQ in their country of origin and/or whose medical courses had been conducted in English. By contrast, refugee doctors had undertaken their medical courses intending to stay in their country of origin, but had been ‘forced to leave’ and ‘start here [in Australia] from zero’. P1, P5, P6, P7, P8, P9 and P10 commented that the fee for sitting the MCQ was high. P1 needed to borrow money; P6 had not yet sat the MCQ because they could not afford the expense; and P5 observed that other refugee doctors would consider the MCQ prohibitively expensive, especially due to the risk of failing and needing to re-sit it.
As noted above, only one of the participants – P9 – had undertaken the Clinical Examination. Although they eventually passed it, they undertook the exam three times. P9 described the first exam, held in person, as ‘the worst experience I have had in my life’, though conceded they had not prepared thoroughly for it. P9 stated that most of the examiners were unfriendly and ‘look at you like … you don’t know anything, you are an idiot’, their ‘attitude’ made them ‘so uncomfortable and really nervous’, and P9 felt unable to ‘complain’ about it during the exam as they feared it would jeopardise their result. After failing that exam, through social media P9 found study partners with whom they met online to discuss practice cases. P9 also undertook a one-week intensive preparatory course, but it was expensive and ‘no one could answer’ their questions about the exam. That course prepared students for a face-to-face exam, but owing to the COVID-19 pandemic, P9 undertook their second Clinical Examination online. After failing that exam, P9 ceased their paid employment to devote their time to studying for it. P9 attended a preparatory course for three and a half months, which they found ‘useful’ because it taught them how to respond to the cases and what examiners were looking for (such as demonstrations of empathy for patients), but it was expensive. P9 also practised cases with different study partners. P9 and P5 noted the high cost of the Clinical Examination, which P9 observed had increased over time.
6. Registration Requirements of MBA Policies and the National Law
Some participants had difficulty meeting the English Standard. P7 had failed the PTE four times in two years, despite passing its reading and speaking components, as they struggled with the written component. Before coming to Australia, P8 had attempted and failed the OET. P1, P4, P5, P7, P8 and P9 undertook courses to prepare for an English test, and P9’s course, which they found online, offered discount fees for asylum seekers. Nevertheless, P1 did not find their course particularly helpful and P5 struggled to find time to prepare for the test owing to their work and family responsibilities. P1 was also preparing for the English test by using books and other material received from a friend, while P7 was undertaking practice tests through an app designed for that purpose. P10 was enrolled in an online English course, but it was focused on enabling them to obtain employment generally, rather than on undertaking an English test for the purpose of meeting the English Standard. P5 nonetheless considered that studying English would assist IMGs to pass the MCQ as well as an English test. However, IMGs had advised P6 not to sit the English test until they had passed the MCQ, as the validity of the results could expire according to the English Standard before they were in a position to apply for registration. Indeed, although P9 passed the OET, they needed to re-sit it because they had obtained their results more than two years before they were able to secure a medical job and apply for registration. P7 and P9 noted the expense of the English test.
P9 also had difficulty meeting the Recency of Practice Standard, which hindered their employment as a doctor. Given the long time that it took P9 to complete all the steps to obtaining registration, a hospital retracted its offer to employ them as a registrar because P9 had not worked as a medical practitioner for the preceding three years (though they had received the offer six months earlier).
P9 and P5 identified other challenges that refugee doctors can face in seeking to obtain an offer of employment in order to apply for provisional or limited registration. P9 observed that employers preferred applicants to provide references from Australians and tended not to offer applicants roles if they only had referees from their country of origin. Once P9 provided references from some Australians, they obtained three job offers, one of which (a hospital medical officer) they accepted. P5 considered there was no guarantee that they would receive an offer of employment after passing the MCQ. Further, even if they were offered a role, due to their family commitments, it would only be feasible to accept it if it was located at a place in close physical proximity to their home. None of the participants had undertaken a PESCI.
7. The Specialist Pathway
Although P1 had completed their training in surgery and passed the MCQ, they were concerned that they might not be able to provide the required evidence of their education to pursue the Specialist pathway, which the project investigators informed them about. P1 passed their final exam in surgery, but had not yet attended a graduation ceremony or obtained a certificate for this qualification when they were compelled to flee their country of origin. It remained too dangerous for P1 to return to seek to obtain the certificate. P1 nonetheless considered asking the medical coordinator of the hospital under whom they completed their specialisation internship, and who knew their exam result, to provide a letter confirming they had completed their study.
P10 had extensive experience in practising in obstetrics and gynaecology, but believed that, in Australia, ‘I have to start from the beginning here and they’re not counting our experience’ and skills.
8. Applying for Registration
P9, the only participant who had applied for registration, detailed challenges they confronted in that process. To apply for provisional registration, P9 needed to provide certified copies of various documents to Ahpra, but the police officer who they requested to certify them was unfamiliar with the format of certification Ahpra required, though they ultimately followed it. The MBA requires applicants for registration who have previously been registered overseas to arrange for registration authorities that registered them in the preceding ten years to provide a ‘Certificate of Good Standing’ for them ‘directly’ to the MBA.Footnote 145 The authority that had registered P9 in their country of origin would not send the certificate to the MBA and required it to be collected. P9 paid for someone to collect the certificate and send it to Ahpra, but Ahpra refused to accept it on the basis that it was not confident the document was genuine. P9 requested Ahpra staff to contact the registration authority to confirm the authenticity of the document or check the number of the certificate on the registration authority’s website, which was another means of verifying it, but they did not do so. P9 then contacted the registration authority again, which finally agreed to email the certificate to Ahpra.
A case manager at Ahpra informed P9 two days before the MBA was meeting to consider their registration application that they needed to arrange for further information to be provided, even though they had given their documents to Ahpra three months before. The case manager indicated that P9 had to provide a clearer copy of their driver’s licence, and the hospital that had offered P9 a role needed to change the proposed level of supervision of P9 in the supervised practice plan it had submitted. The day after the MBA’s meeting, P9 sent the case manager an email and left telephone messages for them, but did not receive a response for several days. Finally, the case manager confirmed that the MBA would grant P9 provisional registration subject to the hospital amending the supervised practice plan. P9 concluded from their interactions with Ahpra staff that they ‘don’t care’. In light of P9’s experience, P7’s concern that they would encounter difficulties because they did not know anyone who could give them direction about the documents they needed to provide to Ahpra when they applied for registration seems warranted.
10. Participants’ Aspirations
All of the participants aspired to work as doctors in Australia: P1 in surgery in a trauma centre; P2 in medical imaging or cardiology; P3 as a physician; P4 and P5 as GPs; P6 as a haematologist; P7 as a GP, obstetrician or radiologist; and P10 as an obstetrician and gynaecologist. Although P8 and P9 would have preferred to work in a specialty (P8 perhaps as a paediatric surgeon and P9 in surgery), they were concerned that the Specialist pathway was difficult and long. P1 and P4 were anxious not to waste their medical training, for instance, by driving taxis, and emphasised that they were eager to help the community. P1 wanted ‘to serve the people who are in need’ and ‘contribute if I can’, and P4 aimed ‘to look after, to give support to my patients, and to their wellbeing, and to give them advice to be an actual partner – participant – back in community, as an active individual’.
D. Discussion
We now discuss consistencies and differences between the findings of our study and earlier research into IMGs’ attempts to obtain registration to practise medicine in Australia, and refugee doctors’ experiences in this respect in other countries. We also highlight obstacles to, as well as matters that could facilitate, refugee doctors’ progression through the steps to registration that our interviews illuminated and that were not identified in previous investigations into IMGs’ experiences in Australia, but were, in some instances, observed in overseas studies of refugee doctors.
1. Access to Relevant Information
Some participants in our study had access to the same sources of information about the processes involved in obtaining registration as the IMGs who were consulted in earlier Australian research. It appears, however, that word of mouth is the central means by which refugee doctors learn about them, and that they require a more reliable, official and consistent channel of information. Certain participants remained largely uninformed about the pathways to registration, even when they had already passed the MCQ. Previous research similarly found that IMGs in Australia can struggle to receive clear and thorough details about progressing through the steps to registration, but this study demonstrated that refugee doctors may be especially disadvantaged in that respect. Overseas studies highlighted that this was the case for refugee doctors in other countries, too.
Unlike IMGs who planned to emigrate, the refugee doctors in our study had no or limited knowledge of the healthcare system or medical practice in Australia before their arrival. Further, despite their good intentions, many of those who interact with refugee doctors (including government-appointed case managers and those working for refugee and resettlement agencies) seemingly lack sufficient knowledge about IMGs’ pathways to registration to provide meaningful assistance to them, as overseas research found was the case in other countries. Not all the participants had accessed the websites of the AMC, the MBA and Ahpra, or the specialist colleges. Notably, however, while these sites include information for IMGs, they do not translate any of these details into a language other than English, or provide any guidance specifically for refugee doctors who are seeking to pursue a pathway to registration. None of the participants mentioned having accessed ‘DoctorConnect’, a useful website for IMGs run by DHAC,Footnote 146 though this site, too, does not offer advice for refugee doctors in particular.
2. Challenges in Pursuing the Pathways to Registration
In contrast to some IMGs consulted for previous Australian investigations, and refugee doctors who were involved in overseas research, none of the participants in this study explicitly alleged that they had been subject to discrimination or bullying during the accreditation, assessment and registration processes. Nevertheless, it is possible that the examiners’ manner in P9’s in-person Clinical Examination, and P9’s difficulty in obtaining assistance from Ahpra staff during the process of applying for registration (including in relation to P9’s attempt to obtain a Certificate of Good Standing) were attributable to prejudice, and local doctors would not have experienced similar treatment. Delays in Ahpra’s management of P9’s registration application and the slow responses of Ahpra staff to P9’s inquiries were consistent with other IMGs’ experiences documented in earlier research.
Also as emphasised by previous research, this study illuminated the many, high costs associated with progressing through the steps to obtaining registration. It is apparent from this study, however, that refugee doctors’ difficulty in affording those expenses could delay or prevent them from ever obtaining registration. This study identified other pressures that could inhibit the advancement towards registration of refugee doctors in particular, some of which overseas research similarly highlighted. These include their need to work in paid employment, their unintended relocation due to political turmoil in their country of origin, and mental and physical health issues they may suffer due to their refugee experience.
3. Assistance for IMGs
This study reinforced the findings of earlier research of the benefits for IMGs of undertaking formal observerships in hospitals, including their chance to learn about Australia’s healthcare system and medical practice, while progressing along the pathway to registration. This investigation identified that refugee doctors can find these opportunities especially helpful, as overseas studies similarly found. Also like overseas research, this study illuminated that refugee doctors might find useful paid or voluntary roles in the health sector generally, too.Footnote 147
Previous investigations had, similar to this study, identified the importance to IMGs of receiving personal and professional support and guidance in proceeding through the steps to obtaining registration. This study, like overseas research, exposed that refugee doctors can feel acutely the absence of such assistance. The study demonstrates that it would be advantageous for refugee doctors if the agencies funded by the Federal Government to deliver settlement services to refugees and asylum seekers could provide this support to them. Nevertheless, it seems that, at present, these organisations are often pressured by their contracts with the Government to find employment for as many clients as quickly as possible.Footnote 148 As a consequence, they may be inclined to encourage refugee doctors to accept offers of unskilled jobs, rather than undertake the more time-consuming and complex task of assisting them to resume their medical careers in Australia.Footnote 149
4. Verification of Qualifications
Earlier Australian research did not highlight the barriers that some of the participants in this study and overseas investigations experienced in applying for verification of their qualifications. Certain hurdles were attributable to the facts that these doctors had fled from countries that were experiencing political turmoil and/or repressive regimes, and from which it was consequently difficult to extract necessary documents.
5. The Standard Pathway and the AMC’s Exams
This study corroborates the finding of previous investigators that IMGs can find the MCQ very difficult. Also as highlighted in earlier research, this study confirmed that, given their family responsibilities and need to work in paid employment, some IMGs can struggle to find time to prepare for the MCQ. This study exposed that refugee doctors might also lack a quiet space in which to study. Like the subjects of previous research, the participants found the AMC’s publication incorporating practice questions, as well as some courses and study groups helpful in preparing for the MCQ, but also that certain courses were expensive and some refugee doctors could not therefore undertake them. This study provides insight into the composition of such study groups, and the ways in which IMGs are forming and finding them, and preparing together for the MCQ. It also illuminates that some study groups need guidance and consistency to be of significant assistance to their members.
While earlier research also observed the high cost of the MCQ, this study demonstrates that some refugee doctors may be unable to afford to sit it. This study showed that another potential barrier to refugee doctors passing the MCQ is that, as their move to Australia was unplanned, they may not have previously studied English as a language or medicine in English. Conversely, refugee doctors who have undertaken such study may have an advantage in preparing for the MCQ, especially if they are familiar with medical terminology used in Australia. Further, this study suggests that learning English before or simultaneously with preparing for the MCQ might assist doctors in passing the MCQ, as well as the English test.
P9’s recount of their experience in undertaking the Clinical Examination provides a perspective that was not identified in earlier research. Those investigations had not raised concerns about examiners’ manner, or noted the importance of preparatory courses (though also their high cost) and candidates’ practice with study partners. Previous research did nonetheless similarly highlight the expense of this exam.
The AMC does not, at present, offer concessions specifically to refugee doctors (such as a reduction of their examination fees) to account for challenges that some of them may face and that IMGs who have immigrated to Australia under other circumstances encounter less commonly or experience less acutely.
6. The Specialist Pathway
Previous investigations had observed that the Specialist pathway can be slow and expensive. Yet this study illuminated a difficulty that refugee doctors in particular can confront in pursuing it, namely, obtaining evidence of their previous training where they have escaped from a country controlled by a repressive regime.
7. Registration Requirements of MBA Policies and the National Law
This study identified challenges for refugee doctors in obtaining offers of employment in order to apply subsequently for limited or provisional registration, which had not been discussed in previous Australian research and could affect other IMGs. Specifically, they may be unable to accept a job offer if it is located far from their home, and they might need to obtain references from Australians.
Findings of this study suggest that earlier investigators’ criticisms of aspects of the English Standard are valid. P7 was disadvantaged due to its requirement to demonstrate academic written English language skills to a high standard (though they could communicate orally to this standard), and possibly also by not having received feedback on how they could improve their results. Further, P9 bore the brunt of the policy only to accept results of English tests if they are obtained within two years of their application for registration. Like previous research, this study identified that the cost of the English tests can be difficult for IMGs to meet.
P9’s experience reinforces the risk identified in earlier research that IMGs can struggle to satisfy the Recency of Practice Standard. In P9’s case, this was attributable to the long time that it took them to complete the steps to registration.
The findings of this study do not call into question whether the NRAS is meeting its statutory aim to protect the public and following its guiding principle to maintain public confidence in the safety of health practitioners’ services.Footnote 150 Nevertheless, obstacles confronted by the participants in accreditation, assessment and registration processes suggest that the NRAS is not consistently following its guiding principle to ‘operate in a transparent, accountable, efficient, effective and fair way’.Footnote 151 Moreover, the experiences of refugee doctors in seeking to obtain registration suggest that the NRAS is not always achieving its goals of: providing access to health services to meet public need; and enabling provision of ‘high quality education and training of health practitioners’ and ‘rigorous and responsive assessment of overseas-trained health practitioners’.Footnote 152
IV Reform Proposals
We now suggest reforms that could assist refugee doctors in their progress towards obtaining registration, some of which build on recommendations of the participants in our study and/or are similar to initiatives that have been introduced in the UK.Footnote 153 Protection of the public must remain the paramount consideration. If implemented, none of our proposals would diminish the rigour of assessments of refugee doctors’ skills and knowledge, or preclude them from undertaking further education or training that they need in order to practise medicine competently and safely.
We recommend several reforms to ensure that refugee doctors receive prompt, accurate and comprehensive information about the stages and processes involved in attaining legal entitlement to practise medicine. We suggest that training is provided to individuals and entities that the Government currently funds to assist people from a refugee or asylum seeker background to integrate into the community and obtain employment (including case managers and resettlement and refugee agencies), so they can give refugee doctors useful information. They could learn about IMGs’ pathways to registration, and the roles played by and contact details and websites of the MBA and Ahpra, the AMC and specialist colleges. Ahpra, the AMC and specialist colleges might be able to run information sessions (in-person and/or online) for them, as well as for refugee doctors.
We also suggest the creation of a formal system for training registered doctors to act as mentors for refugee doctors and appointing them to these roles. In addition to sharing relevant information with their mentees, the mentors could give refugee doctors support and guidance through all the steps to attaining legal entitlement to practise medicine. As P5 suggested, they could assist refugee doctors to identify the documents they need to submit for the purpose of obtaining verification of their qualifications, and help upload them to the relevant website. Further, as P7 and P8 recommended, the mentors could give their mentees direction about which exams and tests they need to sit and how to prepare for them, assist them with their preparation, and reassure them that they have the potential to pass them. The mentors could also help refugee doctors to develop an understanding of the culture of, and communication styles used in, Australia’s healthcare system.
We recommend that Ahpra, the AMC and specialist colleges improve their communication with refugee doctors. The AMC could advise Ahpra when refugee doctors have passed the MCQ, and Ahpra could then contact those individuals to explain the further steps they need to take to progress towards obtaining registration. It remains important for those entities to be vigilant to the risk of their staff subjecting refugee doctors to discrimination or bullying, and to the ways in which they might manifest (such as through delaying unduly in responding to refugee doctors’ applications and inquiries).
We propose that the Government introduce measures to relieve refugee doctors of some of the financial pressures associated with the accreditation, assessment and registration processes. Examples of possible reforms (some of which P5 and P9 recommended) include that the Government: perhaps based on application of a means test, subsidises refugee doctors’ enrolment in preparatory courses and fees incurred for sitting the AMC’s exams and English tests;Footnote 154 provides loans to refugee doctors to pay for those expenses (conditional on the doctors attempting the exams or tests within a specified time period), which they can repay once they obtain registration and medical work;Footnote 155 and assists refugees to pay for their living costs while they are preparing for exams and tests, so they do not need to rely so heavily on employment and can devote time to study. The Government could also allocate funding to the MBA and/or AMC, enabling them to waive, or at least reduce, the fees associated with their processes for refugee doctors. An initiative introduced in the UK provides a useful model in this respect. The General Medical Council, which regulates the medical profession in the UK, pays the fee for verification of refugee doctors’ qualifications,Footnote 156 allows refugee doctors to sit the exams that they need to pass to obtain registration free of charge or at a reduced rate, and permits the refugee doctors it registers to pay their registration fee in instalments.Footnote 157
Various reforms could improve refugee doctors’ prospects of passing the AMC’s exams and English tests. It is clear that refugee doctors would benefit from formal guidance in preparing for these assessments. We recommend that the Government fund either the AMC, or an independent entity that it establishes for this purpose, to evaluate and accredit preparatory and bridging courses that assist candidates in preparing for them. The Government could then, as noted above and depending on their means, subsidise refugee doctors’ participation in them or offer them loans to undertake them. Refugee doctors would be greatly assisted if they could undergo some evaluation that identifies the gaps in their knowledge, so they can receive targeted tuition intended to address them. Australia could adopt a similar approach to the UK, where the National Health Service has funded collaborations between training organisations and charities to offer programs that provide free tuition and educational resources to refugee doctors, supporting their preparation for the English test and clinical exams that they must pass to become eligible for registration.Footnote 158 In addition, the Government could pay IMGs who have passed the AMC’s exams to assist study groups of refugee doctors to prepare for sitting them. To ensure the assessment of refugee doctors recognises their skills and experience, we recommend, as others have suggested in relation to IMGs generally, considering the increased use of WBA in evaluating refugee doctors’ competence to practise medicine.Footnote 159 Further, the AMC could offer refugee doctors the opportunity to undertake the Clinical Examination online, if they believe it would be less intimidating than an in-person exam.
We suggest changes to the English Standard. As others have recommended, we propose that the MBA accept results obtained in a specified English test more than two years before a refugee doctor applies for registration.Footnote 160 If the time during which English test results remain valid under the English Standard is extended, refugee doctors might be more inclined to study for an English test before sitting the MCQ, and this preparation could assist them also in passing the MCQ. P5 considered that the conduct of the MCQ in English deterred many refugee doctors from undertaking it and that studying English would assist them in passing the MCQ. In addition, as Kruk suggested, the English Standard could be amended to give IMGs ‘greater flexibility in demonstrating their English language competency’, including by reducing the minimum score required for written English in the specified tests,Footnote 161 and placing greater emphasis on assessments of doctors’ verbal communication skills.
As other researchers and the participants have recommended, we propose that public hospitals and teaching general practices give refugee doctors observership roles, for instance, as clinical or administrative assistants.Footnote 162 This would provide them with opportunities to learn about Australia’s healthcare system and the standards and protocols of Australian medical practice, improve their communication in English in a health setting, and enhance their chances of obtaining supervised practice positions once they are registered.Footnote 163 It could also motivate them to accelerate their progress towards obtaining registration, including by helping them to prepare for their assessment and, as P4 put it, for ‘serving’ the Australian ‘community’ and embarking on ‘a career in a new country’. Anecdotal reports of refugee doctors who, like P2, have undertaken observerships in Australian hospitals, confirm that they have greatly appreciated and benefited from these positions.Footnote 164 Refugee doctors would probably be inclined to accept the roles even if they are voluntary, but the Government could also fund paid positions.Footnote 165 In addition, the MBA could consider amending the Recency of Practice Standard so that undertaking such observerships can count towards meeting this standard.Footnote 166
Two programs offered to refugee doctors in the UK could provide useful models for Australia. Under the ‘Medical Support Worker Scheme’, some refugee doctors who have passed the English test are given a remunerated role in a multi-disciplinary team where, under supervision, they perform ‘routine clinical tasks’ (such as clinical observations, diagnostic and therapeutic procedures, and clinical audits).Footnote 167 The ‘Clinical Apprentice Placement Scheme’ offers some refugee doctors, who have passed the English test and clinical exams, six-month, salaried supernumerary placements in secondary care, during which they obtain clinical experience and participate in an education program to help them develop skills they need for employment as a doctor in the UK.Footnote 168
Also potentially helpful would be finding employment in the health sector generally for refugee doctors while they are preparing for the AMC and specialist colleges’ exams. Depending on their experience and background, some refugee doctors may be well suited to roles in public health, too, particularly positions where they can support others from their country of origin. These roles could be supplemented by training for refugee doctors that is introduced to acquaint them with Australia’s healthcare system, culture and relevant laws, as others have recommended.Footnote 169
We also suggest that the MBA grant provisional registration to IMGs who have passed the MCQ and the Clinical Examination without waiting for them to receive a job offer, so that hospitals and teaching general practices are assured they can employ them.Footnote 170 This could reduce delays that can result in refugee doctors not being able to meet the Recency of Practice Standard.
V Limitations and Suggestions for Further Research
Whilst this study provides valuable insights into the experiences of medical practitioners from refugee and asylum-seeking backgrounds in navigating the pathways to attaining registration to practise medicine from the MBA, it has the following three limitations. First, participation in the study was lower than anticipated due to difficulty accessing this population. Future research would benefit from a larger sample of participants and the participation of people from a broader range of countries. Second, the fact that participants may have self-selected based on their availability or willingness to participate in the project could have led to selection bias. Future studies could use random sampling methods or broader recruitment strategies in order to include a more diverse group of participants. Finally, language barriers between the participants and project investigators might have affected the depth and clarity of the information gathered during the interviews. Further research could benefit from the use of bilingual interviewers or translators to ensure improved communication and understanding.
VI Conclusion
If refugee doctors share the ambitions of the participants in this study to work as medical practitioners in Australia, it can be to their own and the community’s advantage that they are able to fulfil them. Australia has historically relied on IMGs to meet shortages of medical practitioners, such as those it is currently experiencing. As P3 emphasised, refugee doctors ‘are not simple’, they obtained ‘the highest scores’ to enter medical courses, and ‘they are very hard working’, so ‘we can use [their] capacities … for the benefit’ of Australia. Further, as Thomas Wenzel pointed out 25 years ago, refugee doctors are uniquely placed to counsel and treat fellow refugees and asylum seekers who share their cultural background and experience of trauma.Footnote 171
Refugee doctors must only be permitted to practise medicine in Australia if it is first established that they are competent and safe to do so. The MBA, Ahpra, the AMC and specialist colleges play a crucial role in making these determinations.Footnote 172 Yet this study highlights that refugee doctors can confront many obstacles in seeking to obtain legal entitlement to practise medicine that are unrelated to their capacities. Earlier studies of IMGs’ experiences in Australia identified some, but not all of those barriers, possibly because they did not focus on challenges faced specifically by refugee doctors, as distinct from IMGs generally. We nonetheless observed consistencies between our findings and those of overseas studies of refugee doctors. P9’s ability to overcome the hurdles that many refugee doctors face is noteworthy and reflects their commendable tenacity. Due to their circumstances, not all refugee doctors may have the resources to persist in attempting to attain legal entitlement to practise medicine, but nor should they have to confront such significant obstacles.
Our research has uncovered that refugee doctors can struggle to obtain accurate and comprehensive information about the pathways to registration and processes involved in them. The many and high financial expenses associated with obtaining verification of their qualifications, and preparing for and sitting the AMC’s and specialist colleges’ exams and English tests, can delay refugee doctors’ progress through the steps to registration and even prevent them from ever obtaining it if they are unable to afford them. Refugee doctors may also face challenges in meeting the English Standard and Recency of Practice Standard, as well as in securing suitable employment offers. It is apparent from this study that refugee doctors need personal and professional support and guidance in all the stages leading to registration.
This article has made practical recommendations to address the barriers refugee doctors face and facilitate their progress towards attaining legal entitlement to practise medicine. Each of the proposals could be implemented relatively easily to assist refugee doctors to pursue the careers for which they have been trained and, in so doing, meet Australia’s high and increasing demand for medical services in metropolitan, and especially regional and rural areas. That initiatives similar to some of our suggestions have already been successfully introduced in the UK confirms their viability. The financial cost of implementing the reforms is not great relative to the prospective benefits of enabling refugee doctors to practise medicine. If implemented, the proposals could make refugee doctors’ progress through the pathways to registration less stressful and more efficient, reduce the potential for them to experience discrimination, bullying and undue delays, and ensure they receive necessary support and direction. There is currently momentum to enable more IMGs to practise medicine in Australia. In December 2023, the National Cabinet agreed that ‘the Commonwealth will fund and implement, with states and territories’ Kruk’s recommendations.Footnote 173 It is crucial to harness this momentum to support refugee doctors, and thereby address their underemployment as well as the ongoing shortages of practising medical practitioners in Australia.
Acknowledgements
The authors wish to thank: the anonymous referee for their very careful and helpful review of this article; the de-identified participants in this research project for generously sharing their experiences, many of which have been extremely challenging; Dr Bahare Salehi and Dr Mehdi Ahmadi for their excellent research assistance; Hamed Mahdavi, Bis Hakimi and Asmat Halimi, who are affiliated with the Deakin Centre for Refugee Employment, Advocacy, Training and Education, for their very helpful administrative assistance with this research project; Dr Homa Forotan for introducing us to some of the research participants; and the team at Sharyn Taylor Transcribing and Secretarial for their transcription services.
Funding
The authors wish to thank Deakin Law School for providing funding to undertake this project.
Ethics approval
Ethics approval was obtained from the Deakin University Faculty of Business and Law Human Advisory Group (project number BL-EC 24-23).
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