Doctors from overseas

“G’day doc, I’m right off me tucker and crook azadog. Yesterday arvo me neighbour said it’s just the collywobbles but crikey, he’s mad as a cut snake so I thought I’d better find out what the doc has to say. I know youse are flat out but waddaya reckon, she’ll be right? I feel weak as a wet whistle. Not droppin off the perch yet am I? Probably just old age. Howyagoin anyway, settlinin all right? Gotta love the top end mate, heaps better than the big smoke.”

When I arrived in Australia – in Cooktown of all places – one of my biggest challenges was understanding the accent and the slang. I also struggled with basic expressions. I remember being invited ‘for tea’ one night – so after dinner I went over expecting a cup of tea or coffee only; to my surprise our host had prepared a delicious roast. On another occasion I was asked ‘to bring a plate’; I took a few plates and, just to be sure, some cups and cutlery too.

I thought the communication was problematic because I come from a non-English speaking country. It turned out that most immigrants struggle with language, communication and the often slightly different meaning of common expressions, not to mention the bureaucratic jargon. For example, as doctor Jennifer May wrote in the Medical Journal of Australia, a term such as ‘reciprocal recognition of qualifications’ has a different meaning in different jurisdictions.

The first six months were a crash course in ‘Strine’. The patients were wonderful and seemed to strangely feel sorry for the new overseas doctor in town. They taught me all the basics; some gave me Australian slang dictionaries and Indigenous Australians told me stories about their culture. Still, it took a few years before I could fully understand most conversations.

The preparation

For most immigrants the challenges begin long before entry to Australia. The paperwork and background checks required by the Australian government and healthcare organisations – which can take one to two years to complete – are only a small part.

Croc drama: A crocodile dragged a fisherman from his tent on the riverbank and a woman jumped on its back in an attempt to stop the giant reptile. Source: Cooktown Local News

Even though the decision to emigrate is mostly a voluntary one, and it is a privilege to be welcomed to Australia, it doesn’t mean that there are no downsides. Emigrating doctors and their families have to give up their lives in the home country and say goodbye to loved-ones, familiar neighbourhoods, cultures, customs and careers.

It is not uncommon for overseas doctors and their family members to experience some adjustment problems. Many tears have been shed when settling in a remote Australian outback town or new suburb. It can be stressful when a spouse struggles or the children have problems at the local school.

Often well-established and respected at home, immigrant doctors start all over again. They are initially temporary residents with limited rights and no access to Medicare. Their medical registration is conditional, they have to work in places where many Australian trained health professionals don’t want to work, and their future is uncertain and dependent on passing health checks, police checks, language tests, assessments and exams.

My arrival in Cooktown reported in the local newspaper (2004). Full story below.

It can be difficult to negotiate employment conditions or discuss real or perceived injustices – as a conflict may lead to cancellation of sponsorship or visa. Financial challenges are common as starting over in a new country does not come cheap. There are all sorts of legal and tax problems, such as dual taxation. I had to give up my Dutch citizenship when I became an Australian citizen.

For the immigrant there is always ‘the other world’ of their home country. They often use the holidays to fly ‘home’ and visit family and friends for a few weeks, which is joyful but can be intense and emotional. Migrants may never feel one hundred percent part of the Australian society and at the same time they often don’t fit in anymore in the home country, which can affect their sense of belonging and create feelings of loneliness.

Rural medicine

For me another culture shock was rural medicine. The contrast with Amsterdam, where I trained as a doctor, could not have been greater. I quickly had to learn about tropical diseases, snake bites and Irukandji – just to name a few. Shortly after I arrived a 4.2 meter saltwater crocodile dragged a fisherman from his tent on the riverbank when a woman jumped on its back to stop the giant reptile; the story appeared in all the newspapers.

Although many of the medical textbooks back home were written in English, learning to speak the medical jargon in another language was yet another challenge. Names and doses of commonly used drugs differ between countries, not to mention the different guidelines.

I was able to do a few up skilling courses including trauma and emergency medicine and with assistance from helpful and skilled colleagues – sometimes over the phone – and a great nursing team, we were able to manage many problems locally. I am grateful for all those who have welcomed and taught me over the years – patients, staff, nurses, fellow doctors and others.

Not unique

For a long time I thought my ‘adventures’ were unique but over the years I learned about similar stories, not only from overseas doctors but also from Australian graduates, all struggling during their first placements in rural and regional hospitals and GP practices.

These stories are often tales of incredible resilience and courage and what always amazes me is to hear how valued health professionals are in their communities – even though we may often feel ill-prepared or have doubts about our skills and knowledge.

The demands on doctors in small towns can be high, not seldom 24 hours per day. Working towards another degree or fellowship is taxing for anyone, but for international medical graduates coming from a different background there are many extra challenges. The working hours and fatigue don’t go well with training and exam preparation.

The workload and the tyranny of distance can make supervision suboptimal; there is often limited support and the amount of bureaucracy can be perceived as overwhelming.

On the bright side, there are many people who warmly welcome and support the newcomers. Professional bodies and colleges offer introductory, support and exam preparation programs, but often the local and individual initiatives make the difference. An example is Dr Farooq Ahmad who, after passing his Australian fellowship exam, decided to support others and has helped hundreds of doctors pass their exams.

In the video below Kenyan born Dr Ken Wanguhu describes the importance of being welcomed by a community as well as the rewards of contributing and ‘giving back’.

Concerns

Although many areas of Australia are relying heavily on international medical graduates, not everyone is happy with the influx of doctors from overseas. Critics of the Australian skilled immigration policy have often mentioned the ‘brain drain effect’ on developing countries: the recruitment of healthcare professionals compromises the, often already struggling, healthcare systems in the developing world.

Concerns have publicly been expressed about doctors from non-Western training backgrounds and the uncertainty around standards and relevance of knowledge and skills to the Australian situation.

The regulation changed in the aftermath of the Dr Jayant Patel case. Dr Patel, nicknamed ‘Dr Death’, was permanently barred from practising medicine in Australia in 2015. Legislation introduced in 2009 now protects patients by ensuring that only health practitioners who are suitably trained and qualified to practise in a competent and ethical manner can be registered.

This example is not unique to Australia nor to international medical graduates. Many countries have similar stories, think for example about Dr Harold Shipman in the UK and Dr Christopher Duntsch in the US.

Although there is anecdotal evidence that patients sometimes avoid seeking treatment by international medical graduates, research indicates that there is no difference in patient satisfaction with, and acceptance of, care by Australian and international medical graduates.

Diversity

The ‘doctors from overseas’ bring diversity, expertise, experiences, cultures, innovation and stories to Australia. Cross-cultural experience appears to be valuable in many ways; some have argued that immigrants are more entrepreneurial, resilient and creative. Whether this is true or not, one thing is for sure, starting a new life in a different country takes courage and perseverance.

My wife Nancy and I have never looked back. Although we miss our family and friends in The Netherlands, we’re grateful for the opportunities Australia has given us. I can only hope I am able to give back what I have received.

Source: Cooktown Local News (2004).

UK doctors in Australia – Why they won’t be going home any time soon

The numbers are telling: About 1,500 UK doctors move to Australia and New Zealand each year. This exodus is causing havoc in England. A GP-shortage creates high workloads and overstretched doctors, and a survey showed that over half of UK GPs plan to retire before the age of sixty. This stressful situation has prompted a coming home campaign to entice doctors to go back to the United Kingdom.

Why are doctors leaving, and, will they move back to save the NHS?

Dr Nathalie Departe is a UK-trained GP working in Fremantle, Western Australia. “I moved to Australia in 2009 for a change of scenery. I had visited Australia before and loved it, so when my husband found himself in a career hiatus, we thought we would enjoy the sunshine for a few years.”

“Working in Australia was a breath of fresh air. Patients were pleased to see me, understanding if I ran late, and I was rewarded and not penalised if I spent time with a complex patient to sort out their management. Access to pathology and radiology services was prompt, rather than a standard 6-8 week wait for an ultrasound, and access to allied health services didn’t compare – good luck trying to see a clinical psychologist on the NHS.”

“Initially it was a bit odd to bill patients and not provide free care at the point of need, but I soon came to value the transparency of the transaction. The integration between private and public care makes private care accessible and affordable in Australia, rather than in the UK where private care has to be funded in full.”

Escaping the NHS

“In Australia I can arrange imaging quickly, receive the results the next day and organise appropriate and timely care

Dr Janaka Pieris moved to Brisbane in 2010 to ‘escape’ the NHS: “When I think back to my working life as a GP in South East London, I have two overriding memories: there was never enough time in the day to do the work asked of me, and there was no means of limiting my workload. NHS General Practice is a sink for everything no-one else will take responsibility for. Many GPs feel unable to decline these demands – many of which are not NHS work and therefore unfunded – and as a result, are drowning in work.”

“When a patient presents with painless obstructive jaundice in the UK, I have no option but to refer in to hospital, because I have no access to appropriate imaging, or I cannot get it done in a timely fashion. In Australia I can arrange the imaging quickly, receive the results the next day, discuss the case with a specialist and organise appropriate and timely care. It is much more satisfying from a professional perspective.”

Dr Tim Leeuwenburg made the move in 1999, immediately after his internship in the UK. He is now a GP at Kangaroo Island in South Australia. “I was married to an Aussie and always knew I’d be coming to Australia for love and a better lifestyle.”

“That was 15 years ago. Since then I’ve vicariously witnessed the demise of UK medicine – and am anxious that Australia doesn’t make the same mistakes: Other professions trying to do doctors’ work, capitation and performance payments, privatisation, walk-in clinics, phone advice lines, revalidation. They are all seemingly good ideas, but not evidence-based and all have served to emasculate the profession and increase the number of doctors seeking to retire, locum or emigrate from the cesspit that is the NHS. None of these measures have reduced costs or increased quality.”

“The myth of the ‘fat cat’ wealthy GP laughingly enjoying his round of golf whilst poor patients helplessly waited for his attentions was regularly portrayed in the media

Departe: “Despite working in a nice area and enjoying my job, I had a growing sense of unease with the way UK general practice was going. There seemed to be ever changing targets to qualify for practice payments with increased red tape and less time for consultations.”

“There was a general loss of respect for the role of a GP; it was not unusual for patients to demand medication, tests and home visits inappropriately, then to be outraged if you questioned the need for it. The myth of the ‘fat cat’ wealthy GP laughingly enjoying his round of golf whilst poor patients helplessly waited for his attentions was regularly portrayed in the media, and I felt that general practice was being devalued in the eyes of public and politicians alike.”

Dr Mark McCartney left the UK in 2013 because he was not happy with the working conditions in the NHS, but moved back to England after 12 months because of family circumstances. “There is a huge cultural difference in Australia, where there is a mixed health economy of private and state-subsidised services. The NHS is free at the point of access for patients, and service always struggles to meet the demand and prioritise appropriately. UK hospitals are dysfunctional places and the effects of this trickle into General Practice.”

“UK GPs are mostly paid on the basis of capitation payments depending on the number of patients registered, with additional payments for reaching clinical targets and a small amount of fee for service payments. There is now a shortage of GPs and we work in an environment of running faster and harder just to meet demands, without additional incentives or resources.”

“Australian GPs have the luxury of earning a high proportion of income from fee-for-service payments, including patient fees and Medicare payments. The more patients they see and the more services they provide, the more they earn. Clinical practice is also more interesting with rapid access to x-rays and scans. It is a professionally motivating environment to work in.”

Would you move back to the UK?

Dr Pieris is sceptical about the fully funded induction and returner scheme: “Firstly, it is manifestly insulting to suggest that doctors who have worked in similar systems, such as Australia, need retraining to work in UK general practice. I do more medicine in Australia than ever I did in the UK.”

“Secondly, if people are leaving because of a failed system, a sensible approach would be address those failings, not try to tempt people back into the same environment they left.”

“To return would require most GPs to undertake 6-12 months of supervised training, and to surrender to ridiculous bureaucratic imposts

Departe: “Why would I return to a role where I am restricted in my clinical practice by financial constraints, strangled by paperwork, stressed out by time pressures, undervalued by patients and politicians and where I would earn less money for more work and more stress?”

“To return would require most GPs to undertake 6-12 months of supervised training, and to surrender to ridiculous bureaucratic imposts,” says Leeuwenburg. “The reason doctors are leaving the NHS is because of unfettered demand from patient ‘wants’ not ‘needs’, and reduced income as a result of capitation. Why on earth would you go back?”

McCartney: “Very few GPs will return, unless they have personal or family reasons. UK GPs are retiring early, but this does not seem to be the case in Australia. There are also huge barriers to doctors wishing to move back to the UK in terms of medical registration and licensing to practice. The NHS is wasting resources trying to recruit in Australia and they look foolish because of that.”

Doctor’s advice

“My message for governments,” says Departe, “would be Stop undervaluing good general practice! Good general practice has been proven to provide better value for money and a more integrated care approach than secondary care. By all means, regulate general practice to maintain appropriate standards of care but then pay us accordingly and let us get on with being general practitioners.”

Leeuwenburg: “Listen to grassroots doctors, not NHS managers who have destroyed the NHS and are now sprucing their wares in Australia. Nor to academics who think things like capitation and revalidation are necessary. Our Australian system is marvelous and we should be proud. Sure, there is fat in the health system that could be trimmed, mostly in hospitals and specialists, but primary care is overall incredibly efficient and GPs do a great job.”

“The UK government needs to stop attacking GPs and listen to doctors and the BMA, who have been largely ignored for the last ten years

“Ofcourse there are some outliers, but there are many more who are hard working and ethical, doing the right thing for patients and Medicare. Alienate GPs and risk the collapse of a great primary care system. It will cost more if we surrender to the failed experiments of the UK or privatise us with private health funds.”

“The UK government needs to stop attacking GPs and listen to doctors and the BMA, who have been largely ignored for the last ten years,” says McCartney. “Doctors want to work in an effective service so that they can focus on caring for patients. Learn from Australia that good access to radiology for GPs can keep people away from hospital until they really need to be there.”

Pieris: “The UK Government should let us do our jobs. Trust us. Stop interfering. No-one is saying regulation and scrutiny are not required. However, GPs are not some malign enemy. Stop treating us as if we are.”

Recommended further reading: Doctors from overseas, about my experiences as as a Dutch doctors starting Australia.

Image source: www.queensland.com

Let’s stay out of where they are from and why they’re here

A long time ago I did a locum stint in an asylum seekers centre in The Netherlands.

What struck me was the vast amount of physical and mental illnesses like depression, malnourishment, and neglected chronic and infectious diseases, together with uncertainty, fear, cultural differences and challenging language barriers.

It all came back to me when I saw the people on board of the small, fragile vessel that earlier this year sailed into the Geraldton harbour.

Asylum seeker boat
When the boat sailed into the Geraldton harbour, it didn’t feel like the ‘unprecedented breach of border security’ we heard about in the media. Whatever the reason for their journey, these men, women and children should be looked after properly while they are in Australia.

The sad reality is that many asylum seekers, including children, spend many years in immigration detention facilities. This creates more (mental) health problems. AMA president Steve Hambleton said at the National Press Conference this week:

(…) let’s stay out of where they are from and why they’re here and all the other stuff. Once we are in control or once we take responsibility for people, we should be providing them with first-rate health care.

Whatever the reason for their dangerous journey, let’s hope these men, women and children will eventually find a place where they can live a safe, healthy and peaceful life.

In the meantime, while they are here, we have to take care of them. We are responsible for their health and well-being, including appropriate access to quality healthcare.