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Registration processes and support for overseas trained doctors
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Previous Fragment
(House of Representatives-Thursday, 31 March 2011)
CHAIR (Mr Georganas)
BURLEY, Ms Robyn Margaret
Ms HALL
Ms Burley
Mr COULTON
Mr LYONS
CAMERON, Dr Ian
Dr Cameron
Ms HALL
Mr IRONS
Mr COULTON
Mr LYONS
Mr LYONS
Mr COULTON
Ms HALL
Ms O'NEILL
Dr Jin
BAIG, Mr Nasir Mehmood
Dr Butt
Mr Baig
Mr IRONS
BUTT, Dr Christopher Edward
JIN, Dr Bo
Mr LYONS
TIPPETT, Dr Christine
Mr COULTON
NAIR, Professor Kichu Balakrishnan
HOLLANDS, Dr Michael
Ms HALL
Dr Hollands
Prof. Nair
Ms O'NEILL
Dr Tippett
TEGEN, Ms Susanne (Susi)
McKENZIE, Associate Professor Paul
Mr Tegen
SWINBOURNE, Mr Donald William
Ms Tegen
Dr Cains
Prof. Allan
Dr Graves
Mr COULTON
GARG, Dr Vikas
GRAVES, Dr Debra Jane
Mr IRONS
Dr Garg
Ms O'NEILL
Mr LYONS
CAINS, Dr Stephen Elsworth
Prof. McKenzie
Mr Swinbourne
Ms HALL
ALLAN, Associate Professor John
Content WindowSTANDING COMMITTEE ON HEALTH AND AGEING - 31/03/2011 - Registration processes and support for overseas trained doctors
CHAIR —I welcome participants for the specialist colleges forum. I invite each of you to make a short introductory statement. Please try to keep it as short as possible. I ask you to limit your introductory statement to a maximum of two minutes. Following introductory statements the committee will ask questions to clarify or expand on the information you have presented. This discussion is being recorded by Hansard and will form part of the public record for this inquiry. Although the committee does not require you to speak under oath, you should understand that these hearings are formal proceedings of the Commonwealth parliament. Giving false or misleading evidence is a serious matter and may be regarded as a contempt of parliament. I now invite you to make your brief opening statements.
Prof. McKenzie —Thank you for the opportunity to address the committee this afternoon. The Royal College of Pathologists of Australasia is very actively involved in the current registration processes of overseas trained doctors, or OTDs, and considers it plays a vital role ensuring that appropriately qualified OTDs are able to be registered to practise medicine in Australia while ensuring safe and appropriate quality medical services are provided.
It is acknowledged that there are sometimes tensions between the need for speed and simplicity in assessing OTDs and ensuring that they are safe and competent to practice in Australia. However, after such incidents as Dr Patel in Queensland, the college hopes that the need for thorough processes is recognised as the results of inappropriate registrations of OTDs can have far-reaching consequences. There are differences in how medical colleges and specialists are trained and practise medicine in various countries throughout the world and it is vital that practising Australian doctors and specialists who understand the expected standards of medicine in this country are able to advise on this.
There has been an international shortage of pathologists for many years and workplaces in Australia have had to rely on overseas trained doctors to help address these shortages, though as the problem is worldwide, it has not always been easy to attract appropriately qualified specialists to Australia. The college welcomes overseas trained doctors into the college in a number of ways—as fellows, affiliates or trainees—after the appropriate assessment of their qualifications and experience. The college continually reviews how it assesses overseas trained doctors and over the years has tried to streamline and simplify the process as much as possible, while at the same time not compromising safety and quality. We have also worked very constructively with the Australian Medical Council and the medical boards and now the Medical Board of Australia to enhance opportunities, facilitate processes and provide greater support for OTDs.
The college, having closely reviewed the training programs of the Royal College of Pathologists in the UK, has agreed that training in anatomical pathology and clinical chemistry are substantially comparable between the two colleges, allowing cross-recognition of fellows in these disciplines, facilitating a pathway to Australian fellowship after a year of supervised practice. The college recently developed detailed step guides to assist overseas trained doctors in navigating the system, and these are available on the college's website. These demonstrate the steps involved in the process, the various outcomes that could occur, the pathways to registration and the approximate time lines for processing each step. The step guides include a summary flow chart that provides an overall summary of the process to complement the detail in the guide. The college is considering developing further, shorter, more concise versions of the step guide for some overseas trained doctors who find difficulty in comprehending complex documents in English when English is not their first language.
Other initiatives to assist in streamlining the processes include the introduction of video conferencing for interviews for overseas trained doctors, the better use of electronic technology both at the college level internally and between the college and the AMC, increasing the number of interviews held each year and undertaking various steps in the process simultaneously rather than sequentially.
Cultural orientation and language difficulty are significant problems for many overseas trained doctors from non-English-speaking countries. This is exacerbated in the case of OTDs being assigned to rural and remote posts, where access to language classes is scarce and cultural challenges may be more acute. Assisted by Commonwealth government funding, the college has commissioned independent research into the needs of overseas trained doctors and is developing educational resources to address their needs.
The major difficulty that the college has encountered with the process occurs when the overseas trained doctors or employing bodies or medical boards ignore the well-established procedures. The college in these circumstances is sometimes contacted halfway through the registration process with a request for urgent advice or assistance. Better education of human resources departments in employing organisations in particular is required on this issue.
Another issue relates to employment of overseas trained doctors who have been assessed through the college; they often expect the college to be then able to find a suitable job for them. Whilst the college provides access to our employment section of the website, both to view job vacancies and to place advertisements, and also lists the laboratories in Australia, the college does not have the capacity to act as an employment broker, and this is not well understood by overseas trained doctors. Further, training positions are likely to come under serious pressure as competition for specialist training positions among local graduates is set to escalate with a rise in the number of medical graduates entering the system.
In conclusion, the college is generally supportive of the current processes ensuring that appropriately qualified overseas trained doctors are able to be registered to practice medicine in Australia while ensuring that safe and appropriate quality medical services are provided to the people of Australia. It is acknowledged that there are sometimes tensions between the need for speed and simplicity in assessing OTDs and the need to ensure that they are safe and competent to practice in Australia, but the involvement of the profession and the medical colleges is crucial to this process. Like any system there are always opportunities to refine the processes as issues arise; however, the college does not consider any major changes are required.
CHAIR —Thank you. Dr Cains, would you read your statement.
Dr Cains —Thank you for the opportunity to address the committee on this complex and important issue. In the interests of brevity I will make just three key points and, hopefully, we will expand on them during the discussion. Firstly, in the overall process the OTS applicant and the community, which are the two important players in this whole process, are both faced with a range of bodies, as you well know, handling this issue, from the AMC, the colleges and the registration boards to the immigration department—the whole lot. Generally, they find it difficult to understand who is responsible for what and who is talking to whom, and this leads to confusion and mistrust on both sides.
Both the overseas trained specialists and the community need a single body which has the authority and the respect of the Australian community and which will enable each of them to feel that their interests are being looked after. In the case of the OTS applicants this means a body which is a single point of contact and which will take responsibility and has the authority to facilitate their communication with the other participants in the process. This is along the lines suggested by the colleges of physicians. In the case of the community, the body needs to be seen to have and to take responsibility for the process and to be acting in the interests of the community. It should be able to communicate with the community and its representatives, and this will allow the community to have confidence in the process.
The second area I want to mention is that of the establishment of area-of-need posts. There needs to be a reform of this process. Currently, this is an arbitrary, disorganised and non-transparent process which varies widely across the states. In the same manner that the overseas trained specialist process and the registration process generally have become a federal responsibility and a uniform thing across Australia, the establishment of overseas training posts needs to be standardised across the states and across the different disciplines.
The second aspect that gives concern in the area-of-need posts is the difficulties that we face when a person has been placed in an area-of-need position and finds themselves unable to complete the requirements for full registration. Many people find it difficult to understand how they could be okay for one and not the other, but the point is that different questions are asked in each case. When you ask two different questions you will not unreasonably, at times, get two different answers. The consequences of that are bad. They are bad for the overseas trained specialist because he or she may have been practising for a couple of years before they end up finally not being able to satisfy the process. They are bad for the community who have seen someone working in their community for some time, and it engenders disquiet, mistrust and indeed anger in the community. Resolution of this problem and of the administrative process would go a long way towards improving the community's confidence in the whole process.
The third issue relates to support for the overseas trained specialist. Apart from these administrative aspects, OTSs face a lot of professional difficulties in going through the process. They need support while they are completing their qualifying for full registration and they need support after they have satisfied that and start to practice in the wider Australian community. The support while they are going through the process involves, essentially, educational programs, perhaps run by the colleges, mentoring programs and access to college CPD and training sessions. This needs to be backed up by their employers when they are in area-of-need situations by providing study leave and study opportunities and access to this material. After qualifying they likewise need continuing education. There is a program that you may be aware of which the College of Physicians developed, supported by the Department of Health and Ageing; it is an online program of orientation in the way medicine is practised in the Australian community. I feel that this should be made available to all the colleges and adapted to their particular needs.
So, in summary, a single authority is needed to streamline and restore confidence in the process, reformation of the AON process and standardisation, and funding and facilitation of support for the applicants as they progress through the system. Thank you.
CHAIR —Thank you very much. Mr Swinbourne.
Mr Swinbourne —I think I would echo most of the comments that have been made so far and I do not really want to deal with our processes, because they are all documented in the submissions that we have made. What I want to comment on firstly is to say that the recognition and registration of overseas trained doctors is complex; you will have worked that out for yourselves in looking at all the submissions. It seems to me that that is inevitable given the diversity of qualifications and experience of the applicants, the different standards of training and practice between countries and across specialties, the tension between workforce requirements and the maintenance of standards, and the cost of resources needed to assist doctors to meet the standards expected in Australia.
Our college's experience—I am speaking only for our college—is that we are reasonably comfortable with the current arrangements for the assessment of overseas trained doctors; nevertheless, I accept some of the comments that have been made by the College of Pathologists and the College of Ophthalmologists.
I believe the processes that have evolved over the last five years, and particularly since COAG looked at this in 2006-07, are pretty satisfactory and, from our point of view, work well. We rarely get complaints from overseas trained doctors, whether for specialist recognition or area-of-need appointments, about the process or the way in which we undertake the assessments. We sometimes get complaints about the outcome of the assessments but not in terms of the process.
The main concern of our submission relates to the support needed for specialists who have been classified as partially comparable, and they are applicants who require some additional experience and require to pass our college examinations. So it is not the substantially comparable and it is not the not comparable; it is the partially comparable, and they would represent the majority of people coming out of our assessment process.
Limited Commonwealth funds have been available to assist overseas trained doctors and training sites for this sort of upskilling process. To us that has always been a bit of a mystery. People who want to access those funds really have to do it, as I understand it, through the jurisdictions, through state and territory health departments, direct to training sites, which are, typically, teaching hospitals. We have no idea about the extent to which that works or does not work. Anecdotally, we hear that very few people who require upskilling in radiology have been able to access that sort of support.
Our preference would be for earmarked funds to be available, prioritised through the college and in consultation with the jurisdictions, to be set aside for upskilling of overseas trained doctors in this partially comparable category. That would be along similar lines to the Commonwealth's specialist training program, where the Commonwealth is funding quite a large number of positions now for Australian registrars. I believe that is on the Commonwealth's agenda, but at this stage I do not believe there is a clear direction coming from the Commonwealth or the jurisdictions. That is really all I want to say.
CHAIR —Thank you. Professor Allan.
Prof. Allan —Thank you very much for the opportunity to address you. We have made quite a comprehensive submission so I will try not to repeat that. There are just a couple of points I want to make. One was to echo Dr Cains's points. We believe that the organisation for applications is a very complex and difficult process. Quite often our college staff seem to be the counsellors for all matters around registration, immigration and so on, a central agency. A good model to look it would be in New Zealand, where there is a national agency that is run by the New Zealand Medical Council with a central point. They seem to be able to coordinate many of the medical issues and work with Immigration around that, so that might be something to look at.
Secondly, for the AONs, it is very important from the perspective of the College of Psychiatrists to point out that there are 297 overseas trained psychiatrists who are currently in our pathway to fellowship and about one-third of our 1,000 trainees actually have a primary medical qualification or a psychiatry qualification from overseas, so that is around 500 psychiatrists or potential psychiatrists in Australia and New Zealand, of which most are in Australia. So we have a very big investment in this. Many of those people are in the area-of-need posts, and I would echo the issue about the dual assessment pathway. Although we have introduced the dual assessment pathway and that has been very helpful, that means a dual assessment for a person's comparability to psychiatry and for their capacity to be in the area of need. Although with the Commonwealth reforms we have now introduced that very early on, and we get good assessments of people, there is this disparity between success in the pathway there and then their service in the community. I think a lot of this comes from employers and other people, I will not use the word 'exploitation' but certainly not providing the amount of support that is required for people to pass their examinations and, really, overworking rather than helping people get qualifications from the college's point of view.
At the college we have the education committee, which is my committee, which looks at both the issues of qualifications and trying to improve educational opportunities. I will talk briefly about that and my colleague Dr Garg will talk about the position from the point of view of overseas trained psychiatrists and the issues that they face. I will just make a couple of very positive points. We have been very happy with the support that we have received from DoHA in relation to the STP funding so that when we have had those extended training posts—their name keeps changing but that is now STP—there has been support money for training of overseas doctors. We have had very good programs for that. We have looked at being able to get that direct upskilling to those people and at being able to appoint directors of training to states for overseas trained psychiatrists, to change our education support and upgrade that with a large number of projects that are listed in the document I have given you and change our examination process. In the middle of this year we will be introducing quite a substantial change to our substantial comparability pathway with people being able to have an accelerated pathway to fellowship. So we are very happy with those things, but of course we would like to see more of that and more of that happening.
The other issue for us, and my colleague will speak a little bit about this, is that we understand from AHPRA that there will be a four-year limitation to the possibility of practice for overseas doctors in Australia: if you do not get your fellowship within that time you will be asked to leave. Currently for us there are quite a lot of issues around adaptation to practice. As you can imagine, psychiatry is a specialty where your ability to understand the culture and to understand the language nuances is very important. It might take people a number of years to adapt to that, especially if they come from a non-English-speaking background. It is not about knowledge but about the way that you practise. So our average length of time to fellowship would be around two or three years, but we actually allow people up to nine years and sometimes 10 years to get to that point. There would be significant problems in terms of workforce if we had a cut-off point that was far too short for those people. I will leave it at that for the moment. Thank you.
CHAIR —Thank you. Dr Garg.
Dr Garg —I thank the committee for this opportunity. I thank John Allan. I support his views that are made at this moment. From the Overseas Trained Psychiatrists Representative Committee's point of view there are a couple of issues that are worth standing up for. I am not going to repeat the submission which has been quite detailed. One of the key issues at the moment is the recognition of Australasian experience. A large number of psychiatrists work in area-of-need positions mainly in rural, remote and regional areas and they have a timeframe to finish a requirement to become a fellow. As part of that they go through an examination process, before that their qualifications and experience are assessed and John Allan's committee does that.
One of the shortcomings that the OTPC, overseas trained psychiatrists committee, is looking at is that the current experience of working in the Australasian region as a consultant psychiatrist is not being given due consideration. If that could be done in a matter then a significant proportion of the overseas trained doctors would be able to be given substantial comparability and be given fellowship after a period of scrutiny of their competencies.
At the moment there are more than 10 to 15 doctors working in this country who are about to face their nine-year term. They have served the community; they have served the rural and remote region and they have maintained a high standard in their working profession. Just because they have not been able to finish their exams and their current experience is not recognised towards comparability they will lose their job and career here and go back to their country.
I want to give an example here. We had a doctor working in one part of Australia, the Northern Territory, who worked there for nine years. He was the only child and adolescent psychiatrist. Because he did not pass his exams he lost his job and that part of the world lost one adolescent psychiatrist. There are more psychiatrists who are in the queue at the moment and the AHPRA regulation of four years medical registration is going to be harder.
I welcome the college's support for overseas trained doctors. They have made a significant contribution to help overseas trained doctors. When I came to Australia in 2005 there were no programs or if there were, I was not aware of them. Over the period of the last four years I have seen a number of programs coming up which have helped a large number of overseas trained doctors working in this country.
The only issue that I want to raise is the recognition of the overseas trained doctor's qualification when working in the Australian country. After they have reached this country and they have worked as a consultant psychiatrist in more difficult circumstances and more challenging situations, if that could be given some credit in their assessment towards substantial comparability, that would go a long way.
CHAIR —For example, what would you consider more difficult circumstances? You have spoken about assessing the circumstances in which they work. Would that be rural, remote—is that what you are saying?
Dr Garg —Yes. Generally, if an overseas trained doctor, a specialist, comes and works in a metropolitan region, he would be working as a registrar or a career medical officer. But, if he chooses to go, say, 100 or 300 kilometres into a rural region under the area-of-need program, he would be allowed to work as a consultant psychiatrist with limited scope of practice under supervision, under restriction. Because those conditions are difficult but they have demonstrated their competencies working in those difficult circumstances, I would ask that should be counted.
CHAIR —I would be really interested to know what work the colleges are doing amongst themselves to ensure the streamlining of assessment processes and the terminology from college to college. It is there work being done between the colleges?
Dr Cains —The process, as you would be aware, has been streamlined enormously in the last several years with the unification and standardisation with the AMC. This college works essentially under the guidance of the AMC and the guidelines issued through JSCOTS. This has meant that there is a very clear pattern of pathways that is able to be laid out for an overseas trained specialist applicant. It has been an evolving process over the last few years. There has been comment in this committee about shifting goalposts, but when we make a change, I might say, we ensure that only applicants applying after that change has been listed on the website are seen under the new variation. Anyone who is already in the stream stays under the conditions which existed when they applied for the process.
Ms O'NEILL —That does not seem to be the case with all of the colleges. Would anybody else like to comment?
Prof. Allan —I will just make two comments. One is that we do have a position of no disadvantage, so that when there is a change in the rules we look at how that will affect people and make sure that they get an advantage or stay the same rather than get a disadvantage. Secondly, in terms of the way that the colleges approach it, because of the different specialties I think we all have slightly different approaches. We quite often do an environmental scan of what other colleges are doing. For example, one college that is not here today is the anaesthetists, who have actually have a very good workplace based assessment program, which is easy to do around giving an anaesthetic and what happens in the room. It is a little harder to do that kind of workplace based assessment in other specialties. We have developed our own particular version of that. So they cannot exactly be absolutely standardised, but we do share that information through the presidents of medical colleges committee and there has been a lot of cross-referencing, if that makes sense.
Mr Swinbourne —I think that is right. As I mentioned previously, COAG looked at this in around 2006 or 2007 and set out a number of elements or principles, and I think they are set out in the AMC's submission. All of the colleges, through the AMC and the Joint Standing Committee on Overseas Trained Specialists of the AMC and the CPMC, are really now adhering to those processes. The actual forms of assessment are obviously going to vary from specialty to specialty, but in terms of the consistency of process I would be surprised if there was much variation.
Ms Tegen —If I could just add to that, I think one of the issues is also that the people who work with the overseas trained specialist—whether it is their employer, the college, the AMC, the state government et cetera—should all sign off on what their role is and what the process is at the very start. Sometimes people change. There is a standard and it is all on the website, but there is still this confusion and I think it needs to be signed off on. It is like a contract: 'We are willing to work together to get this person through or to employ this person and we take responsibility for the particular role that we have in supporting this person.' That is not standardised at the moment.
CHAIR —Basically what you are saying is there should be an agreement between the different bodies assisting or working towards getting this person registered about taking on responsibilities and adhering to those requirements.
Ms Tegen —Yes, including the person who has applied to come to the country: 'Yes, I understand that I have to sit my exam within four years or get my fellowship,' and if that does not happen: 'Yes, I've signed off on it. Sorry, I have not done that.' I do not think that is actually being done at the moment, and that is why between different states you have different issues. It causes anxiety in the community, in the individual and obviously for colleges and the government.
Ms HALL —That could be achieved by having a single body that is the focal point.
Dr Cains —Yes, that not only has responsibility but stands up and takes that responsibility, in particular in the eye of the community.
Ms HALL —Absolutely.
Mr COULTON —I have a couple of questions. The first one is on just what you are speaking about. At one of the other hearings someone was talking about the PESCI and they said that it has actually become quite arbitrary with pass or fail, whereas probably in its design it was more of a guideline or a tool to help with the assessment. But it has now become quite definitive and it is a stopping point in the process. Do you have any comment on that?
Dr Cains —I think I am right that the PESCI only applies to general practitioners. Is that correct? Yes. However, apropos of that, we state the purpose of the test to the applicants at our initial interview—we do not have it on the website. If, for example, they are asked to sit our examination, the purpose of that is to give the committee information which allows it to come to its decision more reliably. It is not a hurdle. We have specifically given the tick to two people who, if they were ordinary candidates, would not have passed that examination, but they performed pretty reasonably across the board and in particular they did not raise any red flags of dangerous behaviour and in the background of their other information we felt they were pretty a reasonable proposition. So we emphasise that it is not a hurdle or a gate but an information gathering exercise.
Mr COULTON —Professor Allan, in my part of the world psychiatrists are very thin on the ground. It is a fascinating issue. I say this carefully, but sometimes people who grew up in a city have trouble understanding the culture of a rural area and how rural people think. My colleagues have trouble working out how I think sometimes, but that is another story.
Mr IRONS —We are not that hard to work out.
Mr COULTON —So communication for rural medicine must go to a whole new level of understanding than in the other avenues of speciality. I am just wondering how you keep that mentoring going in a rural area. In my office I quite often get people with psychological problems who fall through the cracks and I can understand that if you were from another culture, another country, trying to get to the bottom of the problem would be incredibly difficult. I am just wondering how you manage that with the overseas trained doctors.
Prof. Allan —That is a fantastic question. Some of it is intuitive. I am from a rural background and for 20 years ran a rural mental health service and employed many, many overseas doctors with this very issue. I think that there are probably three answers to your question. One is that some people are good at it, and that is just because they have good people skills. No matter what the language, they have a capacity to fall into that. Psychiatry often attracts that kind of person. The second answer is that these are things that can be learned by supervision and modelling, so it requires a lot of time from senior people to help the doctors. In my experience in psychiatry—it might be different in other specialties—a person is probably not really ready to be a psychiatrist on their own for a couple of years until they have had that whole immersion in the culture and the practice and an incredible amount of supervision, discussion and all the stuff you do not get formally. That is required. Very rarely do I have to correct people's knowledge; it is about their application of knowledge.
Thirdly, we have some very successful programs around helping people with language and communication. For example, in Victoria we have been running programs where we have been using speech therapists or communication experts to help people understand the way their style of speaking and communication affects patients. It looks at prosody—the rate at which words come—and how to modify what you are doing, how to understand that your language may have particular implications for the way you are expressing emotions which you are not trying to express et cetera. We have had great success with that kind of cultural orientation and training. I think all of those things are needed. A fourth thing to mention is that this requires a lot of support time and sometimes money to go away and do other things, bring in other people and get exposure to a broad range of experiences.
Mr COULTON —On your last point, I would imagine if you were to supervise someone who is an orthopaedic surgeon the results are probably there in front of you. With psychiatry, I presume supervision would mean observing consultations.
Prof. Allan —You mean sitting in the room, yes.
Mr COULTON —How is that paid for? If you are a psychiatrist and you have an overseas trained doctor with you, you are not seeing any of your patients. I am just wondering how that is paid for.
Prof. Allan —You go to your boss and you say, 'You need to cut me some slack here because I have to look after these people.' You need to have an increased establishment to do that. That is the issue we face. When I ran a rural mental health service I was able to make a case for that. I did mentoring via video conferencing and by flying into places. One of the major clinical things that I did was to support people, but there are other services where budgets are tight and there is not that kind of opportunity for people. It does cost money to have people do that. A lot of that is done informally and outside of hours. Most of the work that people do for colleges is pro bono. I could write a book about how that is done.
Mr COULTON —Many of the psychiatrists I know in my area are employed by the government through their local area health networks or whatever. One of the other aspects we have been hearing in other places was that an overseas trained doctor to a large private practice, a general practice, a cardiologist or whatever can be a money making asset for that practice. It seemed to me that with psychiatry it would be the other way around. The incentive to bring overseas trained doctors in some areas is to generate income and eventually they get out of that system and work for themselves. The incentive for psychiatry must be much harder.
Prof. Allan —I should let my colleagues speak but I will say one thing. In psychiatry there are a number of quite successful private arrangements that seem to do both of those things and people report a good experience. We have a good conversion rate for those people becoming psychiatrists, but they do seem to be able to generate money to earn their keep. This is in addition to the STP money, which is a supplement of $100,000 for registrar training that they get from the Commonwealth. So there are opportunities there.
I think it is just an age-old resourcing issue. I am well aware of some of the issues in our committee about your area. We are dealing with some of those at the moment. In fact, in your area they have one of the best supervision plans that you could ever see, which was proposed by someone working in your area. The money to do all of that, plus getting the right people, has been very difficult for them. There is no lack of enthusiasm on the part of the medical administrators and the workers there; it is just that matching the whole process and getting the suitable person to go there has been very difficult.
Ms HALL —To clarify: supervision does not mean sitting in on every session that the psychiatrist has—
Prof. Allan —It is a sampling. I think the way to do it is to do it intensively. I might do two hours with somebody, watch the entire work and then have a long discussion. We might do that once a month for a person at that level; whereas, as a registrar you might do that once or twice a week.
Ms HALL —Exactly, I just thought I needed to make that point so that it did not look like you did it for every session a psychiatrist had with a patient.
Prof. Allan —No, but it is about the availability and time to discuss when issues arise. It is a big commitment.
Dr Garg —On the issue of communication for overseas trained doctors, let us say for people who come from India, India is such a rich country. It has 25 states, each state is diverse in its own culture and language is such an important issue. When they come to this country, learning the cultural nuances and learning the language nuances are part and parcel of their professional development. One of the crucial requirements is having an adequate standard of English. English is such an important issue. Learning the cultural nuances—I am talking from my perspective as well as from what I have seen—happens as on-the-job training. There are communication programs to look at what cultural and local language terms are used and having a peer group helps us. Supervisors also help overseas trained doctors to look at what those issues are.
To answer the question about private practice, at one stage we had a discussion with the overseas trained psychiatrists committee. Most of the committee members said they were interested in this because they are employed in a public mental health system and they work full-time in public health. They are happy to work in a public mental health system because it takes three or four years to, as John said, get the fellowship certificate. By that time they have built up a community and built up cultural ties around them, and it is difficult to move from that place and leave the public system. The general view, from the committee's point of view, is that they want to work in a public system because they have already been working there and they like to be there.
Ms O'NEILL —How do you reconcile the fact that an employer may employ an OTD believing their qualifications and experience to be comparable to those of Australia and, however, discover later that the relevant specialist college will not provide the assessment of comparable?
Dr Cains —It is an area that is of great concern to us. As I said, the problem is there are different questions asked. The question asked for an area-of-need position is: is this person's background—and it has to be decided within a matter of a few weeks—essentially, entirely on paper, suitable for that job? That job may have very specific features to it. The job, for example, may be for a general ophthalmologist. We look at the person and say, 'This person has had no experience in paediatric ophthalmology or glaucoma.' They can then modify that job and say, 'Right, this is a group practice. All glaucoma patients and paediatric patients will be seen by someone else.' That person is therefore suitable for the job, and we can tick them off for it. Clearly, when they face the full registration, they have no background or training in two important aspects of ophthalmology. They are going to have try and work out some specific training areas in that or whatever. It is because there are different questions.
You also say that the employer assumes or has reason to feel this person is comparable to an Australian trained ophthalmologist. This may not be so. They may be feeling that this person is suitable for the job they want to swap them into. That job, as I said, may be very specific and it may be, as was touched on—and I would not like to make too much of a point of it—to see a lot of patients, deliver a lot of surgery for the principals in the practice and have the practice move on. It may be a relatively cheap opportunity to have someone in there to build up their position of competition against others in the area.
In fact, it may end up being called an area of need, where the main criterion appears to be 'we could not find a suitable local person for it' as was quoted to this committee earlier, because they are only paying low money and it is only someone naive from outside, used to lower levels of money, who would take the job. One might then start to wonder: whose area of need is it? The definition of an area of need needs to be reviewed and standardised. It needs to come down to what an ordinary person like us would understand of those three words, which is fairly obvious in itself.
Mr Swinbourne —I thought I would just add to that. In the case of radiology, someone will not be appointed to, or at least be given limited registration for, an area-of-need position until they have been assessed by the college. As Stephen has said, the college looks at the particular requirements for that position. That may not equate to everything that a general radiologist might do, but in any case the college would look at the applicant against the particular requirements of the position and at the same time make an assessment of where we think their strengths and weaknesses might be. For example, if they are going to a practice that requires mammography, or may have an MRI—which is probably unlikely in the country, but anyway—then we need to look at their skills in relation to the requirements for that position. If that particular aspect of practice is not available in that position, yet they need to get experience in that in order to gain full specialist recognition and fellowship of the college, that is a real issue.
Ms O'NEILL —Is it fair to say that the current structures set up opportunities for exploitation of overseas trained doctors?
Dr Cains —I believe so.
Prof. Allan —That is a reasonable call. I think that one of the issues is around whether or not the employers actually honour their obligations to the AON contract, which was often around a limited scope of practice. Then when you look at that later, you might see, for example, in our area people who do not have particular child psychiatry training having to see children because in the country there is no-one else to see the children and there are not alternative arrangements for them to go to the cities or whatever. So often the scope of practice is exceeded. It is probably because the person is trying to give a good service—they are trying very hard to be a good doctor in the community—but the scope of practice might be exceeded. I think there are always opportunities for that.
Mr Swinbourne —There is also an expectation that people in area-of-need positions progress towards full specialist recognition and fellowship. So, if a private practice, for example, is not supporting that person to actually get that additional experience and get there, then they are shooting themselves in the foot, unless they are content to exploit them for two years and then discard them.
Ms O'NEILL —Is there anyone policing that?
Mr Swinbourne —Certainly there are reports required for anyone in an area-of-need position at three months—and, if there are problems identified there, at six months and nine months. But typically it is three months and 12 months.
Prof. Allan —But the issue is that the reports are given by the employer.
Ms O'NEILL —So nobody is watching from outside.
Prof. Allan —Well, you watch, but you would have to go and question the bona fides of the employer.
Dr Garg —Just to add to what the discussion has been in terms of fulfilling the requirements of the college, the people employed in the area-of-need positions—because of the excess workload issues, because of other lack of support issues—cannot fulfil their requirements. That would be a significant issue.
Ms Tegen —I reinforce that statement. The big problem often is that not only have they been dumped into a rural area but they are trying to get their fellowship at the same time and often there is not any support in regard to being able to take the time off, because of the heavy workload. It is not just the private employers; it is also the public employers. In the end, they need throughput, to see the patients.
Mr LYONS —It is not only the patients, is it? The doctor needs the income as well.
Mr Tegen —Absolutely, but if you employ yourself you know that you have to put a certain amount of time aside to do some training or whatever; if you are working for somebody else and they do not actually give you that time off or support then it makes it difficult.
Mr LYONS —I do not know if it is just ophthalmology that gives you insight! What you said was that you have an agreement with the person and have an agreement for the roles of the various silos that they have to work through. That seems to me to be a good way of you guys handling it and not us bringing down some overriding recommendation. I am interested in getting a bit more detail about how that is possible.
Ms Tegen —It is really like an MOU between the different stakeholders who work with that particular person. There is often a misunderstanding about the role of each individual. If, for example, the applicant signs off on: 'Yes, I understand I only have four years. I need to do this, this and this in this process, will I sign off on it?' The employer signs off on it: 'Yes, I understand I have to give time to this person if I'm going to employ them under the immigration process. Yes, I will give them time. Yes, I will support them in sitting their exams and things like that. Yes, I'll make sure that they do have that supervisor working.' The college understand that, yes, it is our role to make sure that they are comparable. I think if people sign off on things then there is more of a commitment.
Dr Cains —I think a unified body which takes responsibility for the whole process, perhaps on a case management basis, may well be able to delineate these things and make sure things are not falling through the net.
Ms Tegen —The medical board is in a good position. You have just created that.
CHAIR —The New Zealand model is very similar to what we are discussing. Is that correct?
Prof. Allan —They coordinate all of the specialist assessments. We have modelled some of our processes on that and they coordinate all of the specialist assessments. Again, the contractual arrangement is much stronger for them. Everyone knows where they are going and they know where they stand.
Dr Graves —I just want to add to that. There is provision within the new legislation with the medical boards now whereby the medical board actually contracts with the AMC. There is already a contract there and the AMC is also contracted with the colleges in relation to this process. So there is a formation of a contracting process. But things like immigration are certainly left out of the process at the moment. I know the feedback from a lot of our overseas trained doctors suggests that that is another issue that is complicating things and the fact of bringing the employer into it as well. There is a nexus there already, but probably some more work could be done in relation to that. It is not that difficult.
CHAIR —Bringing it altogether is difficult.
Ms Tegen —In addition to that, there does need to be a commitment from the government to support them in funding, because the GPs—it took us years and years to get it to the stage where the GPs actually received funding from the federal government to pull people that were going through that OTS process so that we could support them in learning for exams and things like that. That is something that colleges can be involved in. But they need to have some funding. Do not forget the colleges are only funded through membership fees. Private businesses are paying. There is a lot of goodwill there. They are spending a lot of time supporting overseas trained specialists as individuals always at college.
Ms HALL —I think Professor McKenzie started off by saying that the whole issue is about balancing the opportunity for overseas trained doctors, whilst ensuring the safety within our medical system. I think each and every one of us here today is committed to exactly that. For us, the challenge is how can we make that process better than it is today? I was very impressed with the idea of a single body and everybody signing off and accepting responsibilities along the line. I am interested in perhaps expanding the area-of-need comments and the fact that there needs to be reforms in that area, with the arbitrary nature of the areas of need and how we can make it work better for all of us. Also, how we can improve that support process along the way by doing all that and ticking off the boxes as we go through. We are moving some of the barriers, because we have been told there are barriers. How can we get around those barriers, make the system work so that it benefits all the patients that you see and all those people who are seeking to come to Australia? Also, from a government perspective, how can we ensure that the resources are there to ensure every Australian can get the medical treatment they need when they need it? I would not mind a comment from a few of you on those things.
Dr Cains —I will pick up on the area-of-need question. First, many of our area-of-need positions come from Queensland. Queensland Health has recently reviewed its processes and appears to be establishing them in a more transparent way. Hitherto the colleges have had essentially no involvement in the declaration of a post as an area of need and have only come into the process when asked to match the applicant with the description of the post. I will give you an example.
Despite the improved Queensland processes, we have five applications on our books at the moment from Queensland. All of them are applications from a publicly listed company that runs ophthalmic practices. One of them is in a regional area, one in central Brisbane and three are on the Gold Coast. Part of the backing that they need for this application, the documentation, comes from the district workforce thing from the Department of Health and Ageing. It has ticked and authorised two positions in Southport. In the statement it said:
The latest Medicare figures show that Southport currently has better access to ophthalmologists compared to the national average; therefore, I can only give you two district workforce shortage positions instead of the four that you asked for.
The establishment have said the basic simple words of 'area of need' are fairly obvious to all of us. Southport is probably as full as anyone is and central Brisbane is not too badly supplied. It is a bit of a farce. It needs transparency. It needs more clear definitions and understanding of it. It needs uniformity in the process.
Prof. Allan —In terms of the regulation of contracts, you might want to include the medical recruiters in that. They often promise the world and exploit the weaknesses of the system. Many people arrive with an expectation that something is going to happen to them that is completely different to their experience. If a person believes something in good faith about the experience they might have and it is completely different, it does not look very good for us who are running that kind of system. That would be the place to start.
Secondly, from an employer's point of view we have only recently had the dual pathway. We have only recently made it certain that people would have their college assessments as well as get the area-of-need position. They are only just recovering from the idea that these people are not work fodder but they are actually working towards a fellowship as well as being part of that service requirement. So a lot of rehabilitation is needed in the system to make people understand what is actually happening.
To me the notion that part of the area of need would require a contract of support—very much along the lines of what we have been saying about what the level of supervision and the opportunities for education and training are—because at the moment all a person needs to do is be able to be registered. That does not tell you anything about professional development or supervision. It is just so arbitrary.
Ms HALL —So once an area of need is identified and somebody is placed in that position part of the contract should have written into it the proper mentoring, supervision and time off for training, making it a contract for all parties.
Prof. Allan —Then what we need with that contract is to say whose responsibility is it to provide the contract. In one way the employer has to provide some things but there are other training opportunities—for example, colleges provide training or support through the federal government for that kind of training, and state governments have a role in the way they direct training. New South Wales and Queensland have large training institutes and they direct the way that money is spent. We need to find a way to match all of those needs. For the private sector it is the same—we need to find a way to match those needs. It is not a cheap process.
Ms HALL —I would like to talk a little bit more about time limitations and the impact. We have received information on those time limitations and the impact that they have on the people that are involved in the process and the people that are providing the jobs and providing the support. How do we as a committee come up with a recommendation that ticks the boxes to make sure that people do not spend 20 years here before they take out their fellowship or registration of some sort and, at the same time, ensure that there is adequate time, given the occupational constraints of the company, for an overseas trained doctor to be placed in a practice? How do you balance it and what kind of recommendations would you suggest that the committee needs to be making in that area?
Ms Tegen —The first thing, even before you get to the stage where the person is brought out, rather than just checking if they are comparable is that they should be interviewed. We used to bring GPs out and before we did that we actually had several GPs plus local hospital CEOs who were going to employ them. We had people interviewing them over the telephone because it allowed us to vet them more than we could by just looking at their CV and checking it against a position description, which is really our role. Not everyone interviews.
Ms HALL —In my area there is an after-hours GP service. It is staffed by a number of overseas trained doctors. They work every night and at the same time they have to prepare for their exams. It is very difficult for them to do it within the four-year training period. These are the kinds of issues that I am trying to address.
Ms Tegen —Okay, that is the first part. But the second part is whether they are actually able to go through those examinations. There are several reasons why somebody might not do well in an exam. One of them—
Ms HALL —But everyone needs to prepare for an exam. When I did exams I made sure I studied for them first. If you are working towards a degree where you cannot study for your exam then it makes it very difficult.
Ms Tegen —It goes back to the contract: does this person get time off to be able to learn things? A lot of these people just do not get the time off.
Ms HALL —Okay, a contract would cover it.
Ms Tegen —It is about picking the right people in the first place. Some people are just not going to be the generalist that you might need; they are people who only fit a particular role. I think if someone sits in a certain role or fulfils a certain role in the community for, let's say, five to 10 years, they are entrenched in the community, particularly in a rural area where they become part of the community. Ripping them out of that afterwards is difficult. So there are these expectations not only of the community but also of the individual.
CHAIR —You could add that if you had a system, such as the one we spoke about earlier, where all the different partners agreed on a memorandum of understanding, that particular problem—which is one example of many; there could be many other examples—could be overcome by asking, 'Will this person have time to be able to study for a week or a month?' So there are ways of dealing with it.
Ms Tegen —Yes.
Prof. Allan —I think that it is important to have the contract but then it is important what you do inside the contract.
CHAIR —What you do inside the contract.
Prof. Allan —I would think that the interviewing is essential. We interview everybody.
Ms Tegen —I agree.
Prof. Allan —I think that we have started some projects around early intervention. It is not just about the interview. It is also about getting a proper workplace assessment of that person's capacity very early on, in that first year, to know what they might need over the ensuing years rather than let them practise away, poorly supervised with not much change to their practice for a couple of years and then suddenly saying, 'You are fronting up for an exam. You are not going to pass the exam because you have not been practising properly for a couple of years.' I think that is letting that person down as well. So you need to have that early intervention. But one model for that is in medical schools. People fail medical schools in their first and second years these days and not their fifth and sixth years, because you have got to be ruthless about who is going to succeed and who is not going to succeed. Or they fail before they even get in. The workforce driving the need to bring in many people and to lower the assessments—and you have probably heard people saying that it is too hard to bring people in; the colleges are too strong or too tough in their assessments—is really a false hope because we have to get the right people to do that or give them the right assistance when they come.
Ms O'NEILL —I think you have probably hit right at the heart of this. Obviously, you want to be maintaining standards but this negotiation that needs to happen early on seems very much not to be standard. Until the moment of crisis issues are not being dealt with perhaps by the colleges themselves, who are not seeing their oversight role going back further as to doctors who are coming in and seeking to more forward. I have two things I want to ask. The first question is really about the timing that you were talking about here. You have been talking about four years. I know, Professor Allan, that you mentioned the need to have it as a nine-year process because of the particular specialty that you are in. We heard evidence in Brisbane from an anaesthetist for whom the four-year time line was a really significant problem. I am concerned to know what is an appropriate time for people to move to fellowship and how variable it is across the different colleges—and we have here a pretty good range of colleges represented today.
Dr Cains —I think it comes back to one of the fundamental questions: are you wanting people who are of a standard to come here? With ophthalmology it is largely a technical aspect. Although communication is very important, it does not have the same depth as that of a psychiatrist and require a lot of adaptation. Contemporary Western ophthalmology is fairly standard across the world. Do you want people to be evaluated as they come in and you say, 'Yes, you're comparable' or 'No, you're not' or do you want people over a whole range to come in and then be prepared, as a country, to undertake training of those people to bring them up to the standards that we need for people practising here? We have introduced a two-year, top-up training opportunity largely with a view to fairness and flexibility. But are you really intending to run a secondary training program for whoever may apply or are you intending to simply evaluate whether those who apply to come here are comparable? As I see it, there is not a definition of partly comparable. There is perhaps a reasonable understanding of what is substantially comparable and of what is not comparable, and the rest fall into it. By definition, anyone who has trained in a specialty overseas is partially comparable as they know something about the game, so they could be of all sorts of standards and still be validly seen as partially comparable but might be embarking on a course for which they might not have the underlying medical background and so on to be able to complete it anyway. Are we undertaking to manage all of those people or are we largely wanting to get a fair and transparent evaluation of people as they apply to come here?
CHAIR —We will go to Jill. I think Jill had not completed a particular question as I cut her off half-way through.
Ms HALL —I have got to get my train of thought back. You were answering the question about time frames for me and we came to the point where you talked about the interview process and getting things right all the way along so the time frames would not be such an issue. I suppose I have really gone off track—sorry, Deb!—but the question was about the interview and the need for the interview to identify issues that could impact on the fact that people would have difficulty completing the training and to identify at the same time barriers to their completing that training within the time frames. Do you see barriers that exist and that could be identified at the time of interview as preventing people from passing through the process properly? What sorts of strategies do your colleges put in place and what sorts of strategies do you see that we as a committee could recommend to the government be put in place so people can move through the system in that way? I think that is where I was going with my question before.
Dr Graves —I would add one point in relation to the existing system. With area of need currently, our college interviews all of our OTS in area of need as a joint thing; we have done it for many, many years now and it has worked very well. But with area of need we only have to interview them for three, six and 12 months and then after that we do not need to interview them at all. You have to wonder whether there should be an ongoing process there from the college point of view. I know the medical boards will look at those cases when they come up for their re-registration, but they are not going through that process of overseeing what they are doing from a training point of view or what sorts of exams they are sitting. After that 12-month period there is no further monitoring by the colleges at that stage of the game so that is something that could possibly be looked at, an ongoing monitoring process. That obviously comes with a cost but that is certainly something that is not happening at the moment.
Ms HALL —Do you think that 12-month period is the ideal period?
Dr Graves —In certain circumstances. From our point of view we find that is fine, particularly with qualifications and experience that are more comparable to the Australian situation. But for graduates from other countries that period of time is probably not long enough, is probably not adequate, particularly if people need top-up training in relation to getting a fellowship.
Prof. Allan —The answer about the interview is 'yes' obviously, but the proviso is that sometimes people do not see that because you have a person who considers themselves highly qualified, experienced and getting the message is a hard one at that very first point. So you need to follow that up three and six months later to make sure that you understand exactly what 'practice' means to them. There is a list of things that I would be suggesting to you. One is around particular mentoring programs or having directors of training that can help those individuals, because often they will be people in senior posts who you might have looking after the junior trainees but they have to get something themselves. That is a hard issue. The other thing is about whether or not examinations are the best way to go, whether some effort in developing workplace-based assessment or different ways of showing competency, which we are all trying hard to develop, might be better. But there is a lot of controversy about whether everything has to be exam or not exam based. I would not care to speak for anybody about that question.
Ms Tegen —It is the same with ophthalmology. Workplace assessment has been on the agenda.
Dr Cains —To address your timing specifically, we follow the guidelines from the JSCOT and that allows some candidates to have up to two years of top-up training. Thereafter they are expected to proceed with whatever assessment tasks the college has set expeditiously. So if it is to sit an exam, they are expected to sit it the next sitting of the exam, unless it is next week, and if they fail that they would normally be given another opportunity, unless they get flu or something immediately before it and have to drop out. The exams are held six monthly. It runs through that sort of period. And really once that and the opportunities for resitting are exhausted, they are either successful or they have been found wanting. So that determines the time and we are, again under JSCOT's guidance, expected to be reasonably flexible—two years nominally after any top-up training—if there are difficult circumstances.
Mr COULTON —I could tell Dr Allan had been a psychiatrist in a country area because he knew what question I was going to ask before I asked it. But back to your last point, we have heard that the AMC may not be the appropriate tester. It would be like someone applying to be a governor of the Reserve Bank having to go back and do their final exam for an economics degree, and whether they would pass or not. You touched on that in your last answer—that is, is the AMC test appropriate. We heard from a specialist, I think he was an anaesthetist, an English doctor who failed the test. Even though he was a lecturer or a trainer—he was very highly qualified in England and he came out here because of personal reasons, followed his heart out or something like that; married an Australian girl—he failed the first test because the test was aimed at someone who was just leaving university, starting off, whereas he answered it as someone who was—
CHAIR —He had written part of the procedures of the test that he failed.
Mr COULTON —That is right. He actually failed the test because he answered it as someone with 20-years experience who was actually a trainer in that particular field. I am just wondering about the appropriateness of that AMC test. We also heard in Brisbane about a doctor who had been here for quite some time. Due to a cancellation or something they said, 'We want you to sit this test next Tuesday, as you are in Brisbane.' Of course without an amount of preparation he failed and because he failed he had that against him. It just snowballed. I am asking not just you, Professor Allan, but anyone about the appropriateness of that test.
Mr Swinbourne —The AMC exam is really for general practitioners, but I think you are asking about the principle in the case of specialists.
Mr COULTON —Yes.
Mr Swinbourne —In carrying out an assessment, say, after 12 or 24 months of someone getting some experience and perhaps some upskilling, is the appropriate measure an exam, work based assessment or some combination? I think that is really quite difficult. We would take the view that the college exam is the exam that all of our trainees sit. Yes, they are geared up because they have been registrars for five years and have got into the mode of preparing for an exam. It would give the appearance of having some degree of objectivity and uniformity.
In our experience workplace based assessment is really very difficult. We have a shortage of people who are prepared to act as supervisors for overseas trained doctors, in any case, and being able to get the pool of fellows of our college, who are unpaid, to spend the time doing a proper, thorough work based assessment is a real challenge. It is not just a financial resource issue; it is actually having access to the pool of people who are trained and are able to give up the time to do it.
Mr COULTON —Is there a reluctance in making an assessment because, if we use an infamous overseas trained doctor Queensland as an example, maybe there would be ramifications if someone had, say, ticked off their competency as part of a workplace assessment and then things went horribly wrong after that? Is there some concern that there may be ramifications for that sort of assessment?
Prof. Allan —I understand what you are talking about, but most colleges would have a set of standards around making sure that the assessments were thoroughly checked and so on. But the point you are trying to make is that that takes a lot of time and a lot of effort and that it costs a lot of money. Most of that is done pro bono. Even if you started charging and offering a fee, it is just not possible to construct a fee that is going to be reasonable to represent the whole thing. So that is very difficult to do.
You answered your own question, in a sense. The idea that someone would ask you to sit an exam tomorrow and you would be found to know nothing is every specialist's worst nightmare. That is a very frightening experience for people, and the longer you have been out the harder it is to go back and do the exam. So there is no doubt we have to find a better way of dealing with that.
Just on that, in response to the notion of competent authority, that is now, as I am sure you know, for the GPs. But similarly for specialist colleges, where substantial comparability can be based on the membership of a particular overseas college rather than on the individual, we have been looking at our data about exam success, and it is quite clear that some people with certain qualifications are very successful in doing the exam. What is the point of proving them to do the exam again? Why do we go through that process? If we started to put some science rather than emotion into the question we might get some answers.
Prof. McKenzie —Your example of the anaesthetist who had written that guideline is not necessarily representative of all overseas trained doctors. As an examiner for our college, some of the people who have the most trouble getting through are overseas trained doctors who have been perhaps in an area-of-need position for some years but still really find it difficult to get up to the level that we would find acceptable as a baseline in our own trainees. For someone who is deemed to be partially comparable it really is very difficult, from our college's point of view, to have a workplace based assessment. That is the sort of thing we would do with somebody who was going to apply for our fellowship who was already deemed to be substantially comparable.
In trying to assess a level of capability we have tried to use an objective process which is an examination process. I think there is a difficulty possibly for older people to study again. That is one problem. Also there is perhaps a lack of recognition of the need to study and the need to really actively go into the sorts of activities that you would take advantage of if you were a trainee as a younger doctor. We have trainees in our system who are across ages. We have people who are overseas trained doctors who go through the AMC process and then begin our training scheme. Generally, they are very successful. I think it is not just people's initial background, it is not necessarily their original medical degree, it is the commitment that they put into training to bring themselves up to the examination, which is a way of protecting the community. We have to have standards that we stick to in terms of competence. An examination process at least in pathology is a fair but rigorous process.
Ms HALL —Could you send information through to the secretariat on the number of overseas trained doctors working in each of the specialty areas—we have it for psychiatry—and also the number of overseas trained doctors who are involved at board level? That would be useful. My final question goes to the review process. I understand that the colleges all have a process for reviewing unsuccessful applicants. I wanted to run past you what you would think about having a person similar to an ombudsman to look at process, not medical or clinical data, but process to ensure that what is involved at the college level is beyond question—an ombudsman type person who sits over the top similar to the case for many government departments and such organisations.
Ms Tegen —Are you saying an ombudsman for the whole process as part of a person going through that?
Ms HALL —For review.
CHAIR —For example, if someone wanted to challenge a decision made by the whole process—in other words whether it be the colleges, PESCI, the English test—
Ms Tegen —The whole process rather than just one—
CHAIR —An independent body, call them an ombudsman or whatever that would be able to look at a particular case.
Ms HALL —I am asking from a college perspective but, yes, it would be the whole process.
Prof. Allan —Could I suggest that we would be confident of our transparency. As long as it was to look at the whole system because we think there is a lot of trouble in the whole system.
Ms HALL —That is great. Thanks.
CHAIR —Would anyone else like to add to that?
Dr Cains —We have absolute confidence in our process and we feel the role of an external member on the committee is important in ensuring that. That sort of person would be not medical and essentially there to see that natural justice and principles are followed. That is where we would see a role to monitor that. If problems arise from it then certainly it must go to someone outside in terms of process.
Ms HALL —I do understand that all colleges have their own process but this would be above in its absolute process.
Mr Swinbourne —I think it would have a lot of merit. For someone to actually proceed to all of the stages in our appeal process, when they reach the final appeal, it is a real drama and a highly expensive exercise. For an ombudsman to sort it out before it got there would suit us fine.
Ms HALL —How many people would you get in a year that get to that final stage?
Dr Cains —In the last three years I have been doing the committee we have only had, I think, three actual appeals all of which have been decided internally to the satisfaction of all parties. None has proceeded to the formal external appeal.
CHAIR —Before I close the public hearing I want to thank all of you for attending today, giving us your views and thoughts and answering some of our easy and difficult questions. Some were unanswerable as well. Please feel free to feed information through to us, anything else that you may think of that for whatever reason was not brought up today and you think is of importance to this committee. If we have any further questions, we may contact you again at a later stage. Thank you very much for the information that you have given us today and for giving up your time to come and brief this committee. I thank all the witnesses; members of the public that attended today; Hansard, who has been recording everything; the secretariat, Belynda and Alison; my staffer, Hannah; and all the committee members.
Resolved (on motion by Mr Irons):
That this committee authorises publication, including publication on the parliamentary database, of the transcript of the evidence given before it at public hearing this day.
Committee adjourned at 3.05 pm


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Published: Thursday, October 18, 2012 at 6:41 p.m.
Last Modified: Thursday, October 18, 2012 at 6:41 p.m.
DAYTONA BEACH -- When 100,000 bikers roll into town, evangelists, vendors and classic rockers tend to follow. And this year, a presidential candidate is dropping by.
Biketoberfest basics
WHAT: 100,000 bikers coming to Volusia and Flagler counties to enjoy sun, sand, rock 'n roll, beer and a passion for motorcycles.
WHEN: Thursday through Sunday.
WHERE: Main Street, U.S. 1, Beach Street, Destination Daytona and venues across the two counties.
Roarin', rumblin' Biketoberfest provides the backdrop for GOP nominee Mitt Romney and his running mate Paul Ryan when they visit the Bandshell for a "Victory Rally" Friday night at 8.
Whether the rally crowd will include many bikers remains to be seen. But Romney campaign spokesman Jeff Bechdel said the governor and Ryan "really wanted to come to Daytona" and Biketoberfest would likely "be a part of" their visit.
Kenneth Payne of Crestview, a biker on Main Street on Thursday night, said he was going to try to get to the rally.
"I've always been in support of Republicans," he said. "It could be Charlie Brown and I'd still vote for him."
Biker Dennis Morosin of Texas said he's voting for Romney, but he won't attend the rally. "I didn't come here to get involved in politics," he said.
Roy Miller, a biker from Georgia, agreed. He came for a quick trip and said he would be on his way back home by the time Romney shows up Friday night. But that's all right with him. He's in town for motorcycles, not politics.
"Everyone has a passion and this is mine," he said. "I have a motorcycle for every day of the week."
Enjoying the show on Main Street during Biketoberfest's opening day, Ormond Beach resident Sherry Degenfelder said she and her husband would rather stay clear of the congestion and traffic that Romney's appearance will likely bring.
"I wouldn't walk across the street to see Romney," said Degenfelder, who made it to the Bandshell in 1992 to hear what then-President Bill Clinton had to say.
Degenfelder said she identifies herself as an independent, but doesn't think Romney will do enough to help fix the economy or create equal opportunities for women.
Staff writer Katie Kustura contributed to this report.
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subset: commoncrawl


text:
Explore western Alabama from this Howard Johnson University of Alabama Tuscaloosa conveniently located off Interstates 20 and 59 near great restaurants and attractions. Cruise down the Black Warrior River on the Bama Belle riverboat, or visit a student at the University of Alabama, both just six miles away. Tour the only Mercedes-Benz factory in the country, or visit Alabama Adventure amusement park for roller coasters, bumper cars and a Ferris wheel. Start your morning refreshed with a complimentary Rise and Dine continental breakfast as you read the complimentary newspaper and connect to the complimentary wireless Internet access to plan your exciting day. Guest laundry services are available. Relax in your comfortable guest room with microwave and refrigerator. Suites, smoke-free and handicapped-accessible rooms are also available.
Amenities· Accessible parking
· Air conditioning
· Air conditioning
· Alarm clock
· Business center
· Coffee/Tea maker
· Coin operated laundry
· Complimentary continental breakfast
· Complimentary in-room coffee or tea
· Desk with lamp
· Free newspaper
· High speed internet access
· High speed internet connection
· Ice machine
· Ice machine
· Internet services
· Ironing board
· Ironing board
· Jacuzzi
· Meeting rooms
· Microwave
· Non-smoking rooms (generic)
· Outdoor parking
· Parking
· Safe
· Vending machines
· Wheel chair access
Miscellaneous Information
· American Dollars is the native currency.
· Check in time is 2:00 PM
· Check out time is 11:00 AM
· Opened in 2004
· 41 rooms.
· 0 suites.
· 2 floors.
Restaurant InformationCracker Barrel Waffle House Burger King Subway Dearmland Ribs Chilis Ruby Tuesdays Pizza Hut Taco Bell Logans Road House O Charleys Buffet City Hooters Olive Garden McAlisters Deli Cypress Inn Evangilines The Globe Jupitar Bar and Grill
Area Attractions- Alabama Museum Of Natural History
- Bama Bell Riverboat
- Bama Bowling Lanes
- Bama Mini Golf
- Bama Theatre
- Moody Music Building
- Murphy African American Museum
- Old Tavern Museum
- Paul W Bryant Museum
- Bryant Conference Center
- Alabama Bureau of Tourism and Travel
- AMSouth
- Bank of Tuscaloosa
- Childrens Hands on Museum
- Convetnion ans Visitors Bure
- Shelton State Community Coll
- Stillman College
- Colonial Bank
- First Federal Bank
- Regians Bank
- Chamber of Commerce
- Kinkos
- Printing Plus
- Office Depot
- Office Max
- County Court House
- Reginal Medical Center
- Public Library
- African Methodist Episcopal
- Assemblies of God
- Baptist Campus Ministries
- Benville Baptist Church
- Saint John Catholic Church
- Church of Christ
- First United Methodist
- University of Alabama
- Shelton State Community College
- Hidden Meadows Golf Course
- Mimosa Golf Course
- Ol Colony Golf Course
- University Golf Course
- Blue Creek Park
- Rocky Branch Park
- Antique Shops
- Shopping Malls
- Tuscaloosa County Park and Recreation
- ARPT Birmingham Intl
- ARPT Tuscaloosa Regional
- BUS Greyhound
- Tuscaloosa Transit Authority
- RENT Avis


text:
Dear Friends,
Our Easter celebration has begun! This whole week is considered a single day in the liturgy – Easter Day – and initiates the entire 50-day Easter Season. Our joy in the Resurrection of the Lord overflows in our prayers, songs, and activities. I had a great Easter Triduum, celebrating and preaching these sacred days on Staten Island, then at the Holy Apostles Seminary in Cromwell, CT (where I was celebrant and homilist for the Easter Vigil), and in Port Chester, NY for Easter Sunday Mass at my home parish of Corpus Christi.
This is the Feast of the Victory of Life. That's why, of course, the celebration of the Resurrection is a perfect time to intensify our pro-life commitment, and bring the priority of the defense of the unborn higher on our personal list and on the "list" of the Church. It's not that we need any new teaching. The Church has said eloquently was has to be said about abortion (though we can always come up with new and more effective ways to formulate it to speak to the current culture.)
It is not new teaching that's needed. There are, instead, two simple ingredients that need to be added to the Church's pro-life teaching: passion and priority.
We can't make it seem to the world that abortion is just another issue, or only minimally less trivial as much of the world thinks it is. We have to have some passion in the way we respond to it, in word and deed. Passion does not exclude reasonableness or compassion; in fact, it nurtures them, and makes us all the more determined to grow in those virtues.
And we have to give more priority to fighting abortion. One of my key missions in life, as part of ending abortion, is to raise it on the list of priorities that everyone has – starting with "the Church." When something is higher on the priority list, we talk about it more, we spend more time and money on it, we allocate more resources and personnel to the task, and we carry it out like we mean business. Those who think the Church gives too much attention to the abortion issue are missing an awful lot of what is and isn't going on in the Church.
Ultimately, when we have a priority, we stop counting the cost, we stop fearing success, and we're willing to prove it by martyrdom.
Are you on the same page?
Fr. Frank


text:
Unbelievers Cannot See
Or No The Truth :) :)
Suzanne Penman
From: "Suzanne Penman"
To: "Positive Atheism" <firstname.lastname@example.com>
Subject: PA-via_Positive_Atheism_Index
Date: Friday, January 19, 2001 10:21 PM
Just to say that GOD is REAL and God will JUDGE. and all one has to do to know there is a GOD is to KNOW that YOU ARE. IF there were no CREATOR there would be NOTHING AT ALL>:):)
The Written Word that is left for all that Meditate on His name tell us Through His Holy Spirit the truth of all that is Written. But to all that are in Unbelief it is all foolishness and the cannot understand nor see the truth . for Because of their UNBELIEF they cannot know truth as Truth can only come by faith and faith can only come by the WORD and the WORD WAS GOD and the WORD WAS manifested IN HIS SON JESUS CHRIST. so faith Comes BY THE WORD and if one Does not believe IN that WORD then there is no Faith and no understanding for GOD is SPIRIT and ONLY THOSE That have the SPIRIT can understand SPIRITUAL THINGS. and all UNBELIEVERS have no SPIRIT IN THEM they are SPIRITUALLY DEAD and the DEAD NO NOT ANYTHING they are DEAD. BUT even IN this time of GRACE all have the choice to CHOOSE to have LIFE. LIFE can only be given by accepting the one that is LIFE> and that is the WORD, JESUS CHRIST He is ALIVE and HE will be faithful to those that BELIEVE and LIVE BY FAITH IN HIM>
From: "Positive Atheism Magazine" <firstname.lastname@example.com>
To: "Suzanne Penman"
Subject: Re: PA-via_Positive_Atheism_Index
Date: Saturday, January 20, 2001 12:42 AM
Speak English, please!
Cliff Walker
"Positive Atheism" Magazine
Five years of service to
people with no reason to believe
From: "Suzanne Penman"
To: "Positive Atheism Magazine" <email@example.com>
Subject: Re: PA-via_Positive_Atheism_Index
Date: Saturday, January 20, 2001 1:50 AM
Wha....? Did I stutter?:):):) NO!!! Just proves the point that the DEAD NO NOTHING and that the Unbelievers have no Spirit to understand Spiritual things. Otherwise you would know what I had said and what it all meant.
Old Testament Prophets spoke of things to come. and In the New Testament all are being fulfilled with the Birth of Jesus Christ. Even to the happenings of today's NEWS Prophecy is being fulfilled before our eyes. But Those that are blinded by their unbelief do not see the truth in the PROPHECIES of the ages. Those that are not ready for what is ahead may find themselves ending up just as the ones that perished in the FLOOD of Noah's day. As in the day's of Noah so shall those days be. and we that know God can see the days of Noah are here. Noah also warned others but they in unbelief did not listen and when the flood came it was to late. Again those such as Noah are warning all that the Kingdom of HEAVEN is at hand and many do not believe the warning and are going to perish.
You are definitly right about one thing and that is that your destiny is definitly your responsibility. GOD does not twist anyones arm to accept His Son. It is a GIFT of LIFE everlasting that He has and does offer. BUT as with all GIFTS it cannot be enjoyed if not accepted. The Gift that JESUS CHRIST has already bought for you is LIFE But if it is not accepted then there is no life to enjoy. When ADAM sinned in that Garden DEATH came upon the whole world. SPIRITUAL DEATH. But there are some of us that have found the KINGDOM and now have life but there are many that are still in the grave of death. God has sent His reapers to harvest the field. and the TARES and the WHEAT are being seperated. The wheat is being taken into the barn of the Master. BUT the tares are being gathered to be burned. Which would you rather be? a TARE to be burned? or a Wheat to go to the Masters barn? Your right IT IS DEFINITLY your choice what you want to be and where your destiny will be. I cannot choose for you. NO ONE CAN. It is always a PERSONAL choice. Today is the day to choose. for noone knows the hour of His coming for His own. He may come before Morning and if He does There will be no chance to make excuses because you have NONE!
From: "Positive Atheism Magazine" <firstname.lastname@example.com>
To: "Suzanne Penman" <firstname.lastname@example.com>
Cc: <firstname.lastname@example.com>
Subject: Re: PA-via_Positive_Atheism_Index
Date: Saturday, January 20, 2001 5:54 AM
If I am blinded about such things, as you say, then why do you bother speaking to me?
If you have a convincing case to make, you are welcome to start making it.
If you continue your abusive and bigoted tone, though, I will ask you to stop writing to our domain.
Cliff Walker
"Positive Atheism" Magazine
Five years of service to
people with no reason to believe
Material by Cliff Walker (including unsigned editorial commentary) is copyright ©1995-2006 by Cliff Walker. Each submission is copyrighted by its writer, who retains control of the work except that by submitting it to Positive Atheism, permission has been granted to use the material or an edited version: (1) on the Positive Atheism web site; (2) in Positive Atheism Magazine; (3) in subsequent works controlled by Cliff Walker or Positive Atheism Magazine (including published or posted compilations). Excerpts not exceeding 500 words are allowed provided the proper copyright notice is affixed. Other use requires permission; Positive Atheism will work to protect the rights of all who submit their writings to us.


text:
Welcome to Atlantic Marine
Ph. (910) 256-9911
Fax (910) 256-8530
PO Box 659
101 Keel Street
Wrightsville Beach, NC 28480
United States
New Boat Showroom
Preowned Boats
Email Us
Visit Our Website
Atlantic Marine is South Eastern North Carolina's exclusive waterfront dealer for Grady White and Chris-Craft Boats. In the market for a used boat? We have the areas largest selection of used boats to fit all budgets!
Affiliate boat brands carried at Atlantic Marine
Click on the brands above to see a list of the models available.
Engine brands carried at Atlantic Marine
Yamaha Outboards
Other brands carried at Atlantic Marine
Products and Services available at Atlantic Marine
© Copyright 2016 Dominion Enterprises. All rights reserved.


text:
On Monday, the Newnan-Coweta Humane Society issued a statement about the stabbing which left a pit bull dead at a weekend adoption event in Georgia.
The statement was posted to the humane society's Facebook page, along with a statement that any and all comments about the situation will be deleted from their page.
From NCHS Board of Directors:
There was a horrific, tragic incident yesterday at PetSmart with one of our foster dogs, Clara. Below is a message from one of our volunteers that was there yesterday and deeply cared for Clara, regarding the painful decision to euthanize Clara...
NCHS made the very difficult decision to have Clara euthanized because we thought it would be best for Clara. Her injuries were more extensive than the vet originally thought. We did not want her to suffer anymore and ultimately die in the presence of strangers.
Several of the volunteers with NCHS who know and love Clara were there with her when she passed including one of the guys who works at the kennel where she had been boarded. She was surrounded by love and no longer is in pain or suffering.
We did what we thought was best for Clara under the circumstances - not because she was a liability or the cost of treatment. The little dog she attacked was injured - a bite on the neck and needed to be transported to Urgent Care for further treatment and I hear she is going to be okay. Believe me, none of us wanted to euthanize Clara - we love her - we did what we thought was best for her under the circumstances.
According to Tuesday's publication of the Times-Herald, witnesses saw Clara slip from her collar before grabbing the small dog, described as a Westie terrier, by either the neck, or the ear. The small dog's owner repeatedly stabbed Clara and witness Kathy Stottlar stated that she heard him repeatedly yelling:
get the dog off or I will stab him.'
Erin Barr, another witness to the tragic situation, heard the man threaten Clara before anything transpired between the dogs. She told the Times Herald that she heard the man say:
"If you bring that f***ing pit bull near me I'm going to stab it."
Yet another witness stated that at the time that the man started kicking and stabbing Clara, both dogs were standing there, and it was her opinion that they could have been separated before the knife attack started.
Barr noted that Clara did not react when she was being attacked, she recounted the scene:
Clara just lay there, almost smiling with her mouth wide open, not fighting back, as the crazed man continued to knife Clara. It was a bloodbath. He knifed her over and over and over and she just lay there. She did not fight back. There was blood everywhere. My child was there, several children watched and cried and screamed. The crazed mans' own son was just quiet, looking around, in amazement, it seemed."
The small dog sustained minor injuries in the altercation and was released from the veterinary clinic by Monday morning; Newnan Animal Warden Cyndi Hoffman is investigating what transpired on the day of the event.
Prior story about this situation here.
If you would like to continue receiving the latest dog-related news, tips and advice, please click the word "Subscribe," near the top of the article. Follow along on Facebook and Twitter for more stories and updates.


text:
Internet access in Edinburgh: Cafes and Free WiFi
The Ministry of Gaming
20-22 Bread Street, just off Lothian Road,Edinburgh.
Opening Hours: Monday to Thursday - 10am till 10pm; Friday and Saturday - 10am till 11pm & Sunday - 12noon till 10pm.
Cost of going online: 1 hour - £2; 3 hours - £6 & Day Pass - £15.
o Telephone: 0131 228 3452
98 West Bow,Next to the historic Grassmarket, Old Town,Edinburgh,EH1 2HH.
Opening Hours:
Every day: 10am 11pm.
Coffee Home Internet
28 Crighton Place,Leith Walk,Edinburgh,EH7 4NY.
Opening Hours: Monday to Saturday 10am - 10pm. Sunday 12pm - 10pm.
Facilities: Black and White Printing (Using Laser Printers); Colour Printing (Using Inkjet Printers): Photocopying (Black and White)
Cost of going online: 60p for the first 20 minutes and then 3p a minute thereafter.
o Telephone: 0131 477 8336
E-Corner Internet Café & International Calls Shop
54 Blackfriars Street,Edinburgh.EH1 1NE.
Opening Hours: Monday to Friday: 9am 9.30pm & Saturday and Sunday 10am to 9.30pm.
Cost of going online: £1 for half an hour. Membership £5 for 4 hours. A4 Black and White photocopies 10p a copy.
o Telephone: 0131 558 7858.
The Washbar
Just off the Royal Mile on:The Mound,11 North Bank StreetEdinburgh, EH1 2LP
Sunday Thursday: 11.30am - 12 midnight; Friday Saturday: 11.30am 1am & Open until 3am during the Edinburgh Festivals in August and then again throughout December into the first week of January.
o Telephone: 0131 225 6193.
The Jolly Judge Pub
James Court, 7/A493 Lawnmarket, on the Royal Mile,Edinburgh, EH1 2PB.
One of the Scottish capitals first free-to-access WiFi hotspots. Understandably, the licensees just ask that people availing themselves of the free WiFi buy at least one drink during their stay.
Monday Thursday: 11am 11pm; Friday Saturday: 11am 12.30am & Sunday: 12.30pm 11pm.
o Telephone: 0131 225 2669
The City Café
19 Blair Street, Edinburgh, EH1 1QR.
Telephone: 0131 220 0125.
The Beanscene have two cafes in the Scottish capital, which both offer secure, free WiFi access for customers.
Opening Hours: Monday Friday: 7.30am 10pm & Saturday Sunday: 9am 10pm.
Beanscene2 Grosvenor Street, Edinburgh, EH12 5EG
o Telephone: 0131 346 8043.
Beanscene99 Nicholson Street, Edinburgh, EH8 9EW.
o Telephone: 0131 667 5697.
Central Library
George IV Bridge,Edinburgh, EH1 1EG.
Opening Hours: Monday Thursday: 10am 8pm; Friday 10am 5pm & Saturday 9am 1pm.
Iglu Bar & Bistro
2b Jamaica Street,Edinburgh, EH3 6HH.
Michelin Guide Recommended 2007/09/09.
Opening Hours: Closed Monday. Tuesday Sunday: 12pm 1am.
Both the Royal Mile & More and Old and New Towns Walk Talk Tour Edinburgh audio guides are recorded in MP3 format and can be downloaded onto iPhones, mobile phones, MP3 players or iPods. Both tours can be completed in two hours. Listeners can bluetooth the files to their device if they wish. Both tours come complete with a free downloadable map.


text:
17 December 2013
Artwork description
This painting was painted on the 16th of November, 2013 in my Moleskine Watercolour Book.
Sizes are: 13cmx20.5cm
To make this portrait I used one of her photos from an excellent photoshoot, and then I used pencil, watercolour and acrylic.
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