Requirements for Practicing Medicine in Australia

Although national examinations for non-specialist international medical graduates have existed in Australia since 1978, states and territories had adopted different approaches to the assessment of some categories of Area of Need practitioners and specialists. In July 2006 the Council of Australian Governments (COAG) agreed to the introduction of a nationally consistent assessment process for international medical graduates and overseas trained specialists. COAG gave Health Ministers the responsibility for implementation of this decision, and a model for a national process was developed and submitted to Health Ministers on 12 December 2006. The final report on the agreed pathways was presented to the Australian Health Ministers’ Advisory Committee in October 2008.

This model outlines three main assessment pathways:

• Competent Authority Pathway;
• Standard Pathway (including the current Australian Medical Council examination and a workplace-based assessment pathway); and
• Specialist pathways for all specialties, including general practice:
  • Standard specialist assessment;
  • Area of Need assessment; and
  • Overseas trained specialist in specified training position.

The Competent Authority Pathway was implemented from 1 July 2007 and the first stage of the Standard Pathway (workplace-based assessment) for general practitioners and non-specialist hospital doctors was implemented the following year, from 1 July 2008.

The Australian Medical Council is an independent national standards body which is responsible for processing all initial inquiries regarding assessment of international medical graduates and overseas trained specialists.

Further details on assessment requirements that are common to each of the pathways and the specific requirements of each are provided below.

Common Assessment Requirements

Each of the pathways includes some (or all) of the following steps:

• assessment of English language proficiency at a nationally agreed level;
• primary source verification of qualifications;
• assessment against a position description with the level of assessment according to level of risk (for Area of Need positions);
• orientation within three months of starting employment and evidence of satisfactory completion of this submitted to the relevant medical board with the supervisor’s three-month report; and
• access to continuing professional development.

Competent Authority Pathway

Competent Authorities are designated overseas accredited medical training and licensing examination authorities that have been reviewed and approved against criteria developed by the Australian Medical Council as competent to undertake a basic assessment of medical knowledge and clinical skills for the purposes of registration in Australia. One of the criteria used to recognise a Competent Authority is the extent to which the clinical context of the country in which it operates is consistent with the Australian context of health care. This is defined in terms of the pattern of disease, level of medical technology, delivery of medical education and professional ethics. The Australian Medical Council has approved four examination authorities in:

• the United Kingdom (PLAB examination or for graduates of GMC-accredited medical courses);
• the United States of America (the USMLE examination);
• Canada (the MCC Licensing Examination); and
• New Zealand (the NZREX examination).

Graduates of medical courses in Ireland are accredited by the Medical Council of Ireland.

International medical graduates undergo a pre-employment assessment of suitability for a position if required by the Medical Board of Australia. Where the board determines a pre-employment structured clinical interview (PESCI) is required, it is carried out by an Australian Medical Council-accredited provider against the position description. This may be carried out if required for more senior hospital-based positions and is included as a matter of course for general practice positions.

Doctors eligible for the Competent Authority Pathway are granted advanced standing towards the Australian Medical Council Certificate and undergo up to 12 months workplace-based assessment to ensure satisfactory adjustment to the Australian health care system before they are eligible to receive the Australian Medical Council Certificate and apply for general registration.

Table 5.4 shows that a total of 1,387 applicants were assessed through this pathway in 2012. Of these 1,342 applicants qualified for advanced standing. While these are primarily applicants who applied in 2012, the figures also include a number of 2011 applicants who were required to submit additional documentation to confirm their eligibility.

In 2012 a total of 520 Australian Medical Council Certificates were granted, making the applicants eligible to apply for general registration. This is similar to 475 granted in 2011 with a 9.5% increase.

Two-thirds of these granted in 2012 were to international medical graduates from the United Kingdom. Almost one fifth of certificates were issued to international medical graduates from Ireland.

Only six certificates were issued to international medical graduates from the United States of America and five certificates to international medical graduates from Canada.

Table 5.4: International medical graduates: Applications assessment through Competent Authority Pathway, 2012^(a)

Country of training	(c)PLAB	(d)MCC	(e)USMLE	(f)NZREX	(g)GMCUK	(h)MCI	Total	Advanced standing Issued	Certificate issued
(a) Data covers the period 1 January 2012 to 31 December 2012. (b) Other includes: Afghanistan, Albania, Algeria, Antigua and Barbuda, Armenia, Austria, Bahrain, Bangladesh, Belarus, Bolivia, Bulgaria, Chile, China, Colombia, Croatia, Czech Republic, Democratic Republic of the Congo, Dominica, Dominican Republic, Egypt, Fiji, France, Georgia, Germany, Ghana, Greece, Grenada, Guyana, Hong Kong, Hungary, Indonesia, Iran, Iraq, Israel, Italy, Jamaica, Jordan, Kenya, Kuwait, Latvia, Lebanon, Libya, Lithuania, Macedonia, Malaysia, Mexico, Moldova, Myanmar, Netherlands Antilles, Netherlands, Nigeria, Oman, Pakistan, Peru, Philippines, Poland, Romania, Russia, Saba, Saint Kitts And Nevis, Saint Lucia, Samoa, Saudi Arabia, Serbia, Sierra Leone, Singapore, Sint Eustatius, Sint Maarten, Slovakia, Somalia, South Korea, Spain, Sri Lanka, Sudan, Sweden, Syria, Tanzania, Thailand, Trinidad And Tobago, Turkey, Uganda, Ukraine, United Arab Emirates, Uzbekistan, Venezuela, Vietnam, Yemen, Zambia and Zimbabwe. (c) Professional Linguistic Assessments Board Exam. (d) Medical Council of Canada Exam. (e) United States Medical Licensing Exam. (f) New Zealand Registration Exam. (g) General Medical Council of the United Kingdom Accreditation. (h) Medical Council of Ireland Accreditation. Source: Australian Medical Council administrative data, 2013
Canada	0	18	0	0	0	0	18	24	5
India	45	5	5	1	0	0	64	57	25
Ireland	0	0	0	0	0	129	149	139	90
South Africa	2	2	0	0	0	0	6	3	0
United Kingdom	0	0	0	0	871	1	941	945	342
USA	0	1	18	0	0	0	22	22	6
Other(b)	62	52	14	11	3	0	187	152	52
Total	109	78	37	12	874	130	1,387	1,342	520

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Standard Pathway

Doctors who are not eligible for either the Competent Authority or Specialist pathways are assessed through the Standard Pathway. The Standard Pathway has two alternative processes leading to the Australian Medical Council (AMC) Certificate.

• Standard Pathway (AMC examinations). Assessment is by examination only – the AMC Multiple Choice Questionnaire (MCQ) and the AMC clinical examination.
• Standard Pathway (workplace-based assessment). Assessment is by examination and workplace-based assessment – the AMC MCQ examination and workplace-based assessment of clinical skills and knowledge by an AMC-accredited authority.

A PESCI is also required for all international medical graduates applying for general practice positions and for some international medical graduates in hospital positions.

Successful completion of the assessment requirements leads to the awarding of the AMC Certificate.

In 2012, there were 1,656 international medical graduates (Table 5.5) who passed the MCQ (57.5% of attempts). This was a slight increase from 52.2% last year.

The number of international medical graduates who passed the clinical examinations also increased from 836 in 2011 to 964 in 2012. This was 49.7% of attempts.

Table 5.5: International medical graduates: Applications assessed through Standard Pathway, 2012^(a)

Country of training	MCQ exam attempts	MCQ exam passes	Clinical exam attempts	Clinical exam passes
(a) Data covers the period 1 January 2012 to 31 December 2012. (b) Other in MCQ Exam includes: Afghanistan, Algeria, Argentina, Austria, Bahrain, Belarus, Belgium, Bolivia, Bosnia And Herzegovina, Brazil, Bulgaria, Cayman Islands, Croatia, Cuba, Curacao, Czech Republic, Democratic Republic Of The Congo, Dominica, France, Georgia, Germany, Ghana, Grenada, Guatemala, Hungary, Ireland, Italy, Japan, Kazakhstan, Kenya, Kosovo, Kyrgyzstan, Latvia, Lebanon, Libya, Lithuania, Macedonia, Mauritius, Mexico, Netherlands, Norway, Oman, Palestinian Authority, Peru, Poland, Portugal, Rwanda, Saint Kitts And Nevis, Samoa, Serbia, Seychelles, Singapore, Slovakia, Slovenia, South Korea, Spain, Sudan, Sweden, Switzerland, Syria, Taiwan, Tajikistan, Tanzania, Thailand, Trinidad And Tobago, Tunisia, Turkey, Uganda, United Arab Emirates, United Kingdom, USA, Uzbekistan, Venezuela, Yemen and Zambia. (c) Other in Clinical Exam includes: Afghanistan, Argentina, Austria, Azerbaijan, Belarus, Belgium, Bolivia, Bosnia And Herzegovina, Brazil, Bulgaria, Cambodia, Canada, Cayman Islands, Chile, Costa Rica, Czech Republic, Czechoslovakia, Democratic Republic Of The Congo, Dominica, Dominican Republic, El Salvador, Estonia, France, Germany, Ghana, Greece, Grenada, Hong Kong, Hungary, Japan, Kazakhstan, Kyrgyzstan, Latvia, Lebanon, Libya, Malta, Mauritius, Mexico, Moldova, Netherlands, Oman, Paraguay, Peru, Poland, Portugal, Saint Kitts And Nevis, Samoa, Serbia, Seychelles, Singapore, Slovakia, Somalia, South Korea, Sudan, Switzerland, Syria, Taiwan, Tanzania, Thailand, Trinidad And Tobago, Turkey, Uganda, United Arab Emirates, United Kingdom, USA, USSR, Uzbekistan, Venezuela and Yemen. Source: Australian Medical Council administrative data, 2013
Bangladesh	201	121	137	62
China	121	63	67	45
Colombia	27	14	18	10
Egypt	97	51	59	27
Fiji	32	12	17	8
India	419	244	382	182
Indonesia	35	11	13	4
Iran	202	123	128	75
Iraq	78	48	40	22
Jordan	22	10	17	12
Malaysia	46	34	28	15
Myanmar	163	121	108	55
Nepal	43	23	22	9
Nigeria	98	51	50	23
Pakistan	325	185	222	117
Papua New Guinea	7	3	9	2
Philippines	146	50	113	40
Romania	18	11	6	3
Russia	108	43	48	21
Saudi Arabia	7	4	0	0
South Africa	32	23	37	20
Sri Lanka	228	179	165	92
Ukraine	49	21	24	8
Viet Nam	11	7	2	1
Zimbabwe	18	12	17	11
Other(b)(c)	348	192	212	100
Total	2,881	1,656	1,941	964

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Assessment of Overseas Trained Specialists

Prior to 1990, all overseas trained specialists seeking registration in Australia who did not hold a recognised primary medical qualification were obliged to pass the AMC examination and obtain general registration before they could be registered to practise as a specialist. Also, before 1990 only two states (Queensland and South Australia) had separate specialist registers.

In 1991 the Australian Health Ministers Conference (AHMC), in anticipation of the implementation of the mutual recognition scheme, approved a process for overseas trained specialists to be assessed by the relevant specialist medical college in Australia against the standards for an Australian trained specialist in the same field of specialist practice. If the qualifications and relevant experience of the applicant were assessed as substantially comparable to an Australian trained specialist, he/she could apply for registration limited to the field of specialty.

In consultation with the former state and territory medical boards and colleges, it was subsequently agreed that the specialist assessment process should not be seen as a backdoor to specialist training in Australia. For this reason it was resolved that any overseas trained specialist who required more than two years of further supervised training to meet the required standard for substantial comparability (equivalence to an Australian trained specialist) would be assessed as ‘not comparable’ and would be required to sit the AMC examination and obtain general registration.

A national assessment process for Area of Need specialists was not resolved until 2002, when agreement was reached on a separate pathway for the assessment and registration of overseas trained specialists in Area of Need positions. This involves an assessment against a position description that defines the levels of clinical responsibility, supervision and specific clinical skills required for a particular position. The relevant specialist college assesses the individual against the position description, rather than against the standards required by the medical college for a (fully recognised) specialist.

A number of colleges have agreed to combine their Area of Need and full comparability assessments, so that the applicant (and the Medical Board of Australia) can be advised of the additional steps required to achieve substantial comparability at the same time as he or she is being assessed for the Area of Need position. To date some nine colleges (RANZCOG, RACP, RCPA, ACD, RACS, RANZCO, RANZCP, ACRRM and RANZCR) have agreed to undertake the combined assessments of overseas trained specialists.

All specialist applications are administered through the AMC and assessment of comparability to Australian standards is carried out by the relevant specialist college. Applicants who do not meet the requirements for specialist assessment are required to undergo assessment through one of the non-specialist pathways.

Standard Specialist Assessment

Overseas trained specialists applying for comparability to an Australian trained specialist must have completed all training requirements and be recognised as a specialist in their country of training before applying under the specialist pathway for assessment of comparability.

There are three possible outcomes of assessment:

• substantially comparable;
• partially comparable, requiring up to two years upskilling to reach comparability; and
• not comparable.

The majority of medical colleges will allow applicants who are considered substantially comparable to Australian trained specialists to gain fellowship without requiring an additional examination.

International medical graduates with specialist qualifications or specialists-in-training are eligible to apply for general registration under the Competent Authority Pathway (if eligible), in addition to applying for specialist registration through the Specialist Pathway.

In total there were 2,346 overseas trained specialists whose applications to be recognised as a specialist in Australia were being processed in 2011. While these are primarily applicants who applied the previous year, this figure also includes a number of applicants who were required to submit additional documentation or undergo further training to confirm their eligibility.

Table 5.6 shows that 524 overseas trained specialists had their applications approved (that is they were deemed to be substantially comparable) and a further 353 were deemed as requiring further training and/or examinations (that is partially comparable).

Table 5.7 presents data on the countries in which approved applicants were trained. More than half (311 or 59.4%) of all overseas trained specialists, who have had their applicants approved in 2012 were trained in the United Kingdom and Ireland. This is 97 specialists more than in 2011 (214 or 45.5%). The next largest number of specialists in 2012 came from India (61 or 11.6% of all approved applicants).

Table 5.6: Specialist assessment process by medical specialty, 2012

Medical specialty	Initial Processing	College Processing	Substantially Comparable	Partially Comparable	Not Comparable	Withdrawn	Total	Proportion of total (%)
Source: Australian Medical Council administrative data, 2013
Adult medicine	105	91	65	63	11	49	384	16.4
Anaesthesia	45	22	41	38	16	20	182	7.8
Dermatology	6	1	7	7	1	0	22	0.9
Emergency medicine	16	7	14	21	3	4	65	2.8
General practice	403	29	188	29	2	6	657	28.0
Intensive care	5	5	2	7	7	1	27	1.2
Medical administration	1	0	0	0	0	0	1	0
Obstetrics and gynaecology	52	10	41	8	4	45	160	6.8
Occupational and environmental medicine	2	1	0	2	0	1	6	0.3
Ophthalmology	18	13	9	10	6	5	61	2.6
Oral and maxillofacial surgery	0	0	1	1	0	0	2	0.1
Paediatrics and child health	49	33	23	21	10	29	165	7.0
Pain medicine	3	0	0	1	0	0	4	0.2
Palliative medicine	0	0	1	0	0	3	4	0.2
Pathology	28	3	16	25	1	2	75	3.2
Psychiatry	29	2	40	38	3	4	116	4.9
Public health medicine	2	0	0	2	4	3	11	0.5
Radiology	28	6	34	41	4	4	117	5.0
Rehabilitation medicine	3	2	1	3	0	1	10	0.4
Sexual health medicine	2	0	1	0	0	0	3	0.1
Sport and exercise medicine	1	0	0	0	0	0	1	0
Surgery	89	68	40	36	30	10	273	11.6
Total	887	293	524	353	102	187	2,346	100.0

Table 5.7: Substantially comparable specialist applications by country of training and medical specialty, 2012

Medical specialty	Canada	India	New Zealand	South Africa	United Kingdom and Ireland	United States of America	(a)Other	Total	Proportion of total (%)
(a) Other includes: Argentina, Belgium, Brazil, China, Czech Republic, Egypt, Germany, Hong Kong, Iran, Israel, Italy, Jordan, Macedonia, Malaysia, Netherlands, Pakistan, South Korea, Spain, Sri Lanka, Switzerland, Taiwan and Zimbabwe. ource: Australian Medical Council administrative data, 2013
Adult medicine	3	11	0	2	37	0	12	65	12.4
Anaesthesia	1	6	0	3	21	0	10	41	7.8
Dermatology	0	1	0	0	3	0	3	7	1.3
Emergency medicine	2	0	0	0	11	1	0	14	2.7
General practice	5	0	32	2	149	0	0	188	35.9
Intensive care	0	0	0	0	0	0	2	2	0.4
Obstetrics and gynaecology	2	6	0	2	16	4	11	41	7.8
Ophthalmology	0	2	0	1	5	0	1	9	1.7
Oral and maxillofacial surgery	0	0	0	0	1	0	0	1	0.2
Paediatrics and child health	0	3	0	4	9	0	7	23	4.4
Palliative medicine	0	0	0	0	1	0	0	1	0.2
Pathology	0	6	0	1	2	0	7	16	3.1
Psychiatry	0	14	0	1	17	2	6	40	7.6
Radiology	0	7	0	4	14	2	7	34	6.5
Rehabilitation medicine	0	0	0	0	0	1	0	1	0.2
Sexual health medicine	0	0	0	0	1	0	0	1	0.2
Surgery	0	5	0	6	24	1	4	40	7.6
Total	13	61	32	26	311	11	70	524	100.0

Area of Need Specialist Assessment

Overseas trained specialists applying for an Area of Need assessment must also have completed all training requirements and be recognised as a specialist in their country of training. When assessing applicants for suitability for Area of Need positions, medical colleges will determine at the same time (or soon thereafter) what is required to meet standards for fellowship.

An Area of Need applicant is always assessed against a position description. The position description together with the qualifications, training and experience of the applicant will determine the level of risk and the level of supervision or further assessment required.

Specified Specialist Training

Applicants who wish to enter Australia for specified specialist training will require registration by the relevant medical board following advice from the relevant specialist medical college. This provisional registration allows applicants to undertake training or to obtain experience in Australia not available in their country of training for a short period (normally up to one year), but can in exceptional circumstances be extended to three years.