International medical graduates mandated to practise in rural Australia are highly unsatisfied: Results from a national survey of doctors
Introduction
Inadequate access to medical practitioners for rural populations is a significant problem that affects most countries worldwide [1]. Rural communities in higher-income countries too are characterised by a shortage of medical practitioners [2], [3], and by ongoing difficulties associated with recruiting and retaining locally-trained graduates practise in to rural areas [1], [4]. Effective health service delivery to these vulnerable populations continues to be problematic and increasingly reliant on policy interventions.
Health policies to address rural and remote workforce shortages include financial incentives, non-financial incentives and compulsory service programs. More than 70 countries have some kind of compulsory service program, which most commonly involves graduates working a short compulsory period in underserved areas [5]. Although there is little empirical evidence available regarding compulsory service, a number of potential negative effects have been identified on theoretical grounds [6]. First, there may be political difficulties in imposing restrictions or requirements on doctors, based on considerations of autonomy and justice. While such programs are intended by governments to address health inequities and ensure access to doctors in underserved areas, they are also an imposition on the professional independence and freedom of choice of the individual doctor [5], [7]. The health professions themselves are among the most vocal critics of such programs, whilst governments argue that such requirements are reasonable in the context of public investment in doctors’ education and training. Second, compulsory service may also decrease the likelihood of working in underserved areas voluntarily once the period of required service has ended. Finally, compulsory service programs may contribute to a perception of decreased attractiveness of jobs in the designated locations, leading to an ongoing cycle of workforce shortages rather than putting long-term solutions in place [6].
Australia has a related ‘condition of service’ program, used since the late 1990s, which dictates that most International medical graduates (IMGs) are initially restricted for up to 10 years to practise only in specific rural locations [8]. Under this policy (specifically Section 19AB of the Health Insurance Act), IMGs can only access private practice subsidies if they work in a government-designated district of workforce shortage area, where the undersupply of doctors is most acute. A large reason for the introduction of this policy was in fact to reduce the perceived excess of general practitioners (GPs) in metropolitan areas [9], [10], [11]; however, through this policy and ongoing difficulties attracting local graduates into rural areas, the number of IMGs has increased to around 41% of all doctors working in rural Australia [8].
Similar policies are employed in Canada and the United States of America (USA). In the USA, IMGs in training programs are granted J-1 visas with a proviso that they must return to their country of origin for at least 2 years upon completion of their education. However, the J-1 visa waiver program enables these IMGs to remain in the USA on the agreement that they work in a designated Health Professional Shortage Area (rural) for at least 3 years [12], [13]. In Canada, most IMGs start practising under provincial licences, which can only be used in rural areas experiencing a workforce shortfall until they become fully licenced [2], [14]. Available evidence suggests that retention of IMGs in rural areas beyond the timeframe of both these programs is poor [15], [16].
Australia's IMG 10-year moratorium sits within a context of both an expectation of national medical workforce self-sufficiency, and a global consensus on ethical international recruitment [17], [18]. Many first world countries currently rely on significant numbers of IMGs to augment their local supply of health professionals; however, the ethics of actively recruiting IMGs to these countries, particularly from poor countries who can least afford to lose their own health professionals, is highly questionable [19], [20]. Thus, the potential benefits of Australia's IMG 10-year moratorium in meeting population health needs remain in tension with the autonomy and freedom of choice of individual doctors, and unresolved questions about their effects on long term workforce retention in rural and remote areas.
One factor which is known to be critical in workforce retention is satisfaction. Both non-professional and professional satisfaction is central to rural medical workforce recruitment and represents a sentinel indicator of retention [21], [22], [23]. Retaining restricted IMGs in rural locations is likely only if they experience considerable non-professional and professional satisfaction [23], [24]. Several Australian studies have identified specific difficulties experienced by IMGs, including community integration, which can significantly impact on their satisfaction [25], [26], [27]. Moreover, in contrast to IMGs who can choose their practice location, restricted IMGs have limited autonomy relating to their work location and work activity. It seems likely therefore, compulsory service policies such as the 10-year IMG moratorium will be associated with lower satisfaction. To date, only one Australian government report has examined the satisfaction of IMGs, without any stratification of results by ‘restriction status’ or rurality [28], whilst another study examined the professional satisfaction of GPs by rurality, without any stratification by IMG or restriction status [29].
Internationally, no published research has investigated the association between restriction status of IMGs and their satisfaction. The aim of this paper is to investigate the satisfaction (both professional and non-professional) of IMGs in their current location using Australian data, primarily distinguishing between those who are restricted to practise only in an area of workforce shortage and those who are free to choose their practice location. We hypothesise that satisfaction is likely to be less for those IMGs who are restricted to practise in particular locations, in addition to any effect of working in smaller locations. We contend that these locational restrictions are likely to exacerbate any other potential problems confronting IMGs, such as language and communication difficulties, working within a different health system, working in isolation from their cultural peers, and difficulties getting their home country qualifications recognised and attaining full accreditation.
Section snippets
Methods
This paper uses data from the Medicine in Australia: Balancing Employment and Life (MABEL) study, a large longitudinal panel survey of Australian doctors who participate in annual waves of data collection. The primary aim of the MABEL study is to investigate labour supply decisions and their determinants among Australian doctors. We report results for GPs and GP registrars from data collected in Wave 2 between June and December 2009 (n = 3502). Wave 2 questionnaires can be accessed from the
Results
Twenty-seven per cent (940) of the 3502 GPs were identified as IMGs. There were proportionally more IMG respondents in rural areas, ranging from 22% in metropolitan and regional centres to 36–38% across all sized rural communities (<50,000 residents). Almost half of all IMG respondents (n = 440, 47%) identified themselves as being ‘restricted’ in their work location, with the proportion rising to 60–70% for IMGs across all sized rural communities (<50,000 residents). In our cohort, rural
Discussion
This is the first study to examine the effect of mandating IMGs to practise in rural areas of workforce shortage. We investigated the satisfaction of IMGs, distinguishing between those who are ‘restricted’ and those who are ‘unrestricted’ in their choice of practice location. Our results show clearly that these two groups exhibit significantly different patterns of non-professional and professional satisfaction. Additionally with regards to non-professional aspects, our study reveals the
Conclusion
This study has clearly shown that IMGs currently mandated to practise in rural communities are significantly unsatisfied with respect to both professional and non-professional aspects. By separating this cohort from unrestricted IMGs, and accounting for community size and other likely explanatory variables, we have demonstrated a strong association between practice restriction of IMGs in Australia and reduced job and social satisfaction. It follows that the long-term retention of
Acknowledgements
We thank the doctors who continue to give their valuable time to participate in MABEL. Thanks to the other members of the MABEL team for their support, in particular Guyonne Kalb (chief investigator) from the Melbourne Institute of Applied Economic and Social Research, University of Melbourne.
This work, part of the MABEL study, was supported by Australia's National Health and Medical Research Council through both a project grant (454799) and Centre of Research Excellence grant (1019605), and by
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