Doctors of the Second Freshness

“The fish was of the second freshness,” lamely explained the barkeeper.

“My dearest friend,” responded Maestro Voland in his brassy voice, “you were grievously misinformed by someone. I can assure you, there is no such thing as a fish of the second freshness. Fish freshness as it is could exist in one state and one state only— that is in the first, which is the same as the last and the only one.”

 —Bulgakov, The Master and Margarita

Why do we have not enough doctors? Good work, good pay, good status, but still—there are not enough of them to go around. The shortage is hitting metropolitan areas now, not just rural and remote ones. It might take up to two weeks, sometimes longer, to see your GP.

Since my arrival in Australia in 1978 I have seen wild gyrations in the numbers of medicos in this country. The only constant has been the policies designed to protect local graduates from competition, formulated to keep Overseas Trained Doctors (OTDs), or Inter-national Medical Graduates, as they are euphemistically called now, under control. These policies and associated state legislations result in an intentional and avoidable shortage of doctors.

In this essay I will attempt to make a case from the point of view of a doctor of the “second freshness”. That is, from the point of view of an overseas trained doctor, an OTD, who has worked in Australia since 1981, continues to treat patients, but has not passed his Australian exams; who is vocationally registered, has a fellowship of an Australian college, has treated thousands of Australians, but still has to ask for registration, cap in hand, every year; who can be thrown out of the workforce in the blink of a bureaucrat’s eye.

The shortage of doctors is a combined achievement. It should be credited to the Australian Medical Council (AMC), the Australian Medical Association (AMA), state registration boards, and professional colleges. This credit should be shared by the medical bureaucracy and the nation’s politicians, living in a symbiotic relationship with the leadership of the medical fraternity. As long as this symbiosis exists, the country will suffer from a lack of doctors. A powerful, unrelenting medical lobby, acquiescent politicians and self-serving bureaucrats combine to protect the market for local graduates.

What’s Wrong with Being a Doctor?

The answer to this question is both complex and simple. The job is hard, physically and emotionally exhausting, sometimes debilitating. The stress of being responsible for human lives causes high anxiety levels. It is also relatively economically unrewarding, considering how long it takes to qualify. Patients get furious if they receive a bill and outraged if they feel unloved. Governments interfere in clinical decision-making by manipulating Medicare rebates. The threat of litigation in case of a mistake is ever-present.

Show me a doctor who has not wanted to get out of medicine at some stage and I will show you a fresh graduate. And yet, there is something in all of us suckers that makes the practice of medicine irresistible. Is it altruism? Are we running away from our own problems while helping others? Is it obsessiveness? Yes, to a degree—I would prefer to be operated on by an obsessive doctor. Is it enjoyment of the power of the transferential and counter-transferential relationship with a patient? Could be—where else could one experience such emotional closeness with a stranger, the drama of a confrontation, the bliss of resolution and the despair of failure multiplied by the confounders of guilt, anger, exhilaration, pathos and the triumph of gifting a life?

Anyway, Australia is short of doctors. And it’s not an exclusively Australian problem. The entire developed world is much the same. Australia competes for overseas medical graduates with other developed nations in the ever-shrinking market. The attractiveness of overseas trained doctors for the host country takes the form of a considerable budgetary saving—no need to spend a lot of money to train a doctor. Our failure to make medical immigration less applicant-friendly than other developed nations might cost us dearly in the future.

The lack of doctors could be compared with the acute shortage of priests and nurses. Both are caring professions; both are overloaded with the necessity of absorbing suffering as a precondition of competent professional functioning. The ability (and necessity) to absorb a patient’s suffering comes with a high emotional price—burnout, anxiety, family breakdowns, missing out on one’s children growing up, dissatisfaction with one’s quality of life, to name just a few.

Those most closely associated with the emotional overload of their charges, the psychiatrists, are the ones who most frequently suicide—after the anaesthetists and the dentists. It is a consensus in the medical fraternity however, that the ease of access to lethal drugs is the reason why anaesthetists and dentists have higher places on this macabre ladder.

Why Do Locals Not Want to Be Doctors?

I taught undergraduates in Dandenong Hospital for a number of years. In recent years I noticed that despite relatively stable student group sizes there were fewer Anglo-Celtic names and faces. They are being replaced by children of migrant families from Eastern Europe, the Indian subcontinent, South-East Asia, and overseas full-fee-paying students. On the list of interns at the casualty department it is the same. Irish, English, Welsh and Scottish names and faces are in such small numbers as to be insignificant.

The fun of teaching these bright-eyed kids, the recurring delight of shared learning, was as exhilarating as always, no matter where my students were from. However, I was mystified—why were Anglo-Celtic kids not represented? It seemed that they simply did not wish to go into medicine any more. Instead, these kids, wisely, were looking for careers which were less demanding, more lucrative, less dependent on the whims and human failings of their mentors, and free from the demands of an ungrateful public; careers that would give them a better lifestyle, a better balance of public and personal, and would not take fifteen or twenty years of penury before they reached their professional goal.

I do not believe the myths about the higher intellectual capacities of migrant kids, their better work ethic or better family support. Anglo-Celtic kids are simply better informed. What are we going to do when kids from migrant families come to the same conclusion?

Recently, a lot of noise was made of the fact that Australians are the second-longest-lived people on the planet. The implication was that this longevity is due to the exceptional quality of Australian health care. I suspect it may be a combination of contemporary health care and the improved lifestyle choices Australian people are making. After all, despite the enormous amount of money going into Aboriginal health, and the dedication of the people working there, the statistics remain appalling. Smoking, alcoholism, obesity, diabetes, hypertension, cirrhosis and depression add up to early death, never mind the brilliance of a doctor.

Self-Inflicted Injury?

The dearth of doctors in Australia appears to be a self-inflicted injury, worldwide shortage of medical graduates notwithstanding. The legislation regulating the admission to medical practice leaves the regulation of the numbers of OTDs in the hands of people with a vested interest in keeping these numbers down. This legislation protects a market monopoly of local graduates under the guise of public interest, and has a direct bearing on the shortage of doctors. This is the end result of the longstanding co-operation between the medical lobby and politicians, who are keen to be portrayed as the defenders of quality care. The persuasive power of the medico-political lobby was amply demonstrated by the de facto acquiescence of the Australian Competition & Consumer Commission, which was successfully sold the “public interest” myth to the detriment of the very reason of its existence—defeating anti-competitive practices.

My own experience of training in the College of Psychiatrists, and anecdotal evidence available from my long-suffering colleagues, indicate that the specialist colleges are not particularly interested in training an adequate number of specialists, beyond paying lip service to the sacred collegial duty to train registrars. It is a large and personally painful topic. At least two registrars that I know of committed suicide during their training, several attempted it, two suffered psychotic breakdowns, and the number of divorces is so high that it is now accepted as part of the training.

Articles in the popular press blame the government for not funding additional accredited training places. These articles insinuate that the colleges are not to be blamed, that the colleges are whiter than snow in their relentless pursuit of excellence among their trainees. Well, pardon me for being a wet blanket, but the image of a professional college as a collection of angels united by the pursuit of humanity’s happiness does not, somehow, ring true. Take the overall rates of passing college examinations (very low) and the considerable differences within these rates of passing between the local (higher pass rate—first freshness) and the overseas (lower pass rate—second freshness) graduates.

The abysmal pass rate of overseas-trained psychiatrists is not a reflection of inferior training—I have met outstanding psychiatrists who consistently failed their college exams. They are indispensable in public psychiatry, where most of the locally-trained psychiatrists have no desire to be involved full-time. The locally-trained psychiatrists would rather quietly sail along the private pond of the worried well, without the trauma associated with the public psychiatry of the destitute, drug-impaired and potentially aggressive. I suspect that this situation is the same in other colleges.

My experience of psychiatric training in Melbourne hospitals supplied me with a wealth of evidence of the almost total lack of interest by those entrusted with preparing their charges for examinations. The so-called accredited training, apart from bursts of cramming before examinations, is mostly limited to useless and ritualised journal clubs. These lunchtime meetings are supplied with food paid for by the pharmaceutical companies. Doctors in public health are paid so little that the savings from a free lunch are a serious consideration. The material discussed at a journal club is useless in the passing of fellowship exams.

The written feedback after an unsuccessful examination attempt is, apart from the arrogance and self-aggrandisement by its authors, couched in vague parables, hints and hidden pearls of wisdom. These pearls are impossible to dig out from the pages of drivel.

Seniors openly regard junior medical staff as raw material for the battlefields of emergency departments, and as bodies to fill the spaces on the night rosters, not as future colleagues. Their human needs and limits are routinely regarded with contempt and indifference. The contempt shown by the senior staff members towards their junior colleagues is duplicated by the administrative and nursing staff, as well as the public. The trainees routinely work more than twenty-four hours without sleep. Thirty-two-hour shifts are not considered extraordinary. Imagine being attended by one of those sleep-deprived registrars in emergency. Imagine one of those sleep-deprived registrars driving home after a shift.

There is also an unspoken expectation to be an adherent of the left-leaning orthodoxy. A junior or trainee is supposed to sneer at Americans, condemn Israel at every opportunity, disparage the anti-terrorist actions of the free nations, and support those downtrodden and oppressed by capitalism. If you do not, you have as much chance of getting through as the proverbial rich sinner through the eye of a needle.

The Gatekeepers

The statutory bodies designed to protect the monopoly of local graduates, the state medical boards, charged with the application of the Medical Practice Acts of the various states, are highly bureaucratised organisations. These medical boards are not answerable to anyone that I know of. Their dealings and methods are, as a rule, as opaque as if they were designed in the Soviet Union. Medical boards are contemptuous of the people they deal with and routinely ignore correspondence from applicants for months on end. They are so successful in creating an enormous backlog of paperwork, they are sometimes late with certificates of registration, leaving hapless doctors unable to practice, deprived of a livelihood and humiliated, and the awe of the mysterious powers of the medical board enhanced.

The Medical Board of Victoria, for example, openly publishes the names and circumstances of doctors under investigation and the verdicts. This cruel, extrajudicial and, I suspect, illegal practice of shaming does not cause a murmur of a dissent.

In my own case, despite regularly writing to a state medical board, I did not receive a relevant response for six months. It took a letter from the AMA, an organisation traditionally hostile to OTDs, to get a curt and abrupt response. What could be worse than an angry and vindictive bureaucrat, with a totalitarian streak, who feels protected by legislation from having to behave in a manner acceptable in civilised society? Which other organisation in Australia would treat its correspondents with such contempt?

The Victorian Medical Board had no difficulty arbitrarily deregistering me, for no professional or ethical fault of my own, after working in Australian medicine since 1981 in the most difficult and the least rewarding areas of the Australian public health system. No organisation in the country would be prepared to take on a medical board. The Administrative Appeals Tribunal, which in theory is able to do so, is loath to take on the litigation power of a medical board.

I remember my dealings with South Australian, Victorian and Tasmanian medical boards as deeply traumatic experiences, encounters of such humiliating and contemptuous intensity that I was left wondering—was it an Australian organisation, or an English-speaking Soviet-run office? If these people were so rude and derisive with a man who had spent almost thirty years working in Australia, I shudder to think of their attitude to a new migrant doctor. Or were they so offensive precisely because I had worked so long and represented a threat to the ordered world of bureaucratic ordnung?

Not to be outdone, the New South Wales Medical Board, by the intransigence, derision and contempt in which it held overseas-trained doctors, provoked the famous hunger strike in Sydney. Imagine twenty to forty doctors on a public hunger strike, wrapped in sleeping bags, outside the Medical Board building, and you might understand the depth of despair these people felt.

Once the Victorian Rural Workforce Agency recruiters were asked, Why would doctors from stable and prosperous countries wish to come to Victoria? The bright sparks from the agency answered: to experience our unique nature and lifestyle. This agency charges $1300 for a preliminary exam, which is before AMC or RACGP (Royal Australian College of General Practice) examinations, to assess a doctor’s knowledge and suitability for a country practice. Who in his right mind would travel around the world from, say, Holland, to sit yet another exam for which he has to pay that much? On the other hand, a doctor from a non-stable and non-prosperous country—where would he get this kind of money? Result—a screaming need for doctors in rural Victoria. This kind of agency is, in effect, an obstacle to recruitment of OTDs. It is effective in preventing medicos going to rural areas, instead of working to facilitate this process. This creates an outflow of eligible doctors to Queensland, where registration procedure, while still insanely difficult, is a lesser evil.

Then, of course, the OTD has to fork out the fee for the RACGP examination. The RACGP fellowship, which is required in order to gain registration, charges just under $6000 for its examinations.

The fear of competition and the ingrained antipathy towards OTDs are so strong, and the procedures of registering them are so complicated, that proposals to allow nurses instead of doctors to treat patients have now borne fruit. Australian nurses will have the right to dispense treatment to the Australian public in preference to OTDs. Russians have a description of such activity—pissing against the wind.

However aggressive, uncivil and derisive medical boards are, they are just a reflection of the prevailing culture of contempt and hostility most local graduates feel compelled to hold towards their overseas colleagues. It appears to be a sort of lodge recognition sign.

Inculcation of Fear and Conformity

Imagine a real or mock exam for medical trainees—students or postgraduates. There are so-called stations with real or actor-patients, where different problems are presented, assessed, diagnosed, and proposed treatment is expounded. To indicate the time to change to the next station an examination assistant rings a bell. The sight of a group of highly trained and extremely anxious candidates getting up as one and unerringly proceeding to the next location inevitably brings to mind a group of Pavlovian dogs.

Not many people recognise, however, that Pavlov described two sub-groups of dogs. The larger one, about 80 per cent of the group, were amenable to conditioning by fear, while the smaller sub-group refused to be conditioned. The examination process, aimed at the creation of uniform absorption, synthesis and extraction of information, leading to a creation of a monolithic body of knowledge and its expression, cannot accommodate this 20 per cent. They must be eliminated if the process is to achieve its aim. Pavlovian theory was used widely by totalitarian states to achieve conformity.

Paper Sea

Medical boards do not refuse OTDs registration outright. After all, they do need suckers to work in the unpopular, poorly paying jobs and locations. But only after endless hurdles—to impress, to frighten, to control.

The obsessiveness and ritualisation of this process are pathological. When I added up the steps an overseas doctor has to go through before all his or her documents would be deemed complete by a medical board, I was shocked to realise that an OTD needs more documents for temporary registration in Australia than Soviet Jews needed to emigrate from the USSR to Israel. In one state, a doctor, even a locally trained one, has to go through a questionnaire longer than the ones the Soviets designed to discourage people from travelling abroad.

Medical bureaucracy in Australia has gone mad. To justify their existence and funding, apart from keeping OTDs out they need to generate paper. After being a part of this process, this is the only rational conclusion I could reach. The endless requirements, duplication of functions, loss of time and inflicted stress—it all adds up to inefficiency, self-service and navel-gazing. Every year they require more papers, more evidence, and more confirmations.

In the end, however, if you haven’t given up, they will issue your registration—for a period, mostly up to four years. Every year they will require more paper, such as evidence of proceeding towards an Australian qualification, in effect allowing you to work before exams are completed, theoretically endangering your patients. These exams are good for exercising control and have little to do with the quality of a doctor’s work.

An OTD who wishes to be registered permanently has to forget about everything else but studies, including his patients. When you are dealing with such a doctor, what do you think this doctor cares about more—your sore throat or his exams? The sad part of it is that after these exams most doctors revert to what they learned in their medical infancy anyway.

There is another reason why OTDs are required to sit these exams, apart from the need for control by fear. They are lucrative. OTDs are required to pay more than $4000 in fees to sit a combined AMC examination, which consists of multiple-choice and clinical components. Every failed attempt means that the fee is charged again, so repeated failures generate more income for the AMC. If there is a withdrawal, most of the fee is forfeited. Then there are spin-offs. There is a requirement to get a language certificate—more money to pay—even if you have spoken English for a long time and published in English. Do you wish to study as a part of the pre-exam group? Pay up. There is quite an industry based on the anxiety and misery of OTDs, those doctors who could have relieved a national shortage.

After all this exhausting preparation the candidates’ overwhelming anxiety reduces their ability to retrieve the required information, decreasing the objectiveness of the exam results. These are the exams which will determine your fate and the fate of those you love. After each attempt I was physically sick for weeks.

Meanwhile, Australian medical boards grant permanent and unrestricted registration to an Australian graduate who advocates the euthanasia of patients.

Let It Pass, Please!

Now imagine the early morning conference in any hospital in the land. The departmental meeting would consist of, say, twenty to forty people. An outside observer would notice the difference between two groups—local and overseas graduates. Locals would be active and outspoken, laughing, joking, discussing yesterday’s party or footy game or whatever. Overseas grads would be quiet, thinking—please, let it not be me. Let it pass this morning. You see, it is quite acceptable to publicly chastise an overseas graduate, but not a local one. This is despite the fact that most of the unpopular and high-risk jobs in hospitals, prisons, Aboriginal health centres, and rural and remote areas are handled by overseas graduates. Local graduates are not so keen to do these jobs. Apart from the conditions, the pay is significantly lower.

Without the overseas doctors, most of the public health system would simply collapse. So, how do you control this crowd and prevent them from recognising their collective power? By fear.

Even the jobs the Australian graduates do not want are not available permanently. Say there is medical officer position at a psychiatric hospital. It is demanding and sometimes dangerous work. (Doctors do get assaulted and killed by their patients. The number of assaults in emergency departments is increasing.) This position is filled by an OTD. Despite her brilliant performance and excellent references and the screaming need to have this position filled, a medical board will cancel her registration if she has not managed to pass an examination run by the AMC or a specialist college. Logic would dictate: she does the job well, it is a difficult position to fill, she gets paid a junior rate—why not let her continue? This is not how a medical board thinks. Medical boards introduce arbitrary terms, two years, four years or whatever, and if this doctor had not passed an exam they would deregister her. Is she incompetent? No. Is she assaulting her patients? No. Why was she deregistered? It is a medical board’s decision.

So, a medical board will throw a doctor out, withdraw her registration, and wait for another to come along. In the meantime, patients are without a medical officer, or these patients would be added to the already overloaded list of another OTD afraid to open his mouth. Local graduates, however, would not be bound by such considerations. For the locals, training can take as long as it takes, the medical boards set no time limits.

What happened to the deregistered doctor? Who cares! There are so many more where she came from. And so, today you are a doctor, tomorrow you are a taxi driver or a cleaner. And another article appears in a newspaper about the dearth of doctors.

Why do they do it? The official line is that it is to protect the Australian public from incompetent overseas doctors. I beg to differ. I worked in Australia as a doctor for thirty years without having passed an AMC exam. How come? The answer is simple—my Australian-trained colleagues, who, as a rule, are personally decent people, having seen me working, go in and bat for me.

Nevertheless, as a long-term observer, I am far from overwhelmed by the level of competence some local graduates demonstrate. Most Australian-trained doctors are decent and work tirelessly for the benefit of their patients. But, as in any profession, there are some of questionable standard. Neither, I should add, is passing the AMC examinations a guarantee of excellence. I have seen astonishing incompetence among AMC graduates.

Maintenance of professional standards needs to be done, but not as it is done now. The debilitating, exhausting and traumatising examination process is the biggest obstacle preventing the country from being adequately supplied with doctors. An examination, by the way, which I doubt most local doctors would pass after several years in practice.

The simple alternative is an apprenticeship model, as used in many professions, including law. This model is much cheaper, it would empower a local doctor at the coalface of medicine, decrease the trauma inflicted on OTDs, and deliver services where they are desperately needed. After all, it does not take long to recognise the competence of one’s colleague. But this model would diminish the power of the industry, grown comfortable on the OTDs’ misery. So it is highly unlikely to be introduced.

There is a precedent in Australia. Two Tasmanian OTDs were permanently registered, after working in the semi-wilderness for a long time, without sitting a qualifying examination. It took an Act of the Tasmanian parliament and, incredibly, the support of the local AMA, to change the legislation. The sky did not fall, the mortality rate did not increase, epidemics did not break out.

There is enough trauma in practising medicine without intentionally adding to it. The treatment of OTDs and junior doctors, these workhorses of public health, is a moral and ethical blot on the caring profession.

For many years the notion of protecting the public was successfully sold to politicians, who, afraid of seeming indifferent about the quality of care the public would receive, passed these laws without question. Their hands were guided by organisations like AMC and AMA, which were protecting their turf. You could not blame a trade union for protecting the interests of its members, could you?

Not that long ago, some Australian-trained surgeons self-righteously proclaimed that they were not going to operate on patients who smoke. What an upstanding position. What civic courage. Before we all become teary and sniffly, standing in awe in front of these monuments of humane medicine, may I be forgiven for asking rather unsporting question—could it be, by any chance, connected with the higher post-operative mortality rates in smokers? And the corresponding increases in the insurance premiums these surgeons would be required to pay? Tobacco was a legitimate part of the Australian diggers’ rations during the First and Second World Wars. Methinks that the taxes these smokers paid all their lives paid for these surgeons’ training. Now—resume sniffling.

There were times when European-trained doctors were allowed to work in Papua New Guinea, but not on mainland Australia. There were times when even if you passed an AMC exam of exceptional complexity, you were not allowed to be registered to practice, because only the first hundred who passed were admitted, the rest had to try later.

We have a surplus of doctors! It was a mantra, repeated by scores of doctors, bureaucrats, academics and demographers. The most vocal of all was a doctor from Monash. He regularly accused OTDs of all sorts of sins short of intentionally killing their patients. Somehow, he has fallen silent; the funding must have run out. When I spoke with one former health minister, he told me that Australia had a surplus of doctors and he had had no choice but to limit OTD numbers.

I recently attempted to find out how much the Australian public gets for its taxes in health spending. More precisely, I wanted to know how much money is spent on patient care and how much on administrative overheads. After seeing an incredible amount of useless and unreadable circulars, memoranda, submissions, requests and other guff, which was required reading at work, I suspected that the tidal wave of creative writing is the end result of the bureaucratic fear of redundancy. All this paper effluent is regularly delivered, accurately folded and almost never read or responded to. It was utterly, obviously useless. After two days of chasing information, like a dog chasing its own tail, I gave up.

To those who wish to, I suggest following the structure of public health care delivery on the flowchart of the relevant department. You will be proud of your deductive abilities and quickly ascertain that the same services could be delivered with fewer overheads.

Transgenerational Transmission of Trauma in Training

The training in the Australian specialist colleges is as harsh, unforgiving and traumatising as in some dysfunctional families. Those in postgraduate training sometimes are ridden so hard as to be on the brink of developing a psychotic episode from sleep deprivation when the twenty-four hours or more of uninterrupted duty is over. I have done this kind of duty. The most depressing part was that no one in authority gave a hoot. The only support came from patients. They felt sorry for their doctor. The traumatisation of younger medicos is so widespread that it is regarded by the senior staff as part of undergraduate and specialist training. “We did the hard slog, now it is someone else’s turn,” is the conventional wisdom.

And so, the transgenerational transmission of trauma continues unabated in hospitals and clinics across the land. The people who inflict this trauma onto the young trainees today had the same trauma inflicted on them in their professional youth. Now, it’s their turn to pass it on, to feel superior, to rid themselves of the feelings of inferiority hammered into them by their seniors.

This situation, after many years, started to affect local graduates. The realisation gradually dawned that one needs to spend time with one’s children, who tend to grow too fast while you look after strangers, ignoring your own family. Dissatisfaction with the job, the burnout, the overwhelming workload—these were some of the complications starting to point to the only solution possible—share the work with others. The decision to cut the numbers of medical students as well as the numbers of OTDs admitted to practice came back to haunt its authors.

The same people implemented the most disastrous decision in the history of psychiatry and deinstitutionalised every psychiatric patient in the land, whether they were able to function in society or not. These people put the onus of caring for the profoundly psychiatrically ill onto the shoulders of untrained, emotionally involved and often unwell family members and community care teams who were under-resourced and exhausted.

The same people who were in charge then are in charge now. Where is the guarantee that what they are doing now is not as idiotic as what they did a couple of decades ago? When the medical boards of the country are the de facto legislators and executors of the medical workforce, intentionally making it excruciatingly difficult to register to practice; when the workforce agencies are de facto extensions of these medical boards; when the prestige, morale and remuneration of doctors are at an all-time low—where is the guarantee that rural Auntie Molly and Uncle Herbert will not have to wait two weeks to see their GP, as they often must as a consequence of the policies promulgated by the medical boards? The same medical boards who respond to phone enquiries from prospective overseas registrants with such unmistakeable hostility (my experience in one state) that one cannot help but think that one’s services are not wanted? Where do they recruit such hostile people from? The KGB?

Bureaucratisation of Medicine in Australia: Prognosis

There is another reason why we have a shortage of doctors—apart from demographic, bureaucratic and legal ones. It is an outflow of doctors from patient contact. A surprising number of doctors actually are not that keen to be treating real people, and head off to government departments, commercial companies, recruitment agencies, applied research bodies, medical bureaucracies—the list goes on. As a rule, OTDs are not part of this movement, staying at the coalface.

One should not underestimate the number of highly trained doctors who prefer to remove themselves from the stresses of frontline medicine for the rarefied world of bureaucratic decision-making, gradually becoming institutionalised and sometimes incapable of practising medicine. None of these doctors is required to sit a requalifying examination; their registration is sacrosanct, and medical boards happily register them.

The shortage of doctors will continue. Younger doctors are not as naive these days. There is a groundswell of realisation that there is a life besides and beyond medicine. As well, the mystique and sacredness are gone from the vocation—and, I might add, good riddance. Now doctors are seen for what they really are: trained professionals selling their skills on the market of life. Which brings me to another reason for the shortage—not everyone is prepared to be treated badly by the people they try to help. The unwillingness to deal with ungrateful patients will be more and more decisive.

Medical students are watching and learning. They learn that there is no other profession or trade which is expected to bulk-bill, effectively cutting its income by 30 per cent. They learn that to achieve their professional goals they have to concentrate on their own needs, rather then their patients’. They learn that no matter how much time and energy a doctor devotes to his patients it is never enough. They learn that devotion to duty comes at the expense of one’s loved ones. They learn that for the same money they could have a simpler, more pleasant life without the patient contact.

As a result, the medical bureaucracy is likely to grow, drawing graduates away from clinical practice. And do not forget the working doctors who are going to retire. And keep in mind the increasing feminisation of the medical workforce—many women doctors will work part-time for family reasons. Local medical graduates are going to be in a minority at the coalface, at the clinics and hospitals, let alone prisons, Aboriginal medical centres, rural and remote areas and such. We are going to need overseas-trained doctors more then ever.

Are we getting ready to welcome them? Yes, we are—frantically, tirelessly and obsessively, the legislation to increase their difficulties with registration is being prepared. It will make attracting doctors to Australia even harder than it is now. Discussions about the creation of official second-grade doctors are increasing—the so-called doctors’ assistants idea, somewhat of a hybrid between a doctor and a nurse. The Soviets had it down pat. When they had shortages (of everything), they developed substitutes. We are about to follow the Soviet path. It is hardly surprising, since Australian medicine is partly operating on socialist principles of service rationing anyway. The nurse-practitioners’ clinics are on their way. Medicare cannot provide an endless money supply indefinitely—no country has that sort of money.

It has all been so unnecessary: the deliberate humiliation, the obsessiveness with controlling the workforce, the resultant stress, sleepless nights, depression, anxiety. All that was needed was to treat overseas-trained doctors as colleagues, not as interlopers or invaders.

Dr Michael Galak emigrated from the Soviet Union in 1978.