Issue 12 / 8 April 2013

A DOCTOR’S decision to retire from practice once simply meant a process of winding down.

Doctors in the latter stages of their careers could elect not to take on new patients and reduce their hours of consulting. They would limit their scope of practice to patients and problems appropriate to their diminishing energy and skills.

The retiring doctor was generally supported by a network of colleagues who were ready and willing to take on challenging patients, guaranteeing that this winding down process proceeded safely and humanely.

Doctors develop strong and mutually supportive relationships with patients, and are a trusted and reliable source of good advice — people you could trust absolutely with the custody of embarrassing secrets.

The retiring doctor could take time to gently disengage from these relationships, to introduce a successor and facilitate trust in the new doctor. This might take many months.

Doctors in full retirement were able to maintain registration. They were still “doctors”. They thought and acted as doctors with boundaries of practice and prescribing determined by self-awareness and ethical obligations. They had the leisure time to read journals and keep up to date and share the condensed information with busy colleagues.

They were respected elders of the tribe, a trustworthy source of advice based on a life of experience. This advice and support was given and received freely between colleagues. It was also available to previous patients — “Doc, my doctor has diagnosed this thing and recommended this specialist or treatment. We go back a long way and I trust you. What do you think?”

We are now in an era of “high quality” medicine mandated and monitored by politicians. The new Medical Board of Australia is subservient to the Australian Health Practitioner Regulation Agency (AHPRA) and takes refuge behind a palisade of rigid and unwavering definitions, prescriptions, guidelines and “the national law”.

Long established ethical principles governing much of medicine have been replaced by these bodies. To be an acceptably competent practitioner now requires large sums of money and the ticking of lots of boxes. There is an unhealthy obsession with credentials while experience is devalued.

The doctor contemplating retirement has stark choices — either commit fully to the onerous and very costly treadmill of box ticking or surrender registration completely.

The law regards any offender failing to meet its requirements a risk to public safety and unworthy of registration. At the stroke of midnight on the appointed day all professional activity is disallowed on pain of a very large fine.

Why the need for these laws? There must have been the most terrible damage wrought by incompetent retired doctors continuing to practise and prescribe. Obviously, to preserve confidence in the health industry in Australia this evidence has been suppressed by our political guardians and remains a dark and closely guarded secret.

The hairy-chested politicians have thus created a new underclass of “ex-doctor”. I and my ex-patients have been among the first to experience “retirement” in this brave new world. The experience, for all parties has, at times, been distressing, frustrating and expensive, or on occasion, potentially dangerous.

There is a conflict between black letter law and ethical and humanitarian obligations. Advice on managing this conflict sought from the Medical Board, AHPRA and my medical indemnity organisation has been rigidly bureaucratic, irrelevant and mostly worse than useless.

I am unable to access online content of some medical publications reserved for registered practitioners as I may not view advertisements for Schedule 4 drugs. I am still a member of the AMA and can view such advertisements in the print version of the MJA and contribute to MJA InSight, and I have been made an emeritus member of my US-based specialist association.

But the teaching hospital where I worked for more than 30 years has severed all contact, presumably as I no longer meet their accreditation standards.

To those doctors on the verge of retirement, who will join the ranks of ex-doctors, my message is “come on in, the water’s freezing”.

The pain of suddenly becoming an ex-doctor of course diminishes with time. And hardly a day goes by that I am not reminded by something in the media, of how glad I am to be out of the political dog’s breakfast that medicine has become.

Dr Graham Row practised as a nephrologist in Brisbane before he retired on 30 June 2011.

Posted 8 April 2013

54 thoughts on “Graham Row: Ex-doctor underclass

  1. Anonymous says:

    Dear Dr Row – I share your dismay at the banishment by regulation of valuable doctors. As you say, the defence of this “progress” is incredibly flimsy and probably non-existant.
    Not looking forward to it.

  2. Valueadd GP says:

    In this era of evidence based medicine- how about AHPRA do a trial?

    Comparing the Medical Board to the new stystem, and retiring practitioners affect on patient outcomes. Probably find out that the increased bureaucracy and rules made no significant difference. ‘Moving forward’………?

  3. Tom Ruut says:

    I agree with Dr Row completely.AHPRA is a fix to a non existent problem!
    Sadly now if you are not fully registered you cannot teach either.We are losing the benefit of decades of experience from senior practitioners.
    An absolute tragedy!

  4. Dr Frank L Johnson says:

    I have known Dr Graham Row personally as a leading Queensland nephrologist for many years.
    Now Dr Row is yet another senior doctor with a wealth of valuable experience to contribute to the medical profession and the general community who has been cast aside by thoughtless bureaucracy.
    Just consider how many hundreds of our colleagues throughout Australia have suffered the same treatment since the advent of AHPRA/MBA.
    Let your local federal member and your State or Territory and Federal Health Ministers and Opposition Health Spokesmen know what you feel about this. If you have had a similar experience, let them know that also.
    Throughout Australia there should be criteria for limited medical registration to facilitate the graded step down from full active practice at the doctor’s discretion.
    Australian Senior Active Doctors Association (ASADA) considers that this would best be done by transferring the responsibility for medical registration back to the States. Seamless transfer of registration between States was available in the previous system which worked well in contrast to the system under AHPRA/MBA.
    Frank Johnson,
    National President, ASADA

  5. Anthony Paul says:

    I read Graham Row’s comments with interest.
    I had to give up the privilege of being a retired doctor a couple of years ago.
    I had retired from active practice in 1998 and up until my forced retirement I was considered fit to write referrals for family members and scripts for my own medication which I had been doing for some 40 years. Then I suddenly became unsafe to carry out these activities an indeed to be regarded as a doctor. At the same time I note at a whole variety of people are now entitled to call themselves doctor, some of whom any scientifically mind person would consider rather dubious claims.
    Unfortunately the AMA went along with this nonsense, stating we are not emotionally capable of treating our family members. What an insult that was when you consider our age and experience and a whole career based on being objective.
    I despair for Medicine but more importantly for patients.

  6. Greg the Physician says:

    I completely agree with Graham Row. We are losing an incedibly valuable resource in our senior colleagues. Medical schools rely more and more on voluntary, unpaid clinicians to teach in the wards and tutorials. Busy hospital specialists need week-end and holiday cover. Yet people like Graham, with so much knowledge and experience and so much still to offer, are discarded. Presumably they now must go and queue up at their local GP practice to obtain an antibiotic prescription, or a new referral to a specialist they have neen attending for many years. The way the AMA leadership abandoned them in previous negotiations with APHRA is a disgrace in my opinion.

  7. Dr. ARC says:

    As a retired anaesthetist of some 6 years, I also wholeheartedly agree with Dr. Row’s assessment of the situation.
    The establishment of a Commonwealth body such as AHPRA is an unnecessary interference in a system which previously worked very well.
    Because it is based in Sydney, NSW practitioners get to pay a lower fee to remain in full practice, whilst the rest of the profession in other States have to pay more.
    It still costs $132 (this year) to remain on the rolls as a non practising doctors….
    One wonders why the high cost and what is the money used for.
    I suspect that the abolition of partial practising rights has caused quite a lot of resentment and possibly even depression.

  8. G.A.Chapman says:

    At the risk of being branded paranoiac, the attitude of many Hospital staff to older Doctors is appalling (Nurses and Doctors). I do a lot of RRM Locums , and it has to be experienced to be believed, most especially if you show them “another” more efficient way for doing something !

  9. robert mcritchie says:

    I agree entirely with what you have to say.
    Best wishes,
    Bob McRitchie.I have been on this for about 24 months

  10. Angry ED Reg says:

    As a “younger” training doctor, I am disgusted at the way our elder doctors are treated after giving so much to so many.

    As I see it, there are two issues,
    1) The perception of diminishing competency.
    2) The removal of title and significantly decreased respect.

    Indeed, the lack of evidence for the former, and the lost chances to continue to contribute, particularly to the education of the growing plague of new medical students is obscene.

    The latter is absolutely disgusting, after sacrificing so much for so long, to be stripped of ones title and discarded,is, to me, possibly the most offensive thing that could be done to our colleagues, teachers mentors and guides.

    I for one will always be grateful to those who came before, who taught me so much and gave such sage advice. The giants on whose shoulders we stand. They deserve better, they have more than earned the right.

  11. Sue Ieraci says:

    I have to admit to a certain ambivalence here. Perhaps the root cause of feeling lost or abandoned after retirement is the same as in all other industries – lack of planning and preparation, including a diversification of roles and interests. I’m not defending overly bureaucratic regulation, but all professionals have to face a time when work is no longer the source of their identity – titled or not. We all revere the school teachers that were influential in our lives – retired or not, titled or not. Why do we expect to be different? The sense of loss upon retirement may be an internal grief – not imposed from outside. Like all major life events, it takes planning and preparation.

  12. David Swift says:

    This issue touches a nerve every time I raise it with my medical friends, and it is heartening to hear that younger colleagues feel similarly.The treatment of older very experienced doctors is an insult to them, and a stupid waste of a valuable resource. It can’t be too late for some political activism on this. Where do we start?

  13. Theo Kitchen says:

    I retired from Rural General Practice in 2001
    I do rural GP locums which includes emergency and hospital work
    The staff show respect and appreciation for my contribution and are supportive when they know more than me!
    I am fortunate in that my medical indemnity costs are tolerable (about half a week’s work)
    registration and public liability insurance probably double this
    I continue to maintain my vocational registration
    being an RACGP examiner is recognised for this
    I enjoy the challenge and the stimulus of maintaining my VR
    Superannuation rules do not permit me to work more than 25%
    I am glad of this otherwise I would be tempted to work too much as the need is so great
    I offered to step down as an examiner in view of my age
    I was told I was still needed

    I am blessed with good health
    I am lucky/privileged that I can work when I want to and am appreciated
    I regret that so many colleagues are in a less satisfying situation

  14. A/Prof John Svigos says:

    Dear Dr Row,
    Thank you for having the courage to expose an injustice with regard to medical practice.
    We are only where we are as a profession because of the largess of our senior colleagues during and beyond our training years.
    Now that we exist in an era that is ‘politically correct’ then why is there discrimination towards those in peri-retirement?
    Now that we are in an era of utilizing our natural resources then why are we wasting ‘natural resources’ which the community enthusiastically invested in many years previously ?
    In this era of ‘IT’ if APHRA et al cannot trust a doctor to self regulate practice then why not put it to the test by a simple online assessment of capability ?
    Are there any courageous people out there prepared to defend the present status quo or will you simply keep quiet and hope we will all go away so that your para medicals can replace us unless of course they have the same restrictions ?
    Dr Row I am about to enter your ‘freezing pond’ in the next few years with the added liability of not being able to swim well or endure the cold !

  15. Dr Frank L Johnson says:

    In response to the “ambivalence” expressed by Sue Teraci,I would say that it is not that senior doctors are depending on work as a “source of their identity”. They know that they have much to offer in this time of a shortage of medical resources. They have lived a professional life of service to the community and are distressed by the actions of AHPRA/MBA which is discarding the great contribution they could make to the community. This is occurring at a time when it is the policy of all political parties that senior citizens should be encouraged to contribute to the community for as long as they are able and for as long as they choose to. Go to http://www.asada.net.au to see the objects of the Australian Senior Active Doctors Association (ASADA)
    Dr Frank L Johnson National President,ASADA.

  16. Sue Ieraci says:

    Dr Johnson – the aims of your organisation overall are admirable – but there does seem to be one element missing: the empathetic assistance of the older practising doctor to work towards full retirement. Don’t you see this as an important aim?

  17. Stan Stylis says:

    Unfortunately some of our younger colleagues harbour such sentiments, themselves lacking the experience to stop to consider/learn our art, looking only at gadgets that anyone can learn, until one day they realise the wisdom that went with it. Then as they age it dawns on them that there are many ways of “skinning the cat” and that each doctor works out their own way to manage patient’s disease and problems ………. not necessarily by the latest medication (often based on commercial hype and not uncommonly subsequently proven less effective) but also by all the various means/factors of our art.
    Those shortsighted, selfcentered politicians and bureacrats and AHPRA-like bodies will suffer for their ignorance ….but unfortunately so will the rest of the population who won’t know any better as a new generation replace those who did.
    It appears that most of those doctors who have commented are in an older age group themselves and have understood the irreplaceable value gained by experience/time; and I am proud of those of younger age ( such as ” angry ED Reg) who have had the perspicacity to recognise such wisdom and respect their elders ……….. these discerning individuals will no doubt be good and outstanding doctors …. our Discipline’s and society’s main hope. Stan Stylis

  18. Dr K C Wan Occupational physician says:

    A doctor who have been found guilty of unethical practice or incompetence can be deregistered by the medical board but the offender is given the right to present his case and also right of appeal whereas any doctor who does not meet the ANNUAL CPD requirement is denied renewal of registration by AHPRA>it appears that not meeting CPD is now deemed to be equal or worse than being found guilty of unethical practice or incompetence? It is most disappointing that AMA and the chairperson who is also a doctor has gone along with such unfair rigid prerequisite for renewal of registration.

    I have written a letter on this contentious issue that is published in the medical forum wa magazine and can be read at the following url http://www.medicalhub.com.au/wa-news/letters

  19. SS says:

    I have too been disillusioned by the requirements of the new Medical Board. Due to illness I have ceased practice as I recognise I have an impairment that prevents me from practising at the level of specialist practice. I have had specialist recognition in radiology and nuclear medicine as well as a diploma of anatomy and obstetrics.
    I cannot continue teaching at the local medical school (on a voluntary basis) without registration, insurance and continuing CME.
    The loss of experience due to retirement of doctors ( and indeed to all occupations in the community) is enormous. I think that in order to tighten up on some “cowboys” in medicine that a many older doctors with a lot to pass on have been excluded.
    All of my teaching has been unpaid, as I feel that as a recipient of “free” medical education in the 70’s I have an obligation to assist in ongoing education. With the proliferation of training positions there is an increasing need for trainers- where will they come from?

  20. Graham Row says:

    Sue, I understand and agree with the points you raise. I enjoy a planned retirement and the new activities and interests it brings. My point relates to the rigid “one size fits all” rules of the Medical Board of Australia. Retirement from a career as a salaried medical officer in a large hospital or as a GP in a group practice is a different proposition from extricating from a single-handed, private consultant practice. My planning and execution started more than a year from the anticipated date of cessation of practice and to date the process is still incomplete.
    The anger and frustration comes from a sense of entrapment by inflexible rules. To undestand this I recommend a careful reading of the Board’s rules for “Non Practicing Registration” and the 14 March 2012 “Medical Registration – What does it mean? Who should be Registered?” The Board actually admits that some of its advice conflicts with its own definition of “practice” which it seems it is unable to modify. Clearly a win for “overly bureaucratic regulation” and the political controllers on the Australian Health Workforce Ministerial Council.

  21. Tony Krins says:

    I whole-heartedly agree with Dr Row and other senior colleagues who have commented on his article regarding the unnecessary and unreasonable and unjust removal of all title and privileges of older doctors by the health bureaucracy. This bureaucratic robbery of doctors rights is worthy of reversal for a number of reasons:
    1. JUSTICE.
    The arbitrary removal of rights and privileges from people who have not failed in any way (indeed have been a boon to society), is Unjust. It denies Natural Justice.
    2. DEMOCRACY.
    The removal of rights, status and privileges is being done by people other than the doctors themselves. This is a denial of Democracy. It is the practising doctors themselves through organisations like the AMA and the various Medical Colleges who should determine how rights and privileges are wound down and not Bureaucrats.
    3. SERVICE.
    Doctors should be allowed to continue to serve constructively albeit in a reduced way.
    4. STATUS.
    It is insulting to all doctors that on an arbitrary given day they are deemed no longer fit to provide any medical advice, prescribe any medication, refer to other doctors or teach anything of a medical nature.
    5. WASTE.
    The retired medical workforce is able to continue to make some contribution to health-care delivery as their experience and wisdom do not suddenly disappear. They can be mentors and advisors to younger colleagues or institutions. This can only happen if status is preserved.
    6. EVIDENCE.
    There has been no evidence presented to justify insulting and demoting the entire medical workforce as soon as they reduce their medical activity.

    Perhaps we should be lobbying Parliaments, Health Bureaucracies, the AMA and Specialist Colleges for our “natural” and democratic rights? The AMA especially should be demonstrating some leadership in this area.

  22. Ian Hargreaves says:

    Brave New World, where a doctor who retires is a criminal if he gives advice regarding a former patient to the doctor who took over his practice. The sort of thing that isn’t in the textbooks, nor able to be double-blind trialled, like “How did you get Mrs Jones to take her pills? – she keeps refusing to comply”. In the era of NBN and PCEHR, perhaps every retiring medico could just upload his entire patient file to the State and Federal health minister of the day, to provide access to information for future treating doctors. Hardly a breach of confidentiality, given the duty of care of such august political figures. But our political masters might shudder at the thought of the other side getting their STI or cosmetic surgery records…. Alternatively, a tell-all memoir published after retirement. Hippocratic confidentiality applied when one was a doctor to the death, but like the author of The Latham Diaries, they can’t strike you off twice.

  23. Dr Frank L Johnson says:

    Thank you, Dr Ieraci. I am glad you are on side with the goals of ASADA.
    You stated that “there does seem to be one element missing: the empathetic assistance of the older practising doctor to work towards full retirement” and asked “Don’t you see this as an important aim?”.It certainly is a very important aim. I do not agree that this element is missing from the aims of ASADA. One of our major issues is that, under the AHPRA/MBA regimen, there is no category of medical registration to facilitate the staged withdrwawal from full active practice at the doctor’s discretion.
    A major aim of ASADA is to have such a category to assist “the older (or younger) practising doctor to work towards full retirement”.

  24. Simon Strauss says:

    I also read Graham Row’s article with interest and agree with his views. I’d like to make a small addition to the discussion.

    As Graham Row writes: “The doctor contemplating retirement has stark choices — either commit fully to the onerous and very costly treadmill of box ticking or surrender registration completely.”

    In effect a doctor can remain fully registered or he can become a “retired registered medical practitioner” by paying a small fee to be included on the retired medical practitioners’ register. Having done so the retired medical practitioner continues to get the MBA’s alerts and also is allowed to use the protected title “medical practitioner”. Of note, doctors with this type of registration remain subject to the Medical Board’s jurisdiction in relation to their professional conduct.

    There is of course another pathway in that the retiring doctor can elect to become a NON Registered retired medical practitioner thus freeing themselves from AHPRA/MBA’s jurisdiction.

    One of the downsides to becoming a “non registered retired medical practitioner” is that you are not allowed to use the term “Medical Practitioner” or “Retired Medical Practitioner” according to recent correspondence with AHPRA as “medical practitioner” is a protected term.

    I have asked AHPRA to clarify the legality of using the term “Retired Medical Doctor” but as yet, after several weeks and a repeated request AHPRA has not graced me with a reply. But as the term Doctor is not a protected title it seems reasonable to describe oneself as a “retired doctor” or “retired medical doctor”.

    Finally I feel that as more and more doctors elect to become non-registered retired medical doctors AHPRA/MBA will be faced with the loss of the ability to contact literally thousands of retired doctors. And the non-registered retired doctors will no longer have AHPRA/MBA’s foot on their necks having escaped their increasingly arbitrary -irrational jurisdiction!

  25. Graham Row says:

    Simon, You have my sympathy in your efforts to get a sensible opinion from AHPRA. Non Practicing Registration indeed is an option. It would seem that the only practical benefit is the ability to use a protected title. The non-practicing registrant is still bound hand and foot by the all-encompassing “definition of practice” which the Board is apparently unable or unwilling to alter. This, in my view makes the use of the protected title potentially misleading or even deceptive.
    The Board’s March 2012 advice indicates that a non-practicing medical practitioner “must not provide medical treatment or opinion about the physical or mental health of an individual.” Neither registered or non-registered individuals may give individual patient advice.
    For those matters arising after the stroke of midnight on the fatal day, I have not found a humane way to meet one’s ethical obligations to old patients, their families and medical advisers and yet stay within the law. On this point of practical advice there is a deafening silence.

  26. Kevin Macdonald says:

    Dr Row does hit a raw nerve for older practitioners.

    A:It appears extremely unlikely that any change will occur in the complexities of the registration requirements for retired practitioners as there does not appear to be an effective catalyst. The authorities just don’t appear interested in retirees.

    B:Further we have a large and increasing number of medical graduates, some of whom may lack career pathways due to a lack of postgrad placements. Perhaps there could be a mentoring role for senior practitioners but begs the question of A.

    C: The transition to retirement is one of the most significant and important in a lifetime of professional practice. In my experience, the thinking and preparing starts way to late. In my case, I started financial plans etc etc 10 years prior to my expected retirement and it still took 3 years to completely transition.

    D: Be positive. Retirement is an extremely rewarding experience. You need to keep contact with colleagues and the profession. The AMA is an excellent non-craft based organisation for maintaining contact across the many issues involving the profession.

    Kevin Macdonald
    Chair Vic AMA Retired Doctors Group

  27. Anonymous says:

    All politicians should be compelled to undertake courses in politics, and particularly in ethics. They should be required to show evidence of continuing studies, and then retired compulsorily at 65 years of age. Until then they should have no right to dictate to the medical profession.

  28. Alex Wood says:

    Having retired in 1998, I still help at operation by request of highly capable urological surgeons.
    I agree with Dr Row and having helped systems streamline themselves about needs of others like myself, find that AHPRA especially and to a less extent others find it difficult or impossible to understand those of us that fit into minor categories that require different accreditation.
    Were I not safe & capable, I doubt that I would be asked to assist, and to date feel I retain insight about what I am capable of doing and also judgement about what not to do in an overall medical sense.
    ALAS administrators need to have just a few “one size fits all” categories, perhaps because the “world goes too fast” for them to bother?

  29. Rose says:

    The AHPRA was in my opinion established to bring overseas-trained “doctors” into Australia to provide cheap labour into Australian hospitals and “Areas of Need” (?areas of neglect) for political gain. Unlike Dr. Graham Row, valued by his patients, including my mother, esteemed by the medical profession, these overseas “doctors” are not required to meet the stringent requirements of Australian Medical students to gain entry to Australian universities nor are required to complete a University degree in Medicine in Australia. There is no evidence to support that their overseas training is in any way equivalent to Australian training. At least, they should be required to complete secondary school training in Australia in English, as are Australian students, compete for University entry via the UMAT or GAMSAT, and complete an Australian Medical degree, prior to being allowed to work in hospitals, general practice, or undertake any specialist training. The AHPRA has failed to provide any evidence-based data that overseas-trained doctors are trained in English to Australian secondary school standards, , failed to provide data that they can pass the UMAT or GAMSAT, nor complete a degree in Medicine in Australia .
    Nor has the AHPRA any evidence-based data to support that the AHPRA registration requirements for existing Australian medical practitioners , including older specialists/GP doctors, are in any way relevant to the quality of practice delivered by older doctors.
    It is time that the AHPRA itself was required to meet the stringent requirements that it places on Australian graduates in Medicine.
    Let the AHPRA provide evidenced-based data to support its registration requirements for Australian graduates, otherwise I would invite older doctors to consider whether these unsubstantiated AHPRA requirements breach Australian laws including those of evidence and discrimination.

  30. Iain Esslemont says:

    The article by Graham Row and the comments expressed by all the other correspondents are absolutely accurate.

    There are three points which can be made

    • The first was made by Professor John Keane in The Life and Death of Democracy (2009), who wrote: “Violent shenanigans triggered by appetites for power were very much on the mind of the Athenian philosopher Plato (c. 427-c. 347 BCE) when he remarked that democracy was a two-faced form of government, ‘according to whether the masses rule over the owners of property by force or by consent’. He considered democracy to be a gimcrack invention that corroded good government by pandering to the ignorant poor. He likened democracy to a ship manned by sapheads who refuse to believe that there is any such craft as navigation – sailors who treat helmsmen as useless stargazers.”
    • The second point is that degrees are awarded by universities and colleges and not by the Parliament/government and so, one is not “stripped of one’s title” although one may be stripped of one’s registration.
    • The third point is that it was foolish to let the Parliament/government take over the medical profession. I had expounded this in more length in an article I wrote for Medical Forum, February 2009, page 3, and in my autobiography, Life is what you make it (Melrose Books, 2009).
    This latter point is being vigorously resisted by the Republican Party in the US (Oregon State University Socratic Club, ‘No ObamaCare’ ).
    I have had personal experience of the workings of the new system. As with Dr Row, I was unwilling to submit to the “onerous and very costly treadmill of box ticking” and opted to become “registered non-practicing” with its attendant restrictions.
    Eighteen months ago, my wife woke me at 2am with pain in her left breast. She was obviously terrified and I examined her, thus using “my skills and knowledge as a health practitioner in my profession”. That morning, I took her to our GP and breast cancer was confirmed. I had obviously broken the law and I reported myself to the Medical Board. Some months later, I was told to forget about it! After 55 years of medical training, how can a doctor forget his (or her) clinical skills?
    It is unfortunate that the medical profession has come under the management of the government, a bureaucracy without a soul. The current Parliament/government is following the example of the National Socialist Government of Germany of the 1920-30 eras.

  31. Sue Ieraci says:

    Rose, I work in an ED in an outer suburb of Sydney. Our ED would not function without IMGs (internationally-trained doctors)who also received further training within our system. Many of these doctors are absolutely outstanding – with experience and judgment well beyond local graduates due to their previous experience. Whatever the functional shortcomings of AHPRA might be, AHPRA is definitely not an employer organisation that is trying to import “cheap labour”. Retiring doctors need a planned, gradual, dignified exit. Working night shift in a busy outer suburban ED generally doesn’t fit that pattern.

  32. Simon Strauss says:

    I wonder how many medical practitioners know that there is only one medical practitioner on the Australian Health Practitioners Regulation Agency (AHPRA)5 member board! And no medical practitioners at all amongst the 13 AHPRA administrators with 5 having nursing qualifications. (http://www.asada.net.au/forum/discussion/6/who-is-ahpra-why-are-our-medi…)

    In this context it becomes very important to understand the relationship between AHPRA and the MBA; as if the former is the policy maker we should be asking do they (AHPRA) have the education and resources to make judgements affecting the medical profession.

  33. Goldcoaster says:

    A very good article by Dr Row highlighting the sad predicament of senior doctors. But there is something that can be done! A new medical organisation for senior doctors has been created to try and overcome this medical registration problem. It is the Australian Senior Active Doctors Association (ASADA). Go to the website http://www.asada.net.au/ and please join up! See post by Dr Frank Johnson above.

  34. jay rao says:

    I fully agree with the comments made in this article as I approach my retirement in the next 2 or so years. One should utilise the services of senior doctors in a teaching and training capacity with reduced workload and little or no after hours work. As long as one is physically and mentally able to work with self limitations being placed there is no reason why politicians or other bodies should be placing restrictions. A DOCTOR IS ALWAYS A DOCTOR AND NOT AN EX DOCTOR.

  35. Sheila Applegate says:

    I agree with your frustrations with this system. It applies to all professions who have to register with AHPRA. As a pharmacist about to retire I am not looking forward to being in a similar situation.

  36. Greg the Physician says:

    Sue, I think that Rose’s comments are spot on and that you have misinterpreted them. She isn’t saying that IMGs are necessarily inferior to Australian graduates; she is suggesting that the local graduates have to meet higher standards to be registered to practice medicine in this country. I for one find it very difficult to disagree with this assertion. As Rose says, let’s see the evidence that the requirements for registration of Australian graduates are producing better doctors; I bet there isn’t any such evidence, which leads me to conclude that the role and agenda of AHPRA is purely a political one.

  37. Dr Geoff Harding says:

    I knew Dr Row when he was the President of AMAQ. This situation where he and many others find themselves is unacceptable. Today’s medical press contains a story aobut allowing pharmacists to prescribe for UTI’s – I’m cetrtain I would rather have a relative who was a retired nephologist give an opinion on “UTI” than a pharmacist!!!
    This represents the dumbing down of medicine and our community will suffer for it. Our professional organisations need to be ashamed for accepting this nonsense.

  38. Richard Gordon says:

    I am a 66 year old GP. I have waded through the above correspondence and I am surprised but heartened to read the reasoned and sensible comments by Dr Ieraci. All the other correspondents would do well to read her comments carefully, go away and think about them.
    Would you want a relative of yours treated by a fully insured doctor who fulfils CPD requirements or an older uninsured doctor whose competence is not being tested regularly? You may feel that YOU are OK but can you guarantee the competence of others of your age group?

  39. Sue Ieraci says:

    Greg (“the physician”), the examination standards for IMGs are set by the AMC – AHPRA implements them. Workplace assessment is done by the IMG’s clinical supervisors. Rose said “The AHPRA was in my opinion established to bring overseas-trained “doctors” into Australia to provide cheap labour into Australian hospitals and “Areas of Need” (?areas of neglect) for political gain.” WHatever AHPRA’s shortcomings, I don’t think that’s why it was established (do you?). AHPRA came about because of the Productivity Commission’s desire to have a uniform body for regulation of all the health professions, allegedly to facilitate role-flexibility. History has already shown that the original plan for a single regulator was ill-conceived. That doesn’t mean that Rose’s comments were correct, however. AHPRA does not examine or supervise IMGs.

  40. Isaac Brajtman says:

    Why worry about being a non doctor and unable to even prescribe for yourself. You can always go to a nurse practitioner who obviously understands your medical requirements better than you !!!!

  41. Graham Row says:

    Richard, with great respect I think you have missed the point. My plea for a review of the present unjustifiably rigid law relates specifically to the difficulties it creates for retiring doctors and their patients.
    I do not quarrel with the objective of protecting the public from incompetent practitioners. The present registration rules however are driven more by politics than evidence. If CPD was a drug I suggest the authorities would not license it for lack of proven efficacy let alone cost-benefit.
    I have a lovely GP and greatly appreciate the excellent medical care I receive. I have no desire or need to prescribe or to resume the awesome burden of the doctor-patient contract. In this era of proliferating credentials certificates and accreditations even fully registered doctors should be ethically constrained from actions they know or should know to be beyond their limitations. No evidence has been advanced to suggest that retired doctors flagrantly violate these boundaries. As a community I think we are headed for big trouble if we exterminate ethics in favour of black letter law.

  42. Michael Busby says:

    Even when ingloriously stripped of the title, a retired doctor will always be more of a “doctor” than any chiroquaktor will ever be!

  43. Greg the Physician says:

    Sue, I think that AHPRA has a political agenda aimed against the medical profession, as seen by a number of its actions and initiatives. In addition to what has happened to retired medical practitioners, these include efforts to extend prescribing rights, which has already been successful in the case of nurse practitioners and is likely to soon be extended more broadly to other categories of health practitioners. It has also been proposed that AHPRA, through its subservient national Medical Board, initiate its own audits of medical practitioners’ compliance with CPD, despite such audits already being carried out by the various medical Colleges. The possibility of regular recertification (presumably by examinations) has also been raised. We run the risk of the profession becoming grossly over-regulated, and spending more and more of our time meeting bureaucratic requirements rather than undertaking clinical practice, while at the same time there is an underlying role substitution agenda, with other health professionals gradually encroaching more and more on the traditional roles of medical practitioners.
    In this context, I will again defend Rose’s comments, although I certainly accept your point that AHPRA is not directly involved in determining the standards of IMGs. Nevertheless, it is the Medical Board of Australia which determines standards of registration for medical practitioners in this country, and the MBA is answerable to, and probably controlled by, AHPRA.
    Don’t forget that there were and are powerful people in this country who are very opposed to the idea of a strong, independent medical profession. I suggest you read Bruce Shepherd’s brief article in the recent anniversary edition of the AMA News if you have any doubts on this point. Remember Kevin Rudd’s “Towards 2020” summit? The one proposal Rudd highlighted and strongly supported in his concluding remarks was the idea that Australia should have a single medical/hospital system in the country by 2020 – and he certainly wasn’t suggesting the abolition of the public system.
    Be afraid …. be very afraid.

  44. Simon Strauss says:

    Hi Michael,
    A retired doctor can legally use the term “Doctor” as the term “Doctor” is not a protected term.

    Below is a recent communication from AHPRA in response to my specifically asking whether someone who opts out by not joining the ‘retired medical practitioner’s register’ can call themselves a:
    (1) retired medical practitioner
    (2) non-registered retired medical practitioner
    (3) retired doctor:

    AHPRA’s response 6/12/2012:
    Please be advised that you are unable to use the term “Non –Registered Retired Medical Practitioner” as Medical Practitioner is a protected title and requires valid registration. However, you are still able to use the term Doctor.

    Consequently according to AHPRA you can call yourself Doctor or retired Doctor. As I have mentioned before in this forum, I haven’t received a response to my query re the use of the title: Retired Medical Doctor.

    Having read the above you might be led to believe that we now live under an increasingly, pedantic, strange and silly system. So for now I am happy to play the game by referring to myself as a “Medical Ghost” as it usually evokes a response which allows me to explain what AHPRA is doing.

  45. Elliot says:

    Blind Freddy is sure to agree with Graham Row as I and I suspect every doctor would. He has outlined a truly ludicrous situation.
    The problem for us is what to do about it. We need to mobilize opinion where it counts. It needs appropriate lobbying tireless publicity and an effective public relations program. Both the AMA at the Federal level and all the academic and professional medical Colleges, Associations and Societies need to contribute to this as do medical practitioners everywhere. I believe we need to have the AMA direct this sort of public education campaign with on going letters, emails etc directed to Federal Members of Parliament, Ministers and particularly opposition Members and Shadow Ministers. It needs prolonged pressure to have any effect.
    Lets take a step towards removing this pathetic, non evidence supported nonsense.
    You have set the ball rolling. Would you now approach the AMA to carry on, on behalf of us all, from now on?

  46. Rose says:

    Graham Row has written that “to be an acceptably competent practitioner now requires large sums of money and ticking lots of boxes. There is an unhealthy obsession with credentials while experience is devalued.” I agree wholeheartedly. These “credentials” are now often obtained online, or on dummies, with no evidence that they are put into clinical practice – there is a lack of evidence that online or dummy training translates to clinical practice. Other credentials are obtained at great expense at repeat GP Practice accreditation visits, where GP doctors are expected to have expensive equipment equivalent to an emergency department,reception staff trained in CPR, despite the fact that the accreditation GP triage guidelines state that in an emergency patients should be advised to call 000,for an ambulance, to be transported to hospital, not to attend the GP. In my opinion, these onerous accreditation requirements reflect our governments'(federal and state) political agenda to downgrade rural hospitals to nursing homes or MPS- (minus medical practitioner services), hence the nurse practitioner model, and I note that the number of nurses on the AHPRA exceeds the number of doctors, so that GP practices are expected to replace rural hospitals, without any equivalent increase in funding for GPs. Dr. Row’s writes that “experience is undervalued “- surely an understatement applying to retired and practising doctors, who have trained in Australian Universities, hospitals and Colleges for at least 12 years to gain our qualifications, prior to serving our patients in clinical practice. We could not have obtained our qualifications nor continued in clinical practice without a personal commitment to our own training, yet the AHPRA deems that we are not competent to maintain our competence. All doctors are equal, but some AHPRA nurses are more equal than doctors?

  47. Sue Ieraci says:

    Greg “the Physician” – you might do well to revise some of the history of medical regulation in Australia. Under the previous structure of independent state medical boards, each jurisdiction had different regulations, governed by different state legislation (medical practice acts). The Limited Prescribing and Referral regulation that previously existed in NSW was not a national policy. The structure and rights for Nurse Practititoners pre-date AHPRA – that again is governed by legislation. The Performance Stream of regulation, developed and launched in Australia by the previous NSW Board, has structures for assessment of competence that go well beyond CPD – which is essentially a screening tool. Let’s remember that structured CPD was developed by our own Colleges – not by the regulators. Is there any college that does not require CPD for ongoing membership? There are various shortcomings in the structure and function of AHPRA, but they can’t be blamed for all ills. If posters here are aware of more effective structures for displaying ongoing learning, please put them forward.

  48. Frank Johnson, ASADA says:

    Elliot, You are spot on.
    The Australian Active Doctors Association (ASADA) is actively working to mobilise “grey power” to overcome the negative effects of AHPRA/MBA on the availablity of medical work force in Australia.
    The AMA has worked with us many times over the past 15 years or so and we look forward to more such synergism in the future.
    Anyone who wants to join in the struggle against negative bureaucracy should join the AMA or, preferably from my biassed point of view, ASADA. Go to http://www.asada.net.au

  49. Rose says:

    While CPD was developed by our own Colleges, unfortunately some of our Colleges have allowed CPD , training and Accreditation to be contracted to other organisations whose agenda is not in the interest of medical practitioners in recent years. Previously, ACRRM and the RACGP colleges ran GP CPD,and GP registrar training, whereas now there are unhealthy alliances between money driven top-heavy GP training organisations and Medicare Locals, which amount to a restraint of trade. The GP Accreditation bodies send nurses on GP practice visits, whose aim is to repeatedly fail GP practices, while extracting more payments for more visits
    Sue, Nurse practitioner prescribing on the PBS has occurred after, not before, the AHPRA was formed.
    While we doctors have been busy seeing patients, and attending CME training run by our Colleges in the past, we have allowed the regulation of our profession to be usurped by administrators without medical training. So our competence to practice is now assessed outside of our profession, rather than within .
    So Sue, I put forward a more effective structure for displaying ongoing learning , and training, and that it is to return it our Colleges, and please Sue ask the government to allocate our Colleges the funding now given to all GP training and GP accreditation organisations, and funding given to Medicare Locals. I am sure with this extensive funding our Colleges can not only train us, but also show the AHPRA that College membership demands AHPRA registration, freeing the AHPRA nurses to do what they are tranined to do-nursing.

  50. Vernon Hill says:

    I know Graham and the contribution which he has made to his field.I retired thirteen years ago when directing became a full time job and I was not good at ticking the right boxes and remembering the constantly changing passwords.
    Fortunately Rehabilitation is not a glamour specialty so I have had a steady stream of locum offers and enjoy being able to say “Yes” or “No” as the spirit moves me. To keep doing this I have had to ‘tick the boxes’but so far they have not ‘raised the bar too far’. My advice is to keep going and ‘die living’.

  51. Sue Ieraci says:

    Rose – I’m not sure what the point of your last post is, but the details are not entirely accurate. If ACCRM and RACGP have poor structures for CPD, isn’t it up to the members to fix them? My College CPD is all internally regulated. Essentially, conformation with a College’s CPD structure attempts to ensure that you remain within a learning “network” – generally easier in hospital or group practice. Professional isolation can be a real issue. IN this discussion, though, AHPRA doesnt set the standards for your specialty – your specialty sets its own standards. As far as NPs go, the legislation that enabled the registration of nurse practitioners occurred in the late 1990s. All the state medical practice acts have since been updated to create the conditions for national AHPRA. I’m no apologist for AHPRA, but it can only be held accountable for those things for which it is responsible. THis does not include either the recruitment of IMGs or NPs.

  52. Rose says:

    Sue, the point of my last post is that I support Dr. Graham Row’s comments.
    In summary,I, like most others posting on this article,believe that regulation of the medical profession , including requirements for registration, should be determined within the medical profession, not by politicians, nor nurses.
    Regarding CPD or CME, and medical training, again, I , like Greg and others,believe that this should be determined within the medical profession .
    Sue, if you are unaware of who is now funded by the Federal Department of “..Health ” to control training of GP Registrars, control accreditation of GP Supervisors in both private and other GP practices , and control GP Practice Accreditation, I suggest you look on the internet or ask your own GP. I certainly is no longer the RACGP nor ACRRM.
    Regarding GP CPD, CME, funding for GP Practice staff training, I suggest you ask your own GP or local politician., how much these non-GP organisations and Medicare Locals are getting in funding, and whether this is run through the RACGP or ACRRM. It is not.
    The RACGP and ACRRM used to do it a lot less money, and a lot better.
    Dr. Graham Row studied for 6 years as a medical student, another 6 years to be a Specialist, practised competently for decades , so unless the AHPRA or anyone else can prove that he is now incompetent/demented, which his article above clearly shows is not the case, who is to state that he cannot prescribe, refer, teach medical students and medical graduates ?
    Sue, regarding your comments on the AHPRA, I suggest you read Greg’s last post.
    The bottom line is politics- IMGs and nurse practitioners are cheaper, not better, role substitutes for Australian medical graduates.
    Sue,I might add that I practise in a rural area where IMGs do not wish to remain, nor do nurse practitioners wish to venture, which makes me question their role in rural Australia.

  53. gazzainsight says:

    Rob – the move to compulsory CPD – and the audits that logically follow – significantly pre-date AHPRA. This is becoming a part of medical regulation world-wide. Although College CPD programmes are no panacea, they do assist a practitioner to keep in touch with their professional community . Like democracy – no better alternatives have come to light so far.

  54. CKN Queensland Health says:

    I am, sadly, a long way off retirement. I have been appalled at this development, which Dr Row rightly suggests removes a great deal of experience from the sphere of younger doctors. I constantly seek counsel from my retired mentors when difficult clinical problems arise. They are yet to disappoint me – their advice is generously given and always wise, based as it is on a lifetime of learning. They grew up with the literature! AHPRHA’s approach seems an expensive roadblock to common sense.

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