Power Plays and Intersecting Inequalities: the International Medical Graduate Experience of Medical Dominance in Australia
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Power Plays and Intersecting Inequalities: The International Medical Graduate Experience of Medical Dominance in Australia by Vicki Adele Pascoe Bachelor of Arts – University of New England Graduate Certificate Organisational Development and Training – Southern Cross University Graduate Diploma Adult Education and Training – University of New England Master of Education (Hons) – University of New England Thesis Submitted to Flinders University for the degree of Doctor of Philosophy College of Business, Government and Law College August 2017 TABLE OF CONTENTS PAGE TITLE PAGE TABLE OF CONTENTS SUMMARY DECLARATION ACKNOWLEDGEMENTS LIST OF TABLES (3) INTRODUCTION: WELCOME TO AUSTRALIA, 8 THE LAND OF A FAIR GO FOR ALL CHAPTER ONE: METHODOLOGY, THE PATHWAY TO FIND THE 36 VOICES CHAPTER TWO: THE LUCKY COUNTRY, IMGs AND THE HISTORY 87 OF ETHNOCENTRISM, XENOPHOBIA AND RACISM CHAPTER THREE: POLICIES, PROCESSES, POPPYCOCK AND 117 DIMENSIONS OF POWER: STRUCTURAL, HEGEMONIC AND INTERPERSONAL CHAPTER FOUR: MEDICAL DOMINANCE AND THE CREATION 174 OF TOXIC CULTURE CHAPTER FIVE: THE REPRESENTATION OF IMGs AS 210 PROBLEMATIC CHAPTER SIX: IMGs AND INTERSECTION INEQUALITIES, 244 CLASS, RACE AND NATION CONCLUSION: WHERE TO FROM HERE? TRANSFORMATION 276 OR A VERY WICKED PROBLEM BIBLIOGRAPHY 309 APPENDICES (3) 336 LIST OF TABLES TABLE PAGE 1 GP WORKFORCE NUMBERS BY REGIONAL GROUPING 24 AND TRAINING (AUSTRALIAN AND OVERSEAS 2 INTERVIEW PARTICIPANTS 69 3 AMC FEES (AS AT 1 JANUARY, 2016) 146 SUMMARY This thesis uncovers, explores and analyses Australia’s medical culture through the positioning of International Medical Graduates (IMGs). There is currently a health workforce shortage. Australia, while hoping to produce sufficient Australian trained medical doctors to service the population in the future, actively recruits doctors from overseas. Despite Australia’s need for IMGs, the process journey they encounter in this country makes accreditation of qualifications and registration a particularly arduous and lengthy ordeal. The justification for such intense scrutiny is unconvincingly linked to the perceived need for Australia to maintain a high standard of health care. The result for some IMGs is to join the medical unemployed and Australian communities miss out on their skills and experience. The Australian medical profession is the provider of expert medical knowledge and as a result, retains the status of an elite profession. This thesis argues that IMGs however are not assigned the same status. IMGs are ‘othered’, presented as problematic and less qualified. IMGs are positioned as an underclass. The maintenance of a self-interest agenda drives the need to ‘other’ IMGs. Intersecting inequalities of Class, Race and Nation validate and reinforce their positioning. The innovative work of Evan Willis (1989) on medical dominance, comprehensively explains how medical dominance is created and maintained. The original contribution to knowledge offered by this thesis delves beyond to why it exists and continues. Much of the research and literature on medical dominance argues that it is being challenged and changing shape. Nevertheless, its dominance remains. 4 The research presented in the thesis chapters has a broad scope and for this reason, has taken a multidisciplinary approach. An anti-oppressive theoretical framework allows for the voices of lived experience to penetrate throughout and a social justice platform engages the participants and the reader into the interwoven conversations. The data set reveals rich and sometimes shocking evidence to paint a stark picture. Other medical voices from outside the data join the thesis via media responses to revelations of experiences not only from IMGs but also from Australian trained doctors. Coverage has exposed a toxic culture endemic with bullying and sexual harassment. This thesis argues that the positioning of IMGs is organised through the dimensions of Structural Power, Hegemonic Power and Interpersonal Power. These dimensions allow for an exploration of power relations between the structures of the health system, the Australian medical profession and the agency of IMGs. The Australian narrative presented to the world espouses a community of social justice and human rights. Instead, an historical lens traces the formation and persistence of difference represented in ethnocentrism, racism and xenophobia from 1788 to the present. The original contribution to knowledge made by this thesis confirms the positioning of IMGs as an underclass within Australia’s powerful yet toxic medical culture where jealousy, conflict of interests, commercial gains and market share drive a power/knowledge nexus of unethical, discriminative and uncompetitive behaviours. While there are many decent, ethical medical doctors within the profession, clearly there are also many who are not. 5 DECLARATION I certify that this thesis does not incorporate without acknowledgement any material previously submitted for a degree or diploma in any university; and that to the best of my knowledge and belief it does not contain any material previously published or written by another person except where due reference is made in the text. Vicki Adele Pascoe 6 ACKNOWLEDGEMENTS Firstly, I wish to thank the many voices who contributed to this study, for gifting your time and sharing lived experiences. Without you, this thesis would not exist. A very special thank you to my supervisors, the Dynamic Duo: Professor Steve Redhead and Professor Tara Brabazon. Thank you for having faith in me and for your constant encouragement and support in this final leg of my sometimes perilous journey. You are amazing and will always remain an important part of my life. Thank you to the significant others who assisted: Associate Professor Nik Taylor, there from the very beginning of this journey. Thanks to Associate Professor Mary Holmes, Dr Jessie Gunson, and Dr Laura Deane for your valuable contributions. To my friend Gail who went into spirit last year. Thank you for 42 years of wonderful friendship, rest in peace. This was what I kept raving on about. Also in spirit, Irene who I never met but who I tell almost on a daily basis how things are going; a good or a bad day at the desk. It is Irene’s commemorative plaque which is placed exactly where I stroll across to the cliffs and stand at the end of the day to breathe sea air and watch the surfers. Thanks for listening Irene and I will still drop by. To all the people throughout my life who tried to put me down, undermine my confidence and discourage me, it didn’t work. Finally, and most importantly, thank you to Arthur my partner in life. Your unconditional love, support and encouragement over the past 29 years is inspirational. I note for the examiners that no professional editor was deployed in the preparation of this thesis. 7 INTRODUCTION: WELCOME TO AUSTRALIA, THE LAND OF A FAIR GO FOR ALL We have to stamp out medical racism before it takes hold. Overseas trained doctors do not practice inferior medicine. Nor are they less committed to patient care (Haikerwal 2005, p.5). The sociological imagination enables us to grasp history and biography and the relations between the two within society. That is its task and its promise (Mills, 1959, p.6). In 2003, Dr Jayant Patel moved to Bundaberg Queensland to take up an appointment as Director of Surgery at the Bundaberg Base Hospital. The initial conception for this thesis was triggered by what became the Dr Patel tragedy. Reported by a whistle blower nurse, it was alleged that between 2003 and 2005, 30 patients died while under his care. Dr Patel was accused of negligence and was eventually convicted of manslaughter, grievous bodily harm and fraud (Keim et al. 2013). As a result, Dr Patel attracted the nickname ‘Dr Death’. Dr Patel, an International Medical Graduate, was born in Jamnagar India where he studied medicine. Dr Patel subsequently undertook further surgical training in the United States of America and became a US citizen. I thought about the Bundaberg community - where I had once lived and worked for 18 months - and I personalised to some extent the ensuing trauma which resonated through the community as a result of the tragedy. As the narrative unfolded every evening on my 8 television, I was able to imagine myself back in my past Bundaberg workplace and visualised peoples’ conversations about Dr Patel. I imagined the close knit, busy little town a buzz with the story which was perhaps also fuelled by the arrival of the media. During my time in Bundaberg, I visited the Bundaberg hospital on a couple of occasions and I imagined the tense atmosphere there. I wondered how the Bundaberg region’s IMGs would feel about their colleague’s alleged misconduct, particularly those who worked at the hospital. I was still living in Queensland and felt quite closely connected as the crisis evolved. Bundaberg is a rural Community and I was living in another rural Community just four hour’s drive away. The ramifications from the Bundaberg tragedy were widespread, not only were there families in Bundaberg who suffered loss of life or loss of quality of life due to medical mistakes, but it seemed that medical doctors across Australia, particularly those trained overseas and of Indian appearance were being subjected to abuse (Haikerwal, 2005). Hostility towards IMGs surfaced from within the Australian community and there was a growing perception that IMG qualifications and skills were sub-standard. Remembering this case, I was disturbed by a speech made to the National Press Club in Canberra in July 2005. In his speech, the then president of the Australian Medical Association (AMA) Dr Murkesh Haikerwal (an IMG himself) made the observation that Australia, as a result of the Dr Patel case, was experiencing, ‘medical racism’. Dr Haikerwal (2005) stated: Because of the Patel case, doctors with funny names, accents, coloured skin and different backgrounds are getting a hard time. Some patients are avoiding them, some patients are abusing them…we cannot allow honest, highly skilled doctors to be made pariahs in the communities they are committed to serving…because of the negligence of others, they are bearing a burden that isn’t theirs.