New Zealand's critical shortage of specialist nurses made headlines again this week, but it's not the country's only pressing medical need.
The predicted impact of Omicron adds to the urgency, but since the beginning of the Covid-19 pandemic there have been regular reports of a medical workforce in crisis, with longer waiting times and patients being turned away.
Border closures and immigration restrictions have only made the doctor shortage worse. We need to ask, therefore, why many foreign-trained doctors currently living in New Zealand are still not allowed to work.
Brain drain and brain gain
Doctors have always moved around. It's been an important aspect of the medical profession for centuries, as a way of learning new skills and knowledge. According to a 2019 Medical Council workforce survey, around 40 per cent of New Zealand-trained physicians from the 2005 cohort were living overseas after 10 years.
To compensate for this "brain drain", which leads to roughly one in six New Zealand-trained doctors working overseas, doctors from other countries are encouraged to immigrate. New Zealand's health system depends on this migrant "brain gain".
To make matters worse, not all of those who stay are able to work as doctors in their adopted country.
Long pathways to practising
The reason lies in the way New Zealand licenses foreign doctors depending on where they trained. Those with training and experience in "comparable health systems" can generally practise as soon as they receive a job offer.
That comparability is measured by indicators such as life expectancy and doctors-per-capita in other countries. It's hardly surprising that only wealthier countries are on the list.
Doctors who can't claim comparability must first complete a medical knowledge exam from either Australia, the UK, US or Canada, pass an English test and then pass the New Zealand Registration Examination (NZREX).
This process can cost more than $10,000 and takes years – especially since Covid-19 has meant half of the exam offerings were cancelled in 2020 and 2021, adding to wait times.
A hurdle too far
Once a doctor has passed the exams and met the required standard, they must still complete two years of supervised work before being licensed.
This is where the catch comes: first-year supervised positions are limited, prioritised for New Zealand medical graduates and rarely offered to foreign-trained doctors.
Most doctors from comparable health systems, on the other hand, don't need to take the NZREX or complete two years of supervised work. By not competing with New Zealand medical graduates to be licensed, they don't experience the same bottlenecks.
Of the foreign doctors who passed the NZREX between 2016 and 2021, just over half now have provisional registration and can work. This leaves 94 who have passed the exam in the past five years but are still not licensed to practise medicine.
For those who passed the exam earlier, the results are valid for only five years. If they haven't been able to secure a supervised position in that time, they are back to square one.
A wasted workforce
Despite the obvious need, qualified immigrant doctors have reportedly been denied work opportunities at understaffed hospitals during the pandemic.
It is difficult not to see an apparent assumption that a doctor's competency as a physician is associated with the country they are from. This is not an unusual phenomenon – migrant physicians from non-Western backgrounds often experience barriers to registration and licensing in their destination countries.
But in New Zealand the disadvantage some foreign doctors face also extends to the licensing pathways. To be registered, those from non-Western countries must demonstrate clinical skills, including showing Māori cultural competency, while those from "comparable health systems" don't.
One might ask, if cultural competency is important in the context of New Zealand's inequitable health outcomes, why shouldn't all foreign doctors be required to demonstrate this before being licensed?
With so many foreign-trained doctors in New Zealand unable to work, even after passing their licensing exams, we argue the problem is less about brain drains or brain gains. Rather, it reflects a "brain waste" for both the doctors themselves and for Aotearoa New Zealand, as Omicron threatens to stretch a system already in crisis.
- The Conversation