Dr Rebecca Stewart guest blogs for us on an important question. Rebecca is a GP and Medical Educator who is passionate about supporting competence and excellence in medical education, research, and evaluation. Rebecca provides individualized support for GP training, including GPs attempting Fellowship examinations and has developed a suite of study resources, including the first research and curriculum-based study planning App for Australian General Practice visit MedEd Experts

Begin with the end in sight: Pathways in Australian General Practice.

Writing this blog was a hard slog. Navigating through the intricacies of working in Australian General Practice must be one of the most confusing and disorientating journeys I’ve ever been on – and I have been trained and work in Australian General Practice! I cannot imagine how a trainee doctor or a doctor from overseas who is less familiar with the environment would find their way without some guidance. So I hope in writing this blog as an expert I can make your journey to working independently as a GP in Australia a little smoother.

Before we get too much into the detail. Let’s answer the key question here. How can overseas trained doctors (International Medical Graduates) work in General Practice in Australia? The short explanation is that you firstly need to be assessed for and given registration to work in a general practice position. As a minimum this requires you to have passed the AMC Part 1 Exam and meet the AHPRA requirements for English. You also need a job offer with appropriate supervision. At this point there are various options under what is called the 3GA position to work in a post in general practice where you can offer Medicare services.

The road to GP Fellowship can be long and tortuous and requires considerable personal and academic commitment – so before you set off, plan your route to ensure a straight trajectory. Many of the doctors that I work with in preparation for (and/or repeatedly attempting) Fellowship exams started their ‘trip to Fellowship’ late. Or stumbled along the path. Repeatedly finding hazards, including AHPRA Registration hurdles.

Working independently in General Practice should be enjoyable and challenging and doesn’t have to be tortuous.

Some Initial Questions to Ask Yourself.

Before you embark on your journey into General Practice in Australia ask yourself the following questions:

1. Where do you wish to be working in five years? I.e. what type of medicine would you like to practice and what skillsets will you need?
2. Are you subject to 19AA or 19AB legislation? Otherwise known as Vocational Registration and the Moratorium
3. Are you here on a Visa or are you a permanent resident?
4. Do you want to work in an urban or rural area?
5. Can you afford to self-fund your General Practice training?
6. Are you working under any AHPRA registration restrictions?
7. Can you afford to work under A1 or A2 rebates?

If you’re not sure what these questions are about then this blog is definitely for you and you should read on.

There are two key concepts that need to be considered. The first is working in General Practice. The second is the training and assessment required to be undertaken in order to achieve a GP Fellowship.

If you intend to stay living and working in Australia in General Practice in the long term then you both need a job as well as a Fellowship.

Working in General Practice.

To work in Australian General Practice, you need to be able to access Medicare for your patients.

An explanation of Medicare deserves its own blog post. But for now the basic thing you need to understand is that in Australia there is a system of universal health insurance which funds by far the majority of health services in Australia, this includes both community provided services as well as hospital services. All Australian citizens and permanent residents are covered under this scheme. In addition a number of other people living in Australia whose governments have reciprocal arrangements with Australia are also covered under Medicare.

The Australian Government provides funding for services by way of rebating items which doctors are able to charge for. These are called Medicare items.

If you are not able to charge for Medicare in General Practice you are at a serious disadvantage as most patients will not be able to afford to see you or will choose to go see a GP who can access Medicare.

There are two levels of rebates available for GPs. A1 which entitles the patient to 100% of the rebate, and A2 where the patient can only claim 80% of the Medicare rebate.

Medicare Provider Numbers.

To access Medicare you need a Medicare Provider Number. A Provider Number is required for each place of practice and profession your practice in. Provider numbers are available by filling in a form , or through Provider Digital Access/PRODA .

Doctors in Australia are not automatically eligible for a provider number. You are only eligible for a Provider Number if:

• You are a recognised specialist, which the government divides in to General Practitioner and consultant physicians (basically all other specialists); OR
• You are in an approved placement under 3GA (see below) of the Health Insurance Act 1973 ; OR
• You are a temporary resident doctor with an exemption under section 19AB of the Health Insurance Act 1973 and working in accordance with that exemption.

Why Do You Need a Provider Number?

A bit of background is required in order to answer this question. In 1996, Section 19AA of the Health Insurance Act was introduced to recognise General Practice as a vocational specialty in its own right. Prior to this any doctor with General Registration could set up shop as a General Practitioner and charge for General Practice items under Medicare. After 1996 a system of Vocational Registration was introduced, whereby doctors now need to demonstrate (generally through gaining a Fellowship) that they are qualified to work as a general practitioner.

Doctor’s subject to Section 19AA are:

• Those doctors who attained Australian Medical Board registration on or after 1/11/96; and
• Permanent residents; and
• Those doctors who do not hold continued recognition with the Royal Australian College of General Practice (RACGP) or Australian College of Rural and Remote Medicine (https://www.acrrm.org.au/).

You gain continued recognition with the RACGP or ACRRM by either completing their Fellowship requirements or having been “grandfathered” into either College prior to 1996.

So basically, whilst there are some doctors who can gain an exception to 19AA or Vocational Registration. These doctors are slowly dwindling in number over the years.

What Happens If You Are Not Vocationally Registered?

Any doctor who is not vocationally registered must be on what is called an approved 3GA program in order to access Medicare Benefits. This is regardless of whether this doctor has trained in Australia or overseas.

Your 19AA restriction ends when you attain recognition (Fellowship) with a specialist college.

For more information about this, see this Fact Sheet .

3GA Programs.

To enable access to a Provider Number and ensure your patients receive 100% of the Medicare rebate, working within a 3GA program is essential.

You also have to take into account any 19AB requirements (which may restrict you to working in certain areas of workforce shortage).

You can change from one 3GA program to another but your cannot be on programs simultaneously.

These are more than 9 3GA programs. So it can be quite confusing which one to apply for and which one is best.

IMG doctors who have completed their AMC Part 1 and satisfy the AHPRA English requirements are able to apply for most of the 3GA programs listed below. So long as they have an offer of employment and suitable supervisory arrangements.

However, in my experience it can be challenging to go through both the AMC process and work in general practice. So it may be better to focus on getting yourself up to general registration first, obtaining permanent residency and then commencing general practice training via the main 3GA program the Australian General Practice Training Program.

Lets start with the main one.

The Australian General Practice Training Program.

The Australian General Practice Training Program is a key 3GA program and the main pathway for doctors trained in Australia to enter into training in general practice and charge for Medicare items whilst undertaking their training.

It is also a pathway for any IMG who may obtain general registration through the Standard Pathway process by completing the requirements for the AMC Certificate and a year of supervised practice.

Under the Australian General Practice Training Program (AGPT):
* You can train towards Fellowship with RACGP or ACRRM
* You can apply for either general or rural streams. For most IMG doctors you will have to apply for the rural stream as you will be restricted to areas of District of Workforce Shortage.
* Applications open in April each year.
* There is a Selection process
* And Eligibility Criteria
* Training year commences in January

The AGPT is Commonwealth Government funded and includes comprehensive in-practice supervision and training, and external education supports including resources, workshops and Medical Educator support.

The costs for undertaking the program are nil to low.

There are 1350 places for AGPT under the RACGP and 150 places under the ACRRM each year.

The RACCGP Practice Experience Program.

The RACGP Practice Experience Program (PEP): is a self-directed education program designed to support non-vocationally registered (non-VR) doctors on their journey to RACGP Fellowship. To be eligible to apply you have to demonstrate that you have a significant level of prior experience in general practice in Australia. The program is currently a 12 – 18-month program with a mid and end of year intake. It includes education resources and Medical Educator feedback and support.

The program costs the applicant $2,000 per 6 months and there is some Commonwealth funding support.

See here for the Eligibility criteria for this program.

ACRRM Independent Pathway.

The ACRRM Independent Pathway is similar in nature to the AGPT program in both application and structure. However, there is more flexibility in location and no streaming in the program. The program is designed to address areas of workforce shortage by supporting applicants in such positions. There are prior experience requirements and you need to self-fund your participation (approximately $30,000 in total).

It is possible to do a procedural/advanced skill component as part of the program.

Here are the Eligibility criteria for the program.

ACRRM Non-Vocationally Registered Support Program

The ACRRM Non-Vocationally Registered Support Program is similar to the ACRRM Independent Pathway. With the main difference being that there is up to $15,000 Commonwealth support provided.

Rural Locum Relief Program.

The Rural Locum Relief Program (RLRP) aims to ensure that Australian rural and remote communities have access to appropriately experienced and skilled medical practitioners.

The RLRP allows medical practitioners, in rural and remote areas who are subject to Section 19AA of the Act and who meet eligibility criteria of the program, to have temporary access to Medicare rebates when providing short term services through approved placements.

Eligibility

Applicants eligible for the RLRP fall into two broad categories:

• Category 1 applicants: Australian and New Zealand graduates, Australian Citizens and Permanent Resident Overseas Trained Doctors (OTDs) who are subject to Section 19AA of the Act only
• Category 2 applicants: Australian Citizens, Permanent Resident OTDs and foreign graduates of an accredited medical school who are subject to both Sections 19AA and 19AB of the Act (the ten year moratorium)

You need two years prior GP experience for the RACGP pathway. The amount of time you can spend on the program differs in length in each State and territory but is 2-4 years on average. Its quite a flexible program. And probably has to be given that you are moving around doing locum jobs. For each placement you need an onsite VR mentor and you have to be be working in a rural area. (RRMA 3-7 for the technical specifics). There is minimal structure. The only real support is a mentor.

Under the Rural Locum Relief Program it is possible to sit either the RACGP or ACRRM Fellowship exams. And there is funding support for doctors to sit these exams.

The Remote Vocational Training Scheme.

Under the Remote Vocational Training Scheme (RVTS): doctors can train towards FRACGP or FACRRM. You must be working in a rural area or Aboriginal Medical Service

The scheme requires a minimum of 2 years GP experience in the practice you are working in

This is a well-structured and funded program with remote supervision and external Medical Educator support and resources.

Go here for the Eligibility criteria

More Doctors for Rural Australia Program.

The More Doctors for Rural Australia (MDRAP) Program enables access to Medicare before you transition to a college program.

After Hours Medical Deputising Program.

Under the After Hours Medical Deputising (AMDS) Programs :
you are able to train towards RACGP or ACRRM Fellowships. You can work in both metropolitan and regional areas, in clinics or home visits.

All work is after-hours: 6 pm – 8am weekdays, Saturday after 12, Sunday and public holidays.

An interesting component of this program is that higher billing rates are possible in some after-hours segments.

However, your experience under this program is assessed at 50% of the actual time worked as after hours deputising is not considered comprehensive and holistic general practice and is capped at 2.5 years.

Your limited scope of practice can also make it more difficult to contextually apply knowledge for Fellowship exams.

Special Approved Placement Program.

The Special Approved Placement Program (SAPP) :is a program for doctors with extenuating circumstances. Its main aim is to assist doctors to become eligible for another program.

Other Programs.

There are a range of other programs available, however, the Commonwealth Government has signalled that they will be phasing most of these out in the not too distant future.

• Approved Private Emergency Department Program (ADEDP)
• Approved Placements for Sports physicians Program (APSPP)
• Sports Physician Trainees Program
• Prevocational General Practice Training Program (outdated)
• Queensland Country Relieving Doctors Program
• http://www.health.gov.au/internet/main/publishing.nsf/Content/work-pr-ompsOther Medical Practitioners (OMPs) programs

No new participants are being admitted to these programs after 1/11/18 and existing participants will have five years to attain Fellowship or will be moved to less favourable rebates.

With So Many 3GA Schemes It Couldn’t Possibly Go Wrong. Could It?

Yes it can. And frequently. As noted above your time on these schemes is generally limited and aimed at you progressing towards a fellowship.

Here’s a case example to illustrate the point.

Dr X is an IMG who works in a small rural town. He has gained permanent residency, and is therefore subject to Section 19AA of the Health Act, and is an IMG so also subject to Section 19AB. He has a Provider Number through the Rural Locum Relief Program and was enrolled to sit Fellowship exams which he has attempted multiple times, but due to personal circumstances had to withdraw at the last minute. In the meantime, his AHPRA Registration requires renewal, including evidence of progression towards Fellowship, which due to exam withdrawal is now problematic. He is currently not eligible to enrol for the next exam cycle due to a likely lapsed Medical Board Registration, which is required for enrolment. This is a common example of the complexities of the system and the need to ensure that you have a good understanding of all of the factors for both working and training in General Practice.

What Is a District of Workforce Shortage?

Section 19AB of the Health Insurance Act requires Overseas Trained Doctors (OTDs) and Foreign Graduates of Accredited Medical Schools (FGAMS) to practice in an area of District Workforce Shortage for ten years after their first Australian Medical Board Registration.

Whilst many doctors think that this means you will be consigned to a very remote or rural location for ten years. This is often not the case as many parts of the larger cities in Australia are considered to be areas of District of Workforce Shortage.

If you want to visualise this concept you can pop over to the highly helpful doctor connect website.

Exemptions and reductions in the ten year moratorium are available in some cases to this requirement. For more information, see this Fact Sheet .

Training in General Practice.

Vocational registration is attained with Fellowship of either the RACGP or ACRRM. There are significant differences in these programs. So its worth investigating both options before you decided which one is best for you.

Phasing Out of 3GA Programs.

The Commonwealth has indicated that by 30 June 2023 many of the existing 3GA programs will be phased out. Doctors will need to attain Fellowship or join a college-led Fellowship training Program to maintain A1 rebates.

Let’s make an itinerary.

Your route may seem complex. The following diagram is aimed to assist you in reviewing all the options available to you.

The options have been simplified to provide guidance so please revise all eligibility criteria prior to planning your approach.  View a pdf of the flowchart here.

Destination Fellowship.

Vocational Registration is given to work in General Practice when you have attained a Fellowship with the RACGP or ACRRM.

The eligibility for each exam depends on your previous experience in General Practice and what pathway you are on. Check the RACGP and ACRRM exam eligibility for your individual circumstance.

The assessment and Fellowship for the two colleges differ considerably (see table below). ACRRM Fellowship also requires completion of an Advanced Skill (for e.g. Anaesthetics, Obstetrics). Advanced Skills can also be completed as part of a Fellowship of Advanced Rural General Practice (FARGP) with the RACGP.

RACGP Assessments include:

• Applied Knowledge Test (AKT)
• Key Features Paper (KFP)
• Objective Structured Clinical Examination (OSCE)

ACRRM Assessments include

• Procedural Logbook
• MCQ
• Multi-source Feedback
• Case Based Discussion
• Structured assessments using multiple patient scenarios (StAMPS)
• Advanced Skill Assessments – StAMPS and/or a Project

One you have decided that GP is the career for you, it is not only critical to ensure you are on the right pathway, but to map out when you might complete the Fellowship assessments. Many of the doctors that I work with underestimate the degree of difficulty of the assessments. Some sit the exams without adequate preparation as either they ‘will just give it a go to see what it’s like’ or they are pressured to sit due to other factors including AHPRA Registration requirements.

An unsuccessful exam attempt usually impacts upon personal and professional confidence and makes a huge hole in your hip pocket. RACGP has recently introduced a capping on exam attempts and ACRRM has a strict policy regarding multiple attempts so it is better to plan for success in the first instance.

Do I need a Trip Advisor?

If you’re deciding on what journey to take in medicine, Dr Anthony Llewellyn is an experienced health public sector executive, medical educationalist and coach. Contact him at AdvanceMed .

If you’ve already headed a little way down the Fellowship path (any speciality) and are feeling a bit lost, then a chat with Dr Ashe Coxon at Medical Career Planning might help. Dr Coxon is a GP, Medical Educator and Medical Career Consultant.

If trudging down the GP Fellowship road, then Medical Education Experts is here to support your journey with individualised coaching and learning resources .   We have a MAP , a GPS System and a Compass that will keep you on track when planning your study for exams.

Its More Fun To Travel In a Group.

Find some colleagues to enjoy the ride with, and if you’re feeling a bit lost and confused, ask for some professional advice.

Useful Resources and Links:

• 19AA and the 3GA Program s
• DHS Changes to 3GA programs
• Doctor Connect: DWS locator
• Doctor Connect: Working as a GP
• Medicare benefits for health professionals,  intern, registrar and trainee eligibility requirements .
• Other Medical Practitioners (OMPs) programs .
• PESCI Information for IMGs
• RACGP Practice Experience Pathway  
• Section 3GA programs
• Stronger Rural Health Strategy – Streamlining General Practice Training
• Training – improved access to Australian trained general practitioners and quality care

Related Questions.

Question: What is General Practice?

Answer.

In Australia General Practice is considered to be its own medical specialty. In other countries this specialty might be referred to as either family medicine or primary care medicine.

According to the RACGP in Australia, a GP:

• is most likely the first point of contact in matters of personal health;
• coordinates the care of patients and refers patients to other specialists;
• cares for patients in a whole of person approach and in the context of their work, family and community;
• cares for patients of all ages, both sexes, children and adults across all disease categories;
• cares for patients over a period of their lifetime;
• provides advice and education on health care
• performs legal processes such as certification of documents or provision of reports in relation to motor transport or work accidents.

Question: Can I Be On More Than One 3GA Program At a Time?

Answer.

No. You can change from one 3GA program to another but your cannot be on programs simultaneously.

Question: What Happens After I Complete 10 Years In a District of Workforce Shortage?

Answer. Basically you are now free to work anywhere you chose in Australia. Its likely by this point that you will also have been able to apply for permanent residency and even citizenship. So you will essentially be the same as every Australian born and trained GP.