COVID-19 update from the Medical Board of Australia

29 Apr 2020

The Medical Board of Australia responds to questions about its regulatory response to the COVID-19 pandemic.

A message from Dr Anne Tonkin, Chair of the Medical Board of Australia

We are in uncertain times.

Australia has scaled up to respond to the COVID-19 pandemic. Agencies and individuals across the health sector have made significant changes to their operations, planning and policies. We have prioritised our readiness to respond.

The impacts so far have been varied and uneven. Some of us are stretched, dealing with the direct and indirect impacts of massive change while others have been impacted by elective surgery cancellations, reduced hospital activity in relation to non COVID-19 patients and the practice impacts of social distancing requirements.

Like all Australians, our personal lives have dramatically changed.

As a profession, we have mobilised to prepare for the worst. We have not yet faced what we feared, but we don’t know what lies ahead.

Uncertainty has become our new normal and for many of us, this is hard.

More than ever, we must look after ourselves, and out for each other. If you need support, I encourage you to contact your local doctors’ health service, doctors4doctors.

Last month, the Board made a series of pragmatic decisions to boost the medical workforce and ease administrative demands on health services, while maintaining patient safety. Regulation responded to a national emergency.

We continue to be flexible as we plan for the unknown. We prioritise patient safety, while supporting Australia’s readiness to respond to COVID-19. Many of us have been redeployed already and many more of us may be in the months ahead. As individual doctors, we want to help. But what if we are asked to practise outside our familiar scope? What will happen if something goes wrong?

Good medical practice requires us all to know our limits, and practise within them. Understanding our strengths and weaknesses, and the limits of safe practice, is always important. It becomes vital when familiar frameworks are removed.

In Australia, the Medical Board does not regulate scope of practice and will not prescribe what you can and can’t do. The Board understands that if the pandemic worsens, more doctors may need to work outside their usual scope. You should always prioritise patient safety and if you are working outside your normal scope, make sure you have appropriate support and supervision. If we receive a notification, the Board will consider the circumstances in which you are practising.

To help individuals and health services safely navigate changes to scope of practice, we have published more information about what we expect. It addresses questions we have been asked in recent weeks.

The Board will continue to be flexible and welcomes suggestions about reducing administrative burdens and supporting the workforce, when it is safe to do so.

Australia’s doctors, nurses and other healthcare workers have long been the most trusted and valued members of our community. Your response to this pandemic has deepened and justified this trust.

Guidance

Scope of practice – doctors with general and specialist registration

As individual medical practitioners and healthcare organisations prepare to deal with a potential influx of patients, issues around scope of practice are arising. Hospitals are keen to mobilise medical practitioners to work in areas they are most needed and are asking whether they can roster practitioners outside their usual scope or specialist registration.

Individual doctors, as well as organisations who engage medical practitioners, will need to make decisions about scope of practice. That decision should prioritise patient safety. It should take into account each doctor’s qualifications, training and experience, as well as the transferability of their skills to deliver safe care. The decision needs to also consider the conditions in which the doctor will be working, including facilities and their access to supervision and training. Now more than ever, long established local processes for credentialing and defining scope of practice will be crucial.

The Board does not prescribe what individual medical practitioners can and cannot do. That is a decision for each practitioner and the organisation engaging them, prioritising patient safety.

Medical practitioners with general and specialist registration are not restricted in their scope because they have specialist registration. Specialist registration confirms that a medical practitioner has additional specialist qualifications, as well as the qualifications for general registration.

Hospitals and health services are responsible for ensuring that the practitioners staffing their services have the necessary qualifications, skills, training and experience to deliver safe care. Except for practitioners with restrictions on their registration¹, the Board will not be providing advice about who can practise in which positions. Local processes for credentialing and defining scope of practice are in place for this purpose. Among a range of issues, they will consider:

• the practitioner’s qualifications, skills, training and experience
• the transferability of skills to deliver safe care
• the conditions in which the practitioner will be working including facilities, supervision and training.

Scope of practice – international medical graduates with specialist registration only

Internationally qualified specialists can be granted specialist registration without being qualified for general registration. This means that questions can arise about how far outside their specialist registration they can practise.

The Board’s primary focus is on patient safety. Hospitals and health services should use their processes for credentialing and defining scope of practice to determine whether it is appropriate to roster the specialist in another role.

As with practitioners with specialist and general registration, health services should consider:

• the practitioner’s qualifications, skills, training and experience
• the transferability of skills to deliver safe care in the new environment
• the conditions in which the practitioner will be working including facilities, supervision and training.

Protection of title

The National Law², which is the legislation that gives the Board its powers, regulates by protection of title and not by scope of practice.³ A medical practitioner can work in a different scope of practice if it is safe to do so, but they cannot use a title for which they do not have specialist registration. For example, a ‘specialist emergency physician’ using their skills to work in an intensive care unit would be in breach of the National Law if they call themselves a ‘specialist intensive care physician’. Similarly, a ‘specialist intensive care physician’ who uses their skills to work in an emergency department cannot call themselves a ‘specialist emergency physician’. However, using their transferable skills to do this work safely is not in breach of the National Law and does not require any regulatory approvals.

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¹ For example, conditions or undertakings that are published on the Register of practitioners.

² The Health Practitioner Regulation National Law, as in force in each state and territory.

³ There are three exceptions to this: restricted dental acts (s. 121), prescription of optical appliances (s. 122) and spinal manipulation (s. 123).

Continuing professional development

The Board last month confirmed it would not take action if you cannot meet the CPD registration standard when you renew your registration this year.

These relaxed requirements apply to the CPD doctors are expected to undertake in 2020, and to their declaration in the year that covers 2020 CPD.

If you have general registration, this will be the declaration you make when you renew your registration in 2020. If you have specialist registration, it may be related to the declaration you make in subsequent years, about the 2020 CPD year.

We are clarifying this because the CPD cycles for specialist colleges vary.

Issues related to interns

The Board has received enquiries about its advice about intern requirements published on 30 March 2020.

The Board’s position

On 30 March 2020 the Board announced that it would waive the usual rotation requirements for interns in 2020 and accept the following supervised clinical experience for general registration:

• at least 40 weeks full-time equivalent service (a reduction of seven weeks to allow for isolation/sick leave, etc.)
• the clinical experience can take place in accredited and non-accredited positions
• the requirement for the usual rotations of medicine, surgery and emergency medical care are waived. The Board will accept clinical experience in any supervised rotations.

Health services that employ interns must continue to supervise them and provide them, as much as possible, with meaningful educational clinical experiences and teaching, as well as support during what will be a challenging and difficult time.

For the purpose of granting general registration at the end of the intern year, the Board will accept a report from the Director of Medical Services, Director of Training or another person authorised to sign off intern reports which confirms that each intern has performed satisfactorily during the intern year.

Questions and answers

Here are some answers to the most common questions we have been asked in recent weeks about registration requirements for interns.

Can I stop working when I have completed 40 weeks of supervised practice in my intern year?

The Board reduced the minimum supervised clinical experience required of interns in 2020 to at least 40 weeks, from the standard 47 weeks, to allow for sick leave and isolation during the COVID-19 pandemic. It has not reduced the length of the internship. When the period of supervised practice has been less than 47 weeks, but at least 40, the intern will need to explain the reasons for the shortfall. Having to take sick leave or to isolate as a result of COVID-19 are acceptable reasons for reducing the period of supervised practice.

The Board expects interns who started at the beginning of 2020 to continue their internship until the start of 2021, when they can apply for general registration. Interns who started their internship in late 2019 are required to continue their internship until late 2020.

The Board will not approve applications for general registration earlier than the usual intern completion date.

I am due to start my internship in mid-2020. Will the Board’s revised arrangements apply to me?

There is a small group of interns who may start their internship mid-year.

The Board will continue to review the requirements for interns, as the impact of the COVID-19 pandemic becomes clearer. We will be flexible if there are ongoing impacts on health services that affect internships.

I am a medical graduate and have not previously completed an internship. Will I be granted general registration if I complete an unaccredited program that involves health-related practice but not directly clinical work?

The Board requires interns to satisfactorily complete supervised clinical experience for the purposes of general registration. Practitioners whose internship does not include clinical roles (including assessing and treating individual patients) are not eligible for general registration.

Issues related to international medical graduates

Practice with telehealth

With the increasing uptake of telehealth, international medical graduates (IMGs) with limited and provisional registration are seeking advice about whether they can practise using telehealth.

The Board agreed to temporarily vary the definitions of level 1 and level 2 supervision to allow IMGs to participate in telehealth when appropriate supervision can be assured, as follows.

Level 1 supervision

Under the standard definition, level 1 supervision does not permit supervision via telephone contact or other telecommunications.

During this pandemic period, the Board has decided that telehealth can be undertaken by IMGs with level 1 supervision if:

• the supervisor is contactable 100% of the time that the IMG is consulting, and
• the IMG will consult the supervisor in person, via video or teleconference, before each patient consultation ends.

Level 2 supervision

Telehealth can be undertaken by IMGs with level 2 supervision when:

• the supervisor is contactable at least 80% of the time that the IMG is consulting, and
• the supervisor and IMG discuss patients that the IMG has consulted at least on a daily basis (and more frequently if necessary).

Level 3 and level 4 supervision

Telehealth is allowable under the existing requirements for level 3 and 4 supervision.

Moving from level 1 to level 2 supervision when the IMG is employed privately

In March 2020, the Board advised that hospital-based IMGs could move from level 1 to level 2 supervision by providing written notice from the Director of Medical Services or equivalent (without a change in circumstances application) if:

• they have been on level 1 for a minimum of two months, and
• the DMS is confident that the IMG has demonstrated sufficient competence to practise safely under level 2 supervision.

The Board has received questions about whether this applies to IMGs who are working in hospitals but are privately employed, for example, by a private radiology practice.

Advice

The Board’s March 2020 advice applies to IMGs working in and employed by the public health system.

Privately employed IMGs working in the public or private system can apply to change levels of supervision using the ‘change in circumstances’ application process. They cannot change levels of supervision through a written notice from the Director of Medical Services.

Additional resources – college responses to COVID-19 pandemic

The AMA Council of Doctors in Training (AMACDT) has developed an online resource to support current and aspiring specialty trainees to keep up to date with the status of college responses to the COVID-19 pandemic.

This resource summarises publicly available information from college websites about changes to, and the current status of, assessments, education and training, selection into training and wellbeing. It includes links to college COVID-19 webpages as well as to college webpages providing information specifically targeted at trainee wellbeing.

The resource is on the AMA website.