In an era of increasing multiculturalism, when Australia and New Zealand are dependent on foreign-born physicians to meet the nations’ health care needs, the Australasian College of Emergency Medicine (ACEM) is grappling with charges that nonwhite physicians from other countries are subject to discrimination in specialty qualifying tests.

The Melbourne-based nonprofit, which is responsible for training emergency physicians and for related professional standards in Australia and New Zealand, was the subject of a 34-page complaint filed by 33 physicians who were undergoing specialty training that alleged systemic racism.

In response to the complaint and resulting media coverage, ACEM launched an inquiry earlier this year, headed by Helen Szoke, MA, PhD, who worked with Australia’s Human Rights Commission before assuming her current role as head of the charity Oxfam Australia. The inquiry is scheduled to be complete in June.

The physicians who filed the complaint have remained anonymous because of their concerns about professional repercussions, and an Oxfam spokesperson for Szoke referred questions to ACEM spokesperson Fin Bird, BA, who declined to comment and said the complaint itself is confidential.

As a result of the lack of official information, most of what is publicly known about the issue has come from The Australian news site, which on February 9, 2017, reported that the complainants seek to have their failures to pass the 2016 examination overturned on the grounds that the results were racially discriminatory.

The Australian noted that the complainants “revealed their white colleagues are 13 times more likely to be admitted as specialist emergency doctors” and that the disparities illustrate discrimination against foreign and nonwhite physicians. They also noted that nonboard-certified emergency physicians in Australia are paid less than $100,000 a year compared with $400,000 for emergency specialists.

During the second half of 2016, the clinical examination pass rate among nonwhite specialist candidates, who make up more than a quarter of all ACEM enrollments, was just 6.8% among the 204 candidates participating in the program, according to figures cited by The Australian . That compares with a pass rate of 88% for their white classmates. The clinical examination is the last hurdle for physicians attempting to become emergency specialists.

Bird referred questions about the issue to a brief letter from ACEM president Anthony Lawler, MBBS, B.Med.Sci, to “trainees and fellows” that was posted on the ACEM Web site. Bird had previously told The Australian that further comment was being withheld “to respect the integrity of the process and confidentiality of the applicants.”

Lawler’s letter, dated January 31, 2017, references media coverage about the complaint and states that “It is the understanding of the College that we were made aware of the complaint at the same time as the media was notified.” Lawler wrote that ACEM “is taking the confidentiality of this sensitive matter very seriously. We will investigate the claims thoroughly through a fair and robust process, respectful of all parties. However, for obvious reasons of confidentiality, we are unable to speak about individual cases.”

Lawler announced the formation of the expert advisory group to “determine the clear facts in this matter and any appropriate responses,” and promised to “communicate more about the Advisory Group’s Terms of Reference to all trainees and Fellows shortly,” although by mid-March, no further communications about the advisory group’s activities had been posted on the ACEM Web site. Lawler previously told The Australian that the issues raised by the complaint were complex and “making rushed announcements would benefit no one.”

In a nod to the seriousness of the matter, an ACEM statement that ran in The Australian noted that “[t]he college recognises that discrimination can have a serious impact on those affected by it: it demeans the worth of individuals; it prevents our people from reaching their true potential; and it causes the loss of highly desirable talent from our profession.”

The complainants seek to have ACEM “statistically modify” the 2016 clinical examination results to “remove the clear element of racial bias from them.” In a letter to ACEM that was also provided to The Australian , the complainants said that although they welcomed the official inquiry, they were dissatisfied that ACEM had failed to “expressly address our complaint at all.”

The 33 physicians also filed a complaint with the Australian Medical Council, which oversees grants and the licensing of ACEM and all other specialist medical training colleges. Australian Medical Council chief executive Ian Frank told The Australian that his organization would need more information before commenting.

Charges of racial discrimination in emergency medicine training are not new to the Australasian region. The Australian reported that numerous physicians, including nonwhites who were born and educated in Australia, had written to the news outlet, raising concerns of similar experiences with racism at ACEM and several other medical colleges.

Some physicians who contacted The Australian countered that there were other issues at play, including “poorer communication skills and less robust education among some foreign trained doctors.”

Deep cultural divides are evident among the public comments posted in response to The Australian ’s coverage of the issue , one of which noted that racial data are not collected for individuals taking the examinations and argued that the disparities had more to do with overseas medical training than race. Australia’s antidiscrimination act makes it illegal for employers to discriminate against persons because of race, ethnicity, or country of origin, but does not specifically address training requirements.

Among individuals who took issue with the complaint, senior ACEM lecturer Bob Dunn, MBBS, “hit back at claims of systemic racial bias at the school, saying many of those foreign-trained doctors who failed its key exam to become emergency specialists were under-skilled,” The Australian reported on January 31, 2017.

Dunn, an associate professor at Royal Adelaide Hospital, wrote a letter to colleagues saying graduates from overseas medical schools were more likely to rely on “rote learning,” were more likely to make wrong decisions that were potentially life threatening, and often needed “tough love” from teachers, according to The Australian . Dunn also said graduates of overseas medical schools sometimes lacked “specialist level knowledge” and proficiency in English.

Another emergency specialist interviewed by The Australian said the disparity in test results between whites and nonwhites was more likely about “baseline education” in emerging countries than about race.

The complainants argue that the disparities in the testing results are not about substandard skills or language issues, given that they have worked in hospitals alongside white counterparts for years and in many cases shared the same training, according to the January 30, 2017, Australian , which noted that the complainants were all fluent in English, which for many is their first language.

“That the college would pass less than 10 percent of the non-Caucasian cohort, deeming the rest unfit to be emergency medicine specialists, while passing the vast majority of Caucasian candidates is embarrassing to the college,” the complainants wrote in their letter.

ACEM did not publish the physician registrant test results, and news outlets, including The Australian , have frequently relied on anecdotal information, such as the complainants’ statement that they had queried 59 nonwhite students from 2016 and found that just 4 had passed the clinical examination. One of the students (who was not identified by name) reportedly told the complainants that he had repeatedly failed the examination and that racial discrimination had a “demoralizing effect” on him and many other nonwhite students. “We are looked down on by our fellow colleagues and consultants after repeated failures as if we are not trustworthy,” the student said.

According to The Australian , the complainants listed pass rates for all hospitals where ACEM students worked, including at Newcastle’s John Hunter Hospital, where all 4 white candidates passed but all 5 nonwhite candidates failed; at Canberra Hospital, where 1 of the 2 white candidates passed, whereas all 3 nonwhite candidates failed; and at Brisbane’s Prince Charles Hospital, where all 4 white candidates passed, whereas the only 2 nonwhite candidates failed.

In an official Oxfam statement, Szoke previously noted that “it’s concerning that there are so many of these inquiries taking place in the medical profession,” adding that she saw the ACEM inquiry as a positive sign that the issue is being addressed. “We know that racism has a significant impact both on the people who experience it, as well as the broader community,” Szoke said in the statement. “Research shows that there are significant links between experiences of racism and discrimination and poor physical and mental health, reduced productivity and reduced life expectancy. We also know that the challenges of protecting the human rights of individuals occur throughout all levels of society.”

When the advisory group was formed, it was to include 2 current members of the ACEM board, a current ACEM trainee, and a recently graduated ACEM fellow who obtained his or her primary medical training from a country other than Australia, New Zealand, the United Kingdom, Ireland, Canada, or the United States. Bird and Oxfam spokesperson Laurelle Keough, BA, did not provide the names of those on the advisory panel. The Australian reported that one of the members is professor Kichu Nair, chair of the workplace-based assessment committee at the Australian Medical Council, and that former New Zealand health and disability complaints commissioner Ron Paterson is helping guide the inquiry.

In addition to reviewing examination procedures and describing measures that may be necessary to eliminate discrimination in examinations and other college procedures, the advisory group is undertaking surveys and analyzing literature on the subject, according to reports in The Australian .

Before the filing of the complaint and the launch of the official inquiry, the March 13, 2016, Guardian newspaper reported that according to the 2011 census, 56% of Australia’s general practitioners and 47% of its specialists were born overseas. Among those, approximately 40% were also trained in other countries, with the largest numbers coming from the Indian subcontinent, Southeast Asia, and sub-Saharan Africa.

The Guardian reported that a Queensland study found that a physician with Pakistani credentials who had qualifications, education, and personality comparable to one with Australian credentials was less likely to be hired. Foreign-born physicians were also more likely to be treated disrespectfully by patients and other physicians.

Bangladeshi-born and Australian-educated psychiatrist Tanveer Ahmed, who was previously the Australian Medical Association’s head of junior physicians, told The Australian in a February 2, 2017, article that he had heard allegations of racism at ACEM and other specialist physician schools for years. Ahmed said the complainants initially contacted him to ask for help with their case but that he did not consider racism to be the key cause for the discrepancies in clinical examination results.

“It is a failure of the college if they are taking people on as trainees but then have such low pass rates for certain groups,” the news outlet quoted Ahmed as saying. “This is actually the key accusation the emergency department doctors should be making instead of… racism.”

Ahmed said similar problems can be observed across all specialist training colleges, although it was particularly pronounced in emergency medicine.