Psychiatrist Anthony Llewellyn, the medical manager of a regional health district, says the registration maze is ''bordering on what I see as criminal in its inefficiency''. German anaesthetist Ariane Kersting describes it as ''madness''. Some foreign doctors give up and leave; others - like Pakistan-trained Nasir Mehmood Baig, who arrived in 2005 and has a wife and four children to support - drive taxis while navigating their way towards registration. Those who eventually have their qualifications recognised have to work for 10 years in often remote and rural areas shunned by Australian-trained doctors if they want access to Medicarebilling, without which they cannot make a living. Most had no idea of the obstacle course they would face when they answered the call to come to Australia to help plug holes created in the years after the Keating and Howard governments froze enrolments of medical students to contain the Medicare bill. The registration system is so convoluted that MPs involved in a federal parliamentary inquiry examining ways of making it simpler without cutting standards have been left perplexed. Inquiry chairman Labor MP Steve Georganas says the accreditation and registration process is a ''complex mish-mash'' that does not work properly.

It's not as though Australia doesn't need foreign-trained doctors. Almost 40 per cent of Australia's 75,000 doctors trained overseas. About 68 per cent of them work in major cities. Less than a third work in rural and remote areas, but they make up almost half the medical workforce in those areas. In one-doctor towns, often they are the only physician. Nobody denies the need to carefully check medical qualifications, and all agree foreign doctors need a good standard of English. ''Absolutely, they have to be thorough in verifying someone's credentials,'' said Dr Douglas. ''The problem is that the assessment we demand of foreign doctors is far greater than what we demand for our own practitioners.'' After the ''Dr Death'' scandal - the failure of Queensland authorities to check the credentials of Jayant Patel, the surgeon recruited from the US and now serving seven years' jail for manslaughter and grievous bodily harm - registration processes were tightened-up, centralised and supposedly streamlined. Commonwealth and state governments set up the Australian Health Practitioner Regulation Agency in July last year to replace myriad state and professional boards. But the post-Patel reforms seem to have made things more complicated. In June, a Senate committee inquiry into the new regulation agency, after hearing complaints of long delays, poor advice and lost paperwork, called on the agency to ''significantly improve its performance''.

The same complaints have been made to the committee chaired by Mr Georganas. The process is one of the most difficult to understand in the world, according to Rural Health Workforce Australia. Martina Stanley, director of a medical recruitment company, says other Western countries have complex and strict systems, but ''we have the worst system for co-ordination'', with a reputation for ''causing frustration that makes us look ridiculous''. Foreign doctors face a spaghetti bowl of red tape, involving multiple agencies. The Australian Medical Council checks and tests their credentials; the medical colleges govern specialists; and the Medical Board of Australia registers them so they can practise. The regulation agency handles the paper work. Gaining registration can entail more than a dozen processes. Late last year, Queensland MPs from electorates reliant on foreign doctors and alarmed at what they saw as discrimination by regulators and medical colleges, demanded a parliamentary inquiry.

National Party MP Bruce Scott talked of a system ''that has just gone mad''. Independent MP Bob Katter described the process as a disgrace. ''Without overseas-trained doctors, regional Australia could not function,'' he said. In response, Health Minister Nicola Roxon asked the House of Representatives committee on health and ageing to hold an inquiry. It will report early next year after receiving close to 200 submissions and holding 20 public hearings across the country. It heard persistent complaints from doctors forced to do onerous language tests; of accrediting agencies not sharing information; of a lack of transparency; of shifting rules; and of a perception that the medical establishment is a closed shop protecting vested interests. ''It's clear the system is not working properly,'' Mr Georganas told The Sunday Age. ''I don't think what we're talking about is discrimination, but I think it's this stupid bureaucracy that has grown out of each different college and the Australian Medical Council. Every step of the way there's a separate bureaucracy. None of them talk to each other.'' He highlighted the case of Dr Douglas, now vice-president of the Australian Overseas Trained Doctors Association, who told the inquiry of a Kafkaesque ordeal with a ''dysfunctional, difficult and irrational bureaucracy''.

The Canadian is a native English speaker, but to practise here she was required to provide written proof of her language proficiency from her high school that closed decades ago. She was forced to do the costly medical council accreditation process twice in two years, and was confounded by more than one catch 22. She had to obtain a fellowship with the college of general practitioners before she could register as a GP; but she could not get a fellowship until she was registered. As processes dragged on, Dr Douglas said she ''fell into a state of deep depression''. ''It isn't that any one event in itself is particularly shocking,'' she wrote to the committee, ''it is the fact that the problems never seem to end, and just go on and on, to the point where you literally feel like you are losing your mind.'' But simply packing up her life and heading back to Canada to start over again was not an option: her children had settled into school and considered Canberra their home. Personally and professionally, Dr Douglas has committed herself to Australia.

Our nation's dependence on foreign doctors is self-made. The decision by first Labor and then Liberal federal governments in the 1990s to freeze local medical school enrolments was made amid predictions of an over-supply of doctors. But the freeze did not account for a growing population and the reluctance of Australian doctors to work in the bush. So doctors were recruited from overseas. There was a catch. The Howard government barred doctors who entered the country after 1997 from billing under Medicare for 10 years unless they worked in areas of need, often in rural towns. At the heart of the system are the Australian Medical Council and the Medical Board of Australia. Both are unapologetic, defending the need for strict standards to protect patients. Council chief executive Ian Frank conceded the process can be complex, creating stress and frustration for doctors involved. ''Nevertheless,'' he told the committee, ''the assessment and registration of medical practitioners is a high-stakes process where individual failures, as evidenced by the Patel case in Queensland, can be very costly for the Australian community and lead to a loss of confidence in the regulatory processes that we have, not to mention adverse clinical outcomes for individual patients.''

Medical board chair Joanna Flynn said the process had to be stringent to ensure only qualified people were registered. She insisted the complaints did not reveal a systematic failure by the board and associated bodies. ''We try to make a good judgment call between the need to provide medical services to the community and the need to ensure that everybody is appropriately qualified,'' she said. ''I believe that most of the time we get that right.'' But Dr Flynn said more effort could be made in explaining the process. The board and the medical council were looking at ways of reducing duplication, possibly with an online repository of documents so doctors do not have to provide separate certificates to different agencies. A central grievance of foreign doctors is the Medicare rule and their complaint is backed by major professional bodies. Former Australian Medical Association president Andrew Pesce said lifting the 10-year moratorium was the best way of supporting foreign doctors. He said the rule raised human rights issues, while allowing governments to avoid the burden of training enough local doctors and providing incentives for them to work in regional areas. The system meant foreign doctors were conscripted to work in the bush, Dr Pesce said. Given the lack of support, and the nature of rural practice, there ''could not have been a worse place'' to send doctors unfamiliar with Australia.

The Rural Doctors Association of Australia says overseas-trained doctors have prevented a catastrophic collapse in the medical workforce in rural and remote areas, but it too wants the ''unconscionable'' 10-year moratorium phased out. Loading Health Minister Roxon said she did not want to pre-empt the parliamentary inquiry's findings. In a written response to questions from The Sunday Age, she appeared to rule out lifting the 10-year rule. Overseas-trained doctors had ''proven to be a very effective way of improving workforce shortages in the areas of greatest need, which tend to be located in rural and regional Australia, and the government has no current plans to change this''. thyland@theage.com.au