Guide to Working in Emergency Medicine in Australia as a UK Junior Doctor

Emergency Medicine is the most common specialty for UK doctors working in Australia.

Some doctors will focus on Emergency Medicine for their entire time in Australia, while others tend to use it as a stepping stone to other specialties. In either case, if you’re considering applying for Emergency Medicine jobs in Australia, it’s important to know how the experience differs in an Australian Emergency Deparment versus an A&E job in the NHS.

In this article, we’ll break down the following:

👉  How the clinical experience, supervision and support differ between the UK and Australia
👉  What your roster and working hours will look like
👉  Tips for settling into the department
👉  ED-specific guides and tools that are useful in your first few months in Australia

💡  A quick note before we get started: in Australia, the ‘A&E' terminology does not exist – it is known universally as the Emergency Department or ‘ED’ for short.

Clinical

🏥  What structural differences are there with the NHS? 

Australia’s healthcare system is a mixed public-private model, meaning higher earners are required to take out health insurance for private care in addition to the taxes all citizens pay towards public health care. 

The result appears to be that there is more money available which means clinical decision making is not constrained by limited resources. Same-day MRI scans, anyone?

📍 How different is the role of the ED with the wider hospital system?

Tertiary centres in Australia tend to cover a larger area than those in the UK. As a result, specialty teams are concentrated in relatively fewer and larger tertiary centres. This is especially true in larger states such as Queensland, which is a state that is 7 times larger than the UK.  

For example, some hospitals do not have a women’s health or paediatrics center but will have a dedicated trauma service and opthalmoogloy and toxicology teams. 

In ED, this means that you can end up facilitating and receiving inter-hospital transfers regularly. As a result, smaller ‘DGH’ equivalent hospitals will often see less-sick patients with older populations. They will rely heavily on inpatient general medical and general surgery teams to cover a wider range of patients moving through the department.

However, in general, EDs appear more capable of dealing with sicker patients. Many seniors pride themselves on using the Emergency Department for Emergency Medicine (rather than a glorified triage service or waiting area!) 

ED consultants will have generally done time as senior registrars in ICU as part of their training, and many will also have anaesthetics experience too.

As a result, you will find that ED staff perform clinical procedures often handled by other teams in the UK.  

These procedures can include:

👉  Intubations/central lines
👉  Arterial lines
👉  Chest drains
👉  Lumbar punctures
👉  Casting and reducing fractures
👉  Closing simple wounds 

🩺  How are the relationships with specialty teams?

Relationships between specialty teams and EDs are almost universally recognised as better than in the UK. For example, there is almost no haggling with radiologists to process imaging requests. If a scan is requested, it generally happens with little to no fuss.

Similar to the UK, referrals are over the phone. Also, referrals for outpatient follow-up is through an area-wide web form and is the same form for all specialties. There is generally very little faxing or trying to find the correct email addresses to send the referrals. 

⏰  How do wait times compare?

The wait time for patients being accepted by a specialty team and admitted to the ward is generally less than in the UK – in most cases, it is only a few hours.  

In some hospitals, senior ED doctors will have ‘admitting rights’, meaning that they can decide the pathology/treatment and ongoing plan for an appropriate patient and then admit them directly to the relevant ward. The inpatient team then reviews them on the ward rather than ED (and ergo, cannot refuse the referral).

💊  What difference is there in pathways and medications?

Some clinical pathways and first-line medications are inevitably different as they are guided by Australian rather than NICE guidelines, but they largely correlate.

Some examples of the differences: opiate and benzodiazepine prescribing is far more liberal here – I was shocked to find my hospital does not routinely stock co-amoxiclav or codeine!

There will be drugs you have never previously used and presentations you may never have seen that enter your daily practice. It is a daily occurrence here to see agitated meth-intoxicated patients sedated with IM droperidol (unlicensed in the UK).

The ‘analgesic ladder’ has been foregone due to variable patient response to codeine, instead leaning heavily on endone (oxycodone). Being open to the direction and guidance of your seniors is crucial for these situations.

🥱  Do UK-trained doctors tend to cope with the workload?

If you are coming from working in the UK, a very stretched system, you should be able to cope very well in Australia. UK medical training tends to produce resilient doctors who have more experience in face-to-face patient interactions compared to Australia. 

Ultimately, try not to concern yourself with unhelpful comparisons to the knowledge of others but learn where you can and focus on any gaps in your own practice that they may expose.  

Staffing and Support

👋  How much support is there as an RMO?

ED is a great learning experience as there is a good level of senior support. All junior staff are expected to run every patient past a senior – usually a consultant in-hours. This is a welcome reassurance when settling in and a great chance to learn in practical scenarios.

As an RMO, on night shifts, you will be expected to discuss patients with a Registrar. Most EDs will have at least one senior registrar overnight, but this will likely be complemented by several PHOs or Junior Registrars.

(If you are unclear about how the grades in Australia work, see the next question!)

Additionally, you will not be expected to work outside of your competency or run a department overnight within your first year of arriving in Australia. However, this may happen if you have accepted a job somewhere incredibly rural/remote. But, this is rare and will be made abundantly clear in the role description. 

This is partially a product of your registration to practice. For your first year in Australia, you will only have ‘provisional’ registration to practice with AHPRA (the governing body, equivalent to GMC). This means you are not allowed to practice without appropriate supervision.

After 12 months of work (excluding leave), you will receive General Registration and a full license to practice. This means you can go on to work in a more senior role, enrol in a specialty college, work privately or locum.

🙋  How does responsibility vary by grade?

The grading system in Australia is very confusing when compared to the grading system in the UK. Since this topic is so complex, we broke it down in a separate article. Here you will find the translation of grades and the responsibilities for each. 

👩🏻  Are there differences in nurse staffing?

Nurse staffing ratios (4:1) are generally the same as in the UK, as are porters and cleaners. All non-clinical work on the floor and in the back offices is generally carried out by competent admin staff.

Teaching

📓  How much teaching time do you get?

Most EDs will have dedicated teaching time for residents covering a range of practical topics such as snake envenomation. You are expected to attend these lessons and they are usually built into the roster to allow this. There will also be many opportunities for on-the-job teaching and tips, especially given the amount you are expected to discuss with seniors.

If you progress in ED, non-rotational staff posts will often have a half teaching day ever week built into the roster, which usually means protected teaching off the floor.

💰  Is there a study budget?

All public system employees are entitled to a study budget, which comes from the hospital payroll. This may be paid on a request-by-request basis, as in the UK, or given automatically as part of your pay check (meaning everyone automatically gets their full entitlement in divided fortnightly instalments and can then choose to spend it on courses should they so wish). 

In this case, the budget amounts to around $90-100 every fortnight. Study leave/exam leave is usually at the discretion of rota managers/consultants based on cover.

Hours and Pay

⏳  What are the working hours?

Rotas (almost ubiquitously called ‘rosters’ in Australia) are usually released in quarterly instalments for the rotation.

You will usually be rostered a time (day shift, evening/disco shift, or night shift) and an area of the department. Resus shifts are generally coveted by trainees. However, in the beginning, you may not get as much access to this area as you would like.

Most departments are split into the standard model of ‘Acute’ beds, resus bays, short stay and ambulatory care/’fast track’ from the waiting room. 

Corridor medicine, the bane of ED life, does, unfortunately, exist in Australia, although generally to a lesser extent. The corridor of patients waiting for ‘acute’ beds is generally known as ‘the ramp’.

🤑  What is the pay? Is overtime paid?

Pay is accordingly to the applicable state banding and is generally doled out fortnightly rather than monthly.

There is a strong culture of being paid for the hours you work. Overtime is logged and sent to payroll – it is usually paid out without too much hassle. Unlike exception reporting in the NHS you can only claim overtime pay, not time-off in lieu.

Places to Work

🥼  Can I work in an ED in a private hospital?

Private hospitals will sometimes include a private Emergency Department. They will usually not employ international medical graduates who do not yet have General registration with AHPRA.

For doctors, especially if you're looking to gain experience in Australia, these are not necessarily better places to work early in your career. They tend to see only low acuity cases, more similar to an Urgent Care centre than a full Emergency Department, and may have less staffing for both doctors and nurses.

For many serious conditions and life-threatening presentations, patients may get more optimal care in public hospitals.

🦘  What are the pros and cons of working in a very rural ED?

It can be common for UK doctors to find roles in more rural Emergency Departments. Here's a breakdown of pros and cons:

Pros
‍👍  Many rural ED placements offer lucrative incentives to work there
👍  May be a good stepping stone to taking more senior roles in busier locations
👍  Good opportunity to explore the outback
👍  Increased chances of working in a variety of specialities

Cons‍
👎  The living environment will be very different from the UK, with potential for isolation and homesickness
👎  Limited access to perform formal blood tests and x-ray imaging

Guides

Orthoflow

You will inevitably find yourself needing to answer questions such as: Do I need to cast above or below the knee? Do I need to splint this finger/toe? Can this be seen in ortho outpatients? This app has the answers. Well worth the relatively low price and uses simple diagrams and flow charts. The orthopaedic registrars will love you for it!

Eye Manual

I use this more as a library of images to aid in ophthalmology diagnoses, and to highlight possible diagnoses I may not have considered. It describes common presentations and symptoms in an accessible way that is useful to anyone not experienced in this area of medicine.

iResus

The Resus Council’s  ALS algorithm in handy app form. This should be well committed to memory for all those working in ED,  but I propose could be used as an aide-memoire if there is any in-the-moment panicking.

Local prescribing guides

Most health areas will have an app or webpage for these – don’t assume your old trust’s app/microguide will be correct!

BMJ BestPractice 

Although in Australia this is largely replaced by the website ‘eTG complete’. This site does not have an app and sometimes falls short when looking up less common conditions. In these instances, it may be useful to check what the NICE would recommend before speaking to the relevant specialty/your seniors.

Longer-term

🇦🇺  How can you prepare if you want to stay long term?

There is a strong culture of UK-trained doctors making the move to Australia and deciding to stay for training. This is especially true in ED, possibly due to improved working conditions compared to A&E in the UK and the fact most foundation doctors coming here will start there. 

For those thinking of staying longer than just a year – it’s all about the interpersonal connections (and in some cases, can seem almost nepotistic).

Roster shifts, roles, future jobs and even training college places are largely won and lost through references and referrals. Wasting time on pointless audits and CV-boosters is not useful.

Early stages of career progression are more dependent on showing yourself to be a capable worker day-to-day and fostering good relations with colleagues, and if you like the idea of staying longer-term, it can be helpful to make this known early. 

📚 Continue Reading

🚀 This article is part of Messly's Ultimate Guide to Working in Australia. The guide covers all you need to know as a UK doctor to understand your options, research your move, find work, get registered and move out to Australia.
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❓ If you are still weighing up whether a move to Australia is right for you, our article To Aus or not to Aus breaks down the pros and cons, so you can make an informed decision. Read this with Common Questions on Moving to Australia as a UK Junior Doctor.
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🤔 Confused about how the grades work in Australia, and which roles you should be applying for? This article breaks down the grade system and explains which roles might be suitable for you.

✈️  There are four routes to finding a job in Australia. In this detailed guide, we explain how each works and the pros and cons of each, so you can kick-start your search for your dream job Down Under

📄  If you're preparing to submit applications for jobs in Australia, you'll want your CV to stand out from the crowd. This CV-writing guide will help you make an excellent first impression and get you through to the interview stage.

This article was written by Dr Mark Coulson, who moved out to Australia in his F3 year in 2019, and is now entering his third year working in ED at Princess Alexandra Hospital. You can read his personal story of settling into life in Australia here.