The death of general practice – The Experts | Switzer

Source: The death of general practice – The Experts | Switzer

The following is a direct share.

 

By Ross Walker

An article in the Sydney Morning Herald on 1 May 2017 has raised significant concerns around the fate of general practice in Australia.

A new report from the University of Melbourne has seen a reduction in job satisfaction, problems with work/life balance and an increase in corporate ownership of medical practices.

These factors, combined with a significant reduction in income because of bulk billing, the number of people in Australia on some form of welfare, very long hours worked, the pressure to push patients through quickly, and not to mention the constant threat of litigation, has seen doctors leaving general practice in droves and many younger doctors opting for speciality training, where the rewards are greater and the work is often more interesting.

It is a bizarre notion in our society where the public will pay tradesmen a significant fee (and I’m not saying tradesmen aren’t skilled and do not do a good job), which is typically much more than a general practitioner receives who has had years of training with ongoing demands for continuing medical education and I would suggest, a much more stressful, demanding job.

If the general practitioner dares not to bulk bill and actually charge what I would suggest they are worth or heaven forbid, the Government suggests a seven dollar co-payment, there is this ridiculous outcry from the public and the usual nonsense from the socialist left.

I’m a specialist and I’m not complaining about my lot but I’m defending my pathetically remunerated, very dedicated, hard-working colleagues in general practice.

We have already witnessed over the last few decades the death of the general physician, leaving most patients with multiple, complex medical issues and having at times up to five specialists managing their (so-called) health, but better stated, diseases. But, if we lose high-quality general practitioners because of all of the above issues, I can promise you the health of our nation will drastically suffer.

Until general practitioners are adequately rewarded for providing high-quality care, which includes better pay for longer consultations, more focus on preventative health strategies and more autonomy in the management of their own practice by cutting the ridiculous bureaucratic red tape, we will continue to see the current exodus from what was once (and still is in certain practices) a vital service.

Published: Thursday, May 11, 2017

The General Practice (GP) profession in government funded models

Australia’s “universal medical insurance scheme”, Medicare, offering healthcare to Australians, is based on the British NHS model. For too long, a critical shortage in investment into general practice in UK has lead to unsustainable pressures that are beyond the coping threshold.

On average, a general practice receives £136 per registered patient for an entire year of unlimited medical service. This is less than the cost of an annual cable TV subscription. Not surprisingly, patients are lining up for this free-for-all, leading to waiting lists of up to 3-4 weeks.  Under the contractual agreements between general practices and the NHS, practices are prohibited from offering a private service to their registered patients, due to a conflict of interest. Here are some of the consequences that UK is experiencing with this model:

  • Growing resentment amongst GPs, leading to an ever increasing number of GPs quitting full time work, or prematurely retiring from the profession all together, and not being replaced by younger trainees due to a lack of incentive, enthusiasm and practically unrealistic service targets.
  • Surgeries are facing a recruitment crisis.
  • Increased demand and poor funding from the rather stagnant Federal budgets means that the demand simply cannot be met. Safe, effective, efficient and high quality comprehensive medical care would become a distant dream.

As such, general practice is on the brink of collapse under UK’s current model. It’s a real shame that Australian politicians and the Grattan Institute are looking up to this model, without learning from the UK’s lessons. The only way general practice will be sustainable is if there is increased investment into the industry, whether it is from the government or from patients directly, or both. Under-investment is simply not feasible. Bulk billing is not feasible unless the Medicare rebate is in line with the AMA recommended fees, which at present is around $80 for a standard consult. $37.05 is the current Medicare rebate, which is a far cry from the minimum funding required to deliver healthcare.

It’s a shame that the Australian government is already planning to trial this “annual subscription” aspect of the UK model with its Australian title, “health care homes” :

http://www.health.gov.au/internet/main/publishing.nsf/content/health-care-homes

Unrealistic Expectations when visiting your GP

Here are some common scenarios that I encounter frequently:

Patient books a standard consultation (10-15 minutes depending on the practice), but..

The patient then comes up with a shopping list of problems that they want solved then and there itself. The doctor then offers to discuss these issues during another consultation. Many patients will be reasonable about this, especially after the doctor explains that in order to offer quality care, the ideal consultation involves a number of steps for each issue, including taking a relevant history, performing a relevant examination, explaining the possible differential diagnoses, and offering a variety of treatment options. However, there are also many patients who choose to respond with aggression, often using one of the following arguments:

  • “I have never met a doctor who refused to address more than one issue at a time” <– I’m sure you haven’t. They must have solved your life story in 10 minutes.
  • “but this is the main reason I came in today” <–which is why you mentioned it at the end of the consultation
  • “how rude” <–offering an explanation is considered reasonable and polite.

The moment the doctor informs them that it will cost them more, they tend to opt to book another appointment, or disappear all together. Win win situation.

“It should all be on the record. I’ve been through this with others before”

Yes, I do understand it can be frustrating to have to explain a problem more than once. However, there are many reasons why a doctor you’re seeing for the first time should take a proper history from you:

  • It may not all be on the record. This could be because not all notes have been transferred from another clinic, or not all the information you discussed with another doctor in the same clinic may have been documented.
  • If there is a library of notes about you, it’s really not prudent to review in detail every note and correspondence prior to your arrival. This can not only be time consuming, but your presenting problem may have nothing to do with what’s on record. If you go to the library looking for a specific book, you can enquire about it with the librarian, and she can look up the relevant section and point you in the right direction. The librarian will not go through every book on the shelf prior to a patron making an enquiry. The GP setting is no different. Just as a librarian has to know what sections are stocked where in the library, it’s good practice for a GP to familiarise themselves with a summary of your relevant medical conditions prior to a patient visiting them. Once the patient opens up about a specific problem, the GP can then focus on evaluating that particular problem in the overall context, and retrieve the relevant available correspondence.

At the end of the day, transparent two way communication and cooperation from both parties translate to improved healthcare outcomes.

More to come on expectations..

I just need a Medical Certificate

There’s a general train of thought that getting a medical certificate is a matter of rocking up to a GP and going “I’m sick, just write me a medical certificate mate, that’s all I’m here for”.

Guess what? Not happening with me. I understand it’s in your financial interest to obtain a medical certificate, so that you or your child may be compensated for your sick leave, and it looks good on the books to have evidence of your absence. But hang on a sec..if a certificate was just a matter of pulling out a piece of paper and signing it, why do they need evidence from a registered health practitioner?

Here’s why.

Doctors are legally responsible for the statements they make. These statements are based on a doctor’s opinion, following an assessment of a patient’s clinical condition (taking into account their history, examination, diagnosis, management, and expected recovery time).

If we cannot justify why you need a medical certificate, a medical certificate cannot be issued. To deliberately issue a false or deceptive certificate will not only reflect as professional misconduct under the Health Practitioner Regulation (National Uniform Legislation) Act and the Medical Practice Act,  but the Registered Health Practitioner may face a charge of negligence or fraud, and subsequent disciplinary action.

Also, it is illegal to backdate medical certificates (issue a medical certificate in retrospect). There are very few circumstances where there may be an exception.

So, would a doctor really put their career on the line just to save you a few dollars? Maybe a foolish one, in which case, they shouldn’t be practising.

Now what about the patient themselves? Chucking a sickie may actually be considred grounds for disciplinary action by the employer.

Final thoughts: You’re not visiting a doctor to get a medical certificate, you’re getting a medical certificate because of your visit to the doctor. The certificate is based on demonstrable medical evidence. In other words, your health comes first.


Here are some notorious situations where sickies are rampant:

  • Mondays and Fridays.
  • Upcoming university exams.
  • Upcoming major music festivals.
  • Job interviews
  • School holidays.

Top 10 reasons to call in sick:

  1. Vomiting
  2. Diarrhoea
  3. Flu
  4. Sickness bug
  5. Migraine
  6. Stress
  7. Mental health
  8. Hospitalisation
  9. Head cold
  10. Headache

Source: http://www.abc.net.au/news/2015-11-10/research-reveals-best-excuses-for-a-sickie/6926236

 

What’s a GP worth?

Some thoughts and common misconceptions I’ve been faced with:

1.”You guys must be rich with all the referral commissions you get”

Me: Referral commission?

Patient: Yeh, every time you refer us to a specialist, what’s the percentage you get?

No, we don’t get a commission. We refer you so you can get further, more specialised help that GPs are not trained to provide.

2.”You guys must be on a ridiculously high pay rate from the government”

No, we don’t get paid per hour by the government. We get paid by the patient when we offer a service. If we don’t see patients, we don’t get paid. There is a misconception that we are government workers who get paid by Medicare.

How Medicare works is: Doctor bills the patient; patient requests Medicare for a rebate (they ask the government to give the patient some money for an eligible service) to help them with their doctor’s fees. Previously, patients had to physically present to Medicare and submit their claim for the rebate. But now, thanks to the convenience of electronic transactions and EFTPOS and customer service at a general practice, the practice performs the transaction for the patient. Meaning, the money from Medicare is automatically deposited into the patient’s elected account.

If the doctor accepts that rebate as the full fee for the service, then it is called Bulk Billing. Since the patient didn’t have to pay a cent from their pocket, nor go to Medicare to claim a cent, and everything was performed by the practice staff itself on behalf of the patient, the patient is often lead to believe that a visit to the GP is free. That healthcare is free. That doctor’s are laughing millionaires who are being showered in gold and jewels by the government per hour. Nothing could be further from the truth.

3. “Are you just a GP or are you a specialist?”

GPs ARE specialists. The Specialty is called General Practice, and to be accredited as a Fellow of the Royal Australian College of General Practitioners, one must undergo specialist GP training and pass exams. GPs are considered “Specialists in Life”. GPs deal with a broad spectrum of clinical problems, that will often not be attended to by other specialists. For instance:

– Tell the cardiologist about your leg abscess and what do they tell you? Sorry, go see your GP.

– Tell the breast surgeon about your headaches what do they tell you? Sorry, go see your GP.

– Tell the respiratory physician about your breast lump and what do they tell you? Sorry, go see your GP.

– Tell the dermatologist about your heart problems and what do they tell you? Sorry, go see your GP.

– Tell the plastic surgeon about your erectile dysfunction and what do they tell you? Sorry, go see your GP.

– Tell the psychiatrist  about your concern for a skin cancer and what do they tell you? Sorry, go see your GP.

– Tell the orthopaedic doctor about your fear of chlamydia and what do they tell you? Sorry, go see your GP.

– Tell the neurologist about your desire to lose weight and what do they tell you? Sorry, go see your GP.

– Tell the GP about a random health topic and what do they tell you? You’ve come to the right place, let’s see what I can do for you. If it needs evaluation or management by another specialist, let’s refer you on.

The point is, other specialists are fantastic at their service and have all been trained with a basic Bachelors in Medicine/Surgery degree, and completed an internship and more. However, they are not all trained to deal with anything and everything. It’s not that other specialists can and will do everything a GP can do plus more. It’s not that GPs are “just GPs” and specialists know more than “just GPs” – it’s that other specialists are trained to provide a service in that specific specialty. Will you trust a haematologist to discuss contraceptive issues with you? Or a cardiothoracic surgeon to discuss management of your pregnancy issues? No! Likewise, GPs are trained to be your first port of call for any issues concerning your health (as long as they are not an emergency), but not to offer highly specialised care.

GPs are expected to know about and perform 90% of the work, but are remunerated 10% of it! Need a $20K breast job done? No problem. Want to fork out $70 for a standard GP consultation in spite of getting $37.05 back from Medicare? No way, that’s exorbitant!

4. “GPs are only there because they couldn’t get into a specialty”

There are many brilliant GP colleagues of mine who would have made excellent surgeons or what not that the community perceives to be mountains above GPs, however, they went into general practice for a variety of reasons. For instance:

  • Flexible work hours – therefore helping with their family situation or lifestyle choice.
  • Opportunity to assist with a variety of clinical situations and not be limited to one specialty.
  • Regular patient contact for ongoing care.
  • Ability to assist with multiple special interests and procedures.

The list goes on.

5. “GPs should be free”

Whether you’re a pensioner or you don’t work or you simply don’t wish to pay or what not, let me ask you this.. when was the last time you went to a hotel, had a meal, and cussed them out when they slapped you with a bill? Or to a supermarket, and tried to walk out with a trolley full of groceries without expecting to pay? Or to a real estate agent and demanded a free roof over your head? Or the water company to not bill you for water usage? Yes, food, water and shelter are all necessities too.

Have you ever asked an electrician to do up some wires without expecting it to cost anything? Or an accountant to do your tax return for free? Or expect a free car from the dealership? Or a plastic surgeon for a free face lift?
So why GPs?!

Did you know that the GP only gets a cut of the service fee? Even if Medicare only gives $37.05 for a standard consultation, up to half of that (or more) may go towards other expenses, such as staff wages (e.g. reception, administration, practice nurses etc.), rent, utilities, cleaning (e.g. linen, rooms, clinical waste etc), medical software, Computers/printers/phones/IT, Stationary, Insurance, legal fees, medical equipment (e.g. sterilised forceps, electrocautery etc.), treatment items (e.g. medical grade sterile waterproof dressings, cleansing solutions) etc etc. The practitioner (doctor) then has their own professional expenses, such as indemnity, medical registration (almost $700/year), course fees (in the thousands), personal debts, conference fees, professional body subscriptions etc. etc.

None of that comes free. There is zero assistance from the government.

A proper consultation should include a comprehensive service. A GP should have a glance over the patient’s file (which may or may not be poorly documented or organised) for an existing patient coming in, review recent correspondence and investigations, preferably prior to the patient coming in. The consultation should follow the standard medical format of a greeting, history taking, clinical examination, possible office tests (e.g. urinalysis), an assessment of the presentation, including consideration of differential diagnoses, and a management plan, including investigations and treatment – both immediate, long term and preventive strategies. Emergencies must be quickly recognised and referred to the hospital emergency department. Patients should be educated about their condition, and appropriate follow up or referrals should be arranged. All this needs to be clearly documented. As you can see, there is a lot of work that goes into a proper consultation, which is not really feasible in a 5 minute consultation. There is a lot of work that goes on behind the scenes (such as documentation, and reviewing and faxing correspondence, organising team care arrangements etc) that may be classified as “billable” hours or services by other professions.

General practice is a business – one which offers a service, like any other business.
If patients can’t accept this, they have the option to sit in the public emergency department and be triaged as category 4-5 as appropriate, and potentially wait for hours, and unnecessarily clog up the system and burden taxpayer funds.

What’s the solution? Treat General Practice as you would any other business service. If you feel that the government has a responsibility to offer this service for free, then you write to the government and request that. GPs are not government representatives, and do not receive any perks from the government. They have no reason to absorb the cost of their own service at their detriment.

In summary, pay up, or wait it out. If it’s an issue, raise it and write it out.

Message to bulk billing GPs. Please have some respect for yourselves, your peers, and most importantly, your patients’ health. Look around you and note what people around you charge. A massage may be $100; a 30min job with the hairdressers may be $70; a call-out fee for an electrician may be $100; a real estate agent in Sydney may make $16,000 off a sale in less than a week; a patent lawyer may charge $600/hr; a 15 minute check up with a dentist may be $250; a 30min physio appointment may be $100; an hour with a psychologist may be $150; 30min with a Diabetic educator nurse may be $120 etc etc. How many of them have overheads which are more expensive than yours? Do you really value yourself and your patient’s health to be just $37.05 (without the overheads, taxes etc.)?

Engaging in competitive practices against your peers by underselling yourself and undervaluing the profession is dangerous to patients and the profession. Rapidly churning through patients with an incomplete consultation or clinical justification is not only undesirable for a patient’s health outcomes, but may land you in trouble for mistakes or negligence. I urge you not to undermine the medical profession or bring the GP specialty into disrepute. Writing up GP Management Plans for every Tom, Dick and Harry who doesn’t have a chronic disease is an unscrupulous practice and cannot, and should not be supported.

6. Lastly, what do you think a GP consultation is worth?

More to come..