General practice is being eaten away at both ends

Patients are choosing quick and dirty telehealth or expensive pseudomedicine. Will the middle ground ever recover?

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I was at Chemist Warehouse earlier this week, and while waiting for a script, I had the opportunity to absorb the prominently displayed ads for Instant Consult. 

Having nothing else to do while waiting for my script, I looked it up, expecting it to be an adjunct service offered by Chemist Warehouse itself, serviced by non-GP medical graduates. 

What I found instead was that Instant Consult:

• is allegedly endorsed by the RACGP and ACRRM; 
• has several FRACGPs featured on its website as its doctors; 
• charges a gap fee of $45 (no bulk billing except for infants) for a standard consultation of 10 minutes or less;
• charges $55 for consultations longer than 10 minutes; 
• doesn’t do mental health plans etc; and
• boasts that “Over 95% of our consults are just $45!” 

This left me with more questions than answers, if I’m honest, among them: 

Why are the GP colleges supporting this (or is the website just using phrasing to suggest they are)? 

Why are fellowed GPs doing this and what are they hoping to gain, other than quick and easy consults? 

Is this the new face of “general practice”, where people hop on for services from medical certificates to referrals for pathology and other non-GP specialists and more for $45? 

If results need a followup and are taken by the first available doctor, does this not scuttle continuity of care?

How much actual care is it possible to deliver in under 10 minutes, whether it is for a referral for pathology or a non-GP specialist or a followup on test results? 

As someone who briefly worked in a telehealth service (a menopause one — I lasted about three months), and believes very, very strongly in continuity of care and slow medicine (when adequately remunerated), I was disappointed but not surprised. 

Why disappointed? 

Because it’s convenience medicine. On-demand medicine. It’s relatively “easy” medicine compared to the reality of all the things we see in general practice – mental health, women’s health, discombobulating rashes, complex and chronic illness and diseases that take far more than 10 minutes to diagnose, much less manage. 

Beyond the convenience, is it actually care or is it a $45 transaction? 

Instant Consult does state the categories of medicine it won’t prescribe, mainly drugs of addiction. But with that exception, I wonder how much can realistically be covered in a sub-10-minute consultation that is not purely giving a patient what they request and moving on to the next person. 

Contrast that with the other extreme. 

“Functional medicine” has its share of FRACGPs, among others, offering solutions to what ails us all – especially to women caught in that stage of life between their mid-30s and mid-40s, who are exhausted and moody, don’t understand why and are looking for solutions. 

These were the women I used to “see” all day, every day when working in that telehealth role that was a silo for pseudomedical menopause woo.

The fact that I said no to the vast majority of them, and advised they find a good GP, didn’t bode well for my tenure there. Some services offered:

• DUTCH testing;
• non-TGA-registered pellets and compounded hormonal medications; 
• monthly hormone panels in women who are still menstruating; 
• blood panels by people with only a BSc who advise women on what to do next;
• and supplements. Allll the supplements. 

These women paid a lot of money to get time with their provider. In the consultation they felt heard and validated and were told they were not going mad. As well as normal blood results, they were given some mindfulness tips, or told to eat lunch away from the laptop or to walk barefoot on grass daily for 20 minutes. 

You get the idea. 

All things that a decent GP could and even should do, in an ideal world, and possibly does not do only because she is too busy, too exhausted and too backlogged and the patient has only booked a standard 15-minute consult for a consultation that should take at least 20 (and be charged appropriately). 

Years ago, this demographic of patient was pejoratively referred to as “the worried well” and we’d sigh and roll our eyes. 

In reality, medicine is not limited to people with “real” illness, however we define that. Patients who are “just anxious” in our book are sick in theirs and will seek care, even if they have to pay for it.

With a loss of community, with a loss of access to timely and sensible reassurance from a trusted care provider, others will step into the space and sell woo. 

I do niche general practice work nowadays, but every week people ask me if I do any GP work, saying “I want you to be my GP. Is there a waitlist I can be placed on for this?” 

I charge privately and people are willing to pay because they feel heard and they get results. As always, charging most people allows me to see a handful of my choosing for no gap fees, which is my choice (but need not be yours). 

Nonetheless, I won’t lie. I feel sad every time I see an ad like that for Instant Consult or hear about people paying $500+ for an hour with a functional medicine practitioner (who may not even be a doctor) to have unproven investigations and be sold non-evidence-based supplements.

At the end of the day the issue underlying both is the same: lack of timely access to a specialist GP who can diagnose, reassure, educate and empower the patient on what to expect and walk with them along the path life is sending them on. 

Dr Imaan Joshi is a Sydney GP; she tweets @imaanjoshi.