17 June 2022

‘Lady Doctors’ are being milked dry

Comment KnowCents Mental Health Women

The burden of mental health care is falling on female GPs, leaving them drained and out of pocket. Here’s how that can change.


There is an old English fable that describes a period of drought.  

In the midst of famine, a mysterious lady arrives leading a giant cow. She instructs the villagers that the cow will fill any pail, no matter the size, with milk. Only one bucket per home can be filled each day and each bucket must then be carried away, unaided, by the person who had brought it up the hill.  

The cow is able to provide a seemingly limitless supply of milk, one pail at a time, until one day when someone brings an unfillable bucket, full of holes and sits down to milk the cow. The milk gushed into the bucket but ran away through the holes. As the last milk is drained, the cow’s hide has become dull, clinging to the curves of her famished ribs. In great distress, the maddened cow runs far away, over the hills, and is never seen again.  

Many of our patients find mental health care inaccessible and unaffordable. There is a deep and growing shortage of psychiatrists, and allied health cover is patchy.  

Increasingly, the mental health burden of care is shifting on to general practice. Female GPs carry a disproportionate load of mental health care, and the rate of burnout and mental illness in this group is high. This goes twice over for rural areas.  

The stories from female GPs commonly contain this sort of comment: “Patients will come to see me and say ‘I usually see Dr Michael/Dr Jarrod/Dr John, for simple things, but I don’t want to waste his time with my mental health, so I’ve come to you.’” 

We can talk about individual boundaries, the ability to say no, the capacity to insist on a fair day’s pay for a fair day’s work. We can also discuss why the stigma is so high with mental health that patients feel they need to apologise for “bothering” us with their concerns.  

However, there are common, systemic issue that drive this behaviour and it is decimating the female GP workforce.  

What is a ‘Lady Doctor’? 

The term Lady Doctor is used to describe a bundle of stereotypes and assumptions about the nature of healthcare that genders our work. The Lady Doctor effect has been seen across time, disciplines and cultures. This part of our professional identity is usually not chosen, it tends to be imposed on us by the community, and by our medical colleagues.  

As GPs, we are all expected to care for our patients, but the Lady Doctor is the one who is assumed to care as a vocation, a passion, something that she is both innately good at and finds intrinsically fulfilling. Gendered stereotypes of “feminine” and “masculine” skillsets feed the idea that women are the better choice if you need time and empathy because they enjoy that sort of thing. Lady Doctors also carry other gendered obligations in the community.  

Lady Doctors are empathic, compassionate, understanding? and communicate well. They are also caring, generous and self-sacrificing. In general practice, this means they see more preventive care? and slow, complex, and emotionally intensive medicine. They also see less lucrative procedural medicine?, which explains the 30% pay gap. The devaluing of “women’s work” in general practice is reflected in the MBS, where patients are financially penalised for having complex problems. 

Patients with mental health issues are more likely to be disadvantaged. There is also an expectation that this sort of caring work is “vocational” so patients and families feel an implicit permission to ask for more time, while lower fees, time pressure and patient self-selection excludes female GPs from doing more highly-reimbursed (“male GP”) work. This has a cumulative effect to devalue female GPs’ time and labour, and contributes to the disproportionate financial and emotional burden of Lady Doctor work.  

Managing the Lady Doctor problem 

  1. Individual responses 

The wellness industry makes a fortune telling Lady Doctors they are the problem because they lack resilience. Everyone talks about resilience being about the ability to bounce back after adversity. However, the ability of a ball to bounce is a function of the ball and the surface on which it is required to bounce. Even a superball can’t bounce in a swamp.  

It is critical that we understand where individual and systemic responsibilities lie so we stop blaming the individual for a systemic problem.   

Lady Doctors often cope by creating portfolio careers, doing part time clinical work and part time education, policy or niche GP work, like breast health, lactation consultancy or dermatology. Anything with a salary offsets the financial cost of practice. This reduces access to mental health services for the community, but enables female GPs to survive.  

  1. Education and training 

The MBS defines the skills the federal government thinks are important for mental health care: depression, anxiety and eating disorder assessment and treatment with focused psychological strategies. This is an oversimplification of a GP’s job. The myth that we merely need to get better at diagnosing simple mental health issues and delivering evidence-based techniques is harmful, because these skills are insufficient to meet the needs of our increasingly complex patients. The GP curriculum is vast, and it’s inevitable that some areas of clinical practice will be covered in insufficient depth prior to fellowship.  

Young Lady Doctors need to be supported with ongoing education, supervision and mentoring that is affordable and relevant if they are to continue to provide mental health services to their communities.  

  1. Interventions at the practice level  

Some practices have created innovative solutions to the problem of sustainability. They may share the clinical, emotional and financial load intentionally or outsource some of the Lady Doctor work to other health professionals. However, many practices are happy to direct the low paid complex work to the most junior members of the team because it is financially lucrative, and emotionally easier to do so.  

Until the MBS and practice managers decide that one minute of complex mental health care is worth the same as one minute of work removing an ingrown toenail, Lady Doctors will continue to be penalised for accepting complex patients.  

  1. Systemic change 

There are broader systemic issues. We are holding more complexity in our communities, because our hospital systems are overloaded. We carry the emotional load of worrying about patients we know well, when we cannot get them the care they need. When I know one of my young, complex, homeless, traumatised patients may have temporal lobe epilepsy I should be able to access a psychiatrist without having to penetrate multiple layers of gatekeeping.  

We also to need to get prevent the pinball experience. There is a lot of unpaid labour when our patients bounce around the system. Every triage without treatment is costly. To the patient, in time and trauma. And to us in unpaid care coordination work.    

If we are to retain mental health capacity in our communities, we need to stop assuming we can milk the compassion of Lady Doctors through the holes in our policies. We need change on individual, practice and broader system levels, or the mental health capacity in our communities will continue to drain away.  

Dr Louise Stone is a GP practising in Canberra and an Associate Professor at the Social Foundations of Medicine Unit at ANU Medical School; she tweets @GPswampwarrior. This piece is adapted from a presentation at the RANZCP 2022 Congress.  
Jeremy Knibbs is on leave.

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21 Comments on "‘Lady Doctors’ are being milked dry"

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Dr Aletia Johnson
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Dr Aletia Johnson
1 month 19 days ago
I loved this article so much! Yes, I am a LADY doctor, I do LADY things (in my best Little Brittain voice). I don’t think it’s necessarily along gender lines, there are lots of very empathic male doctors at my practice too. I specialise in complex mental health patients with multiple physical issues that get put in the too hard basket until they come to see me and I sort it out for them, because I’m’thorough’. They’re very grateful, sure, but I can’t eat gratitude! I don’t do it because society indoctrinated me into it. I do it because it’s… Read more »
Maureen
Guest
Maureen
1 month 21 days ago
Where is the evidence for the statement “ many practices are happy to direct the low paid complex work to the most junior members of the team ”. In my 43 years of experience, working long hours, and part owning a practice for 35 years, I found that, as I have grown older, my patients have grown older and much more complex. I have had junior doctors, working half my hours, taking home much more in pay than I have, as they have been the ones treating simple problems When patients have to book well in advance for an appointment,… Read more »
Peter Bradley
Member
Peter Bradley
1 month 21 days ago
Maureen says…”In my 43 years of experience, working long hours, and part owning a practice for 35 years, I found that, as I have grown older, my patients have grown older and much more complex. I have had junior doctors, working half my hours, taking home much more in pay than I have…” This was my experience also. The patients age with you…or you age with them, whichever. They then cling to you all the more – which is nice in a way, as you know them and their issues well, and can manage them better than any other doc… Read more »
Dr San
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Dr San
1 month 26 days ago
Fantastic article, very validating and hits the nail on the head. Of course there will be male docs also who excel in mental health and spend prolonged time with distressed patients and bulk bill them because they feel sorry for them. I’ve never actually come across any, but they must exist. I walked out of the door this morning telling my husband “I hate my job”. I’m exhausted. Yes I love nurturing my children, it gives me great satisfaction, and I can’t do it properly if I’m exhausted and drained by patients. Yet I can’t help caring about patients and… Read more »
Katie Williamson
Guest
1 month 26 days ago

Ditto Dr San!

Peter Bradley
Member
Peter Bradley
1 month 26 days ago
There is a solution, Dr San. Just seek out a salaried position. This has been a preference as the best way to remunerate GPs I have held for decades, after I nearly went belly up trying to be all things to all people back when I owned a practice. Later, as a contractor, things were better financially, but I was still frustrated at how the need to milk Medicare items and meet all their criteria was not really the way I, (or I suspect many lady Drs like you), prefer to work. I sense that finally, quite a few of… Read more »
Hema Iyer
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Hema Iyer
1 month 27 days ago
Good points raised dr Louise. We lady doctors do attarect certain kind of patients . our experience with our own children and issues in family life makes us more compassionate and caring .it is not comparing male and female gp roles .Both are needed for a balanced general practice. Just a close view of female gp’s working style and need for part time work due to family responsibilities which needs her to balance her feet on two boats at the same time There is need for more family friendly hours for female gp’s when their children are young. which is… Read more »
DR J N Parikh
Guest
DR J N Parikh
1 month 28 days ago

I am very surprised Most female GPS never work full time and are disproportionately busy with cervical screening. As solo male bulk billing GP I very much attract such patients. That is GP Unpredicatble

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