This proposal is as useful as all that extra training we GPs should somehow fit into our overloaded syllabus.
This week, the federal government has suggested another item number to be shoehorned into the Medicare schedule, because, let’s face it, the schedule isn’t full enough.
We already struggle to cobble item numbers together, like Lego bricks, into a model that roughly represents the complexity of our consultations. Every day, we create consultations in collaboration with our patients that focus on whole-person care. And then, somehow, we try to build a model of that consultation, using the bricks we have, so they can get an appropriate rebate.
Let’s see what that model might look like, in my context.
We see a woman in middle age, with fatigue. As we talk, we uncover a few precipitants.
- She has heavy periods and a family history of thyroid disease so she could have hypothyroidism, or iron deficiency anaemia, or any number of other problems.
- She has a history of childhood trauma, so this could be depression, or anxiety or complex PTSD.
- She cares for teenage children and ageing parents and is in a challenging workplace. If she is engaging with MyAgedCare, NDIS, Workcover or Centrelink, she could easily be suffering from administrative trauma, with hours and hours of pointless paperwork.
- She is a middle-aged woman in a young woman’s world, becoming invisible and responsible for the emotional labour of the universe, so she could be appropriately tired. Added to that could be layers of intersectional disprivilege. Maybe she isn’t the typical white, middle-class woman who features in this menopausal enlightenment of recent times. Maybe she has a lifetime of harassment, discrimination and abuse.
- She could also be sick of sucking up the weight of the world, and she could easily be burying an enormous amount of rage.
- She could be deeply lonely. Or poor. Or grieving.
- Maybe her chronic illness is not well managed or has worsened.
- She may well be wondering what all this sacrifice was actually for, when the world burns and little seems to change. She remembers marching for women’s rights, and worries that Brittany Higgins represents a world where women still suffer from inequity, even if the language has changed. She will worry about her future, with less superannuation and security, and little respite from her domestic violence.
- She could have cancer, COPD, heart disease or anything autoimmune. It could always be lupus.
- She is in the zone of perimenopause, so it could be her “hormones”.
As her menopausal (just saying) GP, I am supposed to decide which “bucket” to put this mess in, as I build my Lego representation of this consultation. It makes me angry. If I commit to one or the other, I am seen to be deficient somehow.
- Women’s hearts behave differently, so perhaps her tachycardia is a sign of a cardiac issue. I could use a healthy heart item. Don’t I take her heart seriously? GPs need more training to understand heart disease in women!
- She is a trauma survivor, so I could put this in a mental health item number. Aren’t I being a little reductionist, focusing on her physical health when it’s obvious she has mental health concerns? GPs need more training in trauma!
- Women are still not looking after themselves well enough, so shouldn’t I do a 40s health check and do some social prescribing? Aren’t I just medicalising misery? GPs need more training in lifestyle medicine!
- Women are gaslit and their concerns are never taken seriously. She came in telling me she thinks her symptoms align best with a neuroendocrine tumour. Her friend had one that was overlooked for years. She has done her research. Shouldn’t I take her seriously, and order an MRI? GPs need more training in woman-centred care!
- Obviously, she is perimenopausal. Shouldn’t I prescribe menopause replacement therapy and take her symptoms seriously? Shouldn’t I also see the whole person and not brush off her concerns by prescribing hormone therapy as though she is just a uterus on legs? GPs need more training in menopause!
Each of these scenarios has its own item number, or at least a proposed item number. In front of me are bricks for a 36, a 2713, a work-cover item, the proposed domestic violence item number (please tell me that died in the water), the proposed menopause item number, a 703, or a combination of all of them.
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I have the woman who needs the best rebate I can muster on one side, and the PSR on the other, both breathing down my neck to maximise/minimise the rebate.
No wonder we get sick of people criticising the models we create with our Lego billing. “You put in far too much yellow” the community, regulatory authority, legal expert, policy maker and politician yell. “Obviously GPs need more training to build models!”
I’ll just say this once.
Menopause was not discovered by this government. I, and many others of my era, were teaching about it in (gasp) the 1980s, when we were all railing against the tendency to whip out the uterus, because it wasn’t doing anything useful anymore.
I’ll say it again.
We learned about menopause four decades ago. When it was in the curriculum. We prescribed hormonal therapy then too. Although I do admit I didn’t prescribe the first HRT patch because the drug rep at the time gave us chocolates in the shape of women’s bottoms.
Oh, and I trained a nurse to do pap smears and run a women’s clinic with me in the country, so we weren’t all patriarchs who had no respect for our nursing colleagues.
I ran a masters degree in GP psychiatry in the 90s, because, yes, we knew about depression then, and it was in the curriculum. We knew that women’s hearts were different then. Contrary to popular opinion, we also knew about the clitoris, and we were well versed in endometriosis. We knew about domestic violence, sexual abuse, childhood trauma and managed the lot to the best of our ability.
And there wasn’t a “cure” or a universally applicable guideline for any of them. There still isn’t.
GP item numbers are a little like the primary school curriculum. Whenever there is a disaster in the community, the relevant government will try to shove more into the primary curriculum. A drowning? Swimming lessons. A death of a child on the roads? Road safety.
For GPs, any bad health outcome will be “emphasised” in our curriculum and added to our item numbers.
I give the government and advocates this challenge. You have 125 hours of teaching in a group and 125 hours one-on-one with a GP supervisor in the three to four years of GP training.
In that, we are meant to emphasise five or six domains of practice: interpersonal skills, clinical management of illnesses, health promotion, professionalism and ethical responsibilities and finally, the “business” of general practice.
What will you displace in this precious time for all you ask us to teach? Remembering, of course, that we learn on our own, as well as at the hands of our master medical educators and supervisors.
In terms of clinical management, I could, of course, send this woman’s uterus to the local “menopause clinic” that has sprung up to treat this part of a woman. And charge appropriately for their “specialised” service. Or the woman’s heart disease clinic. Or the Medicare Mental Health Clinic. Or any number of gated communities in my primary care swamp.
I could act on the assumptions I am clearly hearing that nurses would do a better job of whole-person care, because we patriarchs are simply too reductionist to take women “seriously”.
However, at the end of the day, there is this dilemma.
Under all those “obvious” symptom clusters lies a complex, multidimensional person, who may well have an emerging disease that is difficult to find, and expensive to diagnose.
In the last 12 months, I have found a few diseases in a cohort that simply looked perimenopausal, but actually had a Krukenberg’s tumour, a C3 glomerulonephropathy, vitamin D toxicity, endometrial cancer and a neuroendocrine tumour in the appendix.
Plenty of others had issues with their mental health, domestic violence, workplace harassment, untenable carer responsibilities and exacerbations of their chronic diseases.
I am not exceptionally talented at rare diagnoses. I am simply a GP who has to consider them. Because they turn up. At least 6% of the time. Not everything that quacks like a duck is actually a duck.
Obviously, I’m cranky about all this. Must be my hormones.
Associate Professor Louise Stone is a working GP who researches the social foundations of medicine in the ANU Medical School. She tweets @GPswampwarrior.
