Whether it’s a referral or access to a patient’s life savings, no one has an automatic right to your signature.
Once I was asked by reception staff to see a patient whose usual GP was behind. She had elsewhere to be and couldn’t wait any longer: could I please squeeze her in for a referral?
I saw the patient and took a brief history of the reasons for the referral, given it would have my name on it and I’ve never been the type of doctor to write “please do the needful”.
To my surprise I got a call from reception as the patient left my room. Why was she being charged a gap fee?
“Because we had a consult?”
“But it’s just a piece of paper!” the patient reportedly said.
I went out. Brought her back into my room.
I advised her that if she didn’t wish to pay for the consult, I’d take the piece of paper back and she could do as she pleased.
She paid.
Pieces of paper do matter. I was reminded of that this week on one of the many social media pages that I lurk on, this time on medical tourism. Several of my patients have, against my advice, gone overseas for surgery – weight loss, plastic – saying Australian surgeons were too expensive.
Imagine my surprise when someone posted about THE AUDACITY of her GP REFUSING to sign her compassionate release of superannuation form to access surgery when she’d already booked in dates and paid a deposit.
Several people chimed in, including one of the companies that facilitate this process for Australians undertaking these surgeries.
The gist of the advice?
“Keep looking, you may need to ask more than one GP to get someone who’ll say yes.”
“How tedious, these doctors who try to keep your own money from you!”
“I had to ask three GPs before someone finally agreed. As a result, I’ll be going to him from now on as my regular GP.”
“If all else fails, you may need to use a company to access your super – they take a fee of ~ $2k to enable this.”
“It’s perfectly reasonable and recognised that excess skin is a valid reason to have plastic surgery.”
This is what the government says about it.
Many patients seem to see the work we do as gatekeeping or worse – “Why can’t I just order this online?”; “Why can’t I just bypass this, my GP does NOTHING?!”; “It’s just another way for them to charge me money to do nothing!” etc.
Just because our patients don’t recognise the gravity of the situation doesn’t mean we are exempt from it ourselves.
Like prescribing medication, filling out forms is a legal responsibility. These are legally binding documents that we are being asked our judgment on: does our patient really need that much time off, on Centrelink? Does our patient really need to withdraw anywhere from $16,000 to $31,000 for surgery in Thailand or Turkey?
Under the ATO criteria the reason must be life-threatening, acute or chronic illness for which wait lists on public hospital lists are too long, or that a surgeon has suggested going private for which the cost is unaffordable.
Where exactly, does surgery, even following bariatric surgery, much less face and neck lift, fall on this graph? And while it is the patient’s money, what are the repercussions likely to be if the ATO conducts an audit?
Related
I am reminded of all the care we take as doctors to screen for people who shop around for drugs of addiction; I remember the warning we were given as junior doctors: be careful, because once you say yes to one, the word will spread and you’ll end up being the go-to for all likeminded people in the area.
I can see how this would be the case once you say yes to something like this to one person and they tell their peers in social media groups. “Dr Joshi signed these forms for me, she said it’s my money, I can do what I want with it, why should the government intervene?”
By that argument, why not let patients prescribe their own medications?
Their own surgery?
These groups talk about spending tens of thousands to get it all done – facelift, neck lift, upper and lower blepharoplasties, chin lifts, fat transfer, tummy tuck, arm lift, thigh lift, mons lift … why not, when a single procedure in Australia would cost you the $30K or more? Plus you get to recover in a five-star resort, travel business class AND go shopping with other women having similar procedures during recovery!
WILD.
I’m a dinosaur. I am appalled that this is what Australia is becoming, enabled by those among us who may see nothing wrong with the commoditisation of medicine, especially discretionary procedural work.
And I am reminded again of what has held me in good stead across 23 years of medicine in both a surgical and a non-surgical speciality: first do no harm.
It might be harming your patient to help them access what is likely a significant chunk of their superannuation (plus 32% tax I understand) from their retirement to spend on discretionary work now. It may be setting them up for failure to have this done in another country, where even if the standards are high the risks will be higher because of language barriers. If there are complications in the weeks and months postoperatively, you’ll have participated in enabling this harm.
As with drug-seeking patients in years gone past, I have a strict policy: unless I know you and have been your regular doctor for a significant period of time, I say no to filling out “pieces of paper”. If that upsets you, I guess this is where our therapeutic relationship ends.
That piece of paper is a legal document in which I am vouching to the government that you do indeed meet their criteria for release of superannuation on compassionate grounds. While I sympathise, I fail to understand how a tummy tuck or face/necklift meets criteria for chronic illness that necessitates accessing your superannuation.
Equally hard is overlooking the predatory behaviour that some companies are using to influence vulnerable patients without declaring any potential conflict of interest.
So. Well done to those GPs who say no. As to the ones who say yes, I’m unsure what criteria you use to rationalise this to yourself but I hope you’re confident if ever audited.
Dr Imaan Joshi is a Sydney GP; she tweets @imaanjoshi.
