The grass can be greener inside general practice. Let’s stop envying others and help ourselves.
As more and more GPs have been contemplating and actively moving to mixed billing and gap fees, there have been some teething troubles.
As the Budget failed to deliver anything tangible for general practice, this discontent became more obvious, added to by the sensational but ultimately doubtful expose by Nine newspapers and the ABC.
There are those usual GPs who, at least for the benefit of social media, feel they can’t simply ignore the need of those genuinely unable to pay and who continue to look for ways to see patients for free at point of access. Many others have moved on, accepting that there is only defeat ahead for the speciality and us as individuals if we don’t charge gap fees for most if not all people.
So it is no surprise that I regularly see anxious posts and receive the occasional DM asking if it is normal to move to private billing and to go from being frantically busy to deathly quiet – only 50% full; no longer filled out for weeks advance; no closed books.
Others wonder out loud if they’ve made a mistake, and should have stayed in UBB or go back. Yet others ask advice on next steps or if they should move into emergency locums, as I have.
There are sometimes heated discussions, with some doctors struggling to make sense of charging. Some have received abuse (one posted a patient complaining and asking for a refund as the treatment “didn’t work”) and others feel put on the spot by front desk staff, who disclaim responsibility and advise patients that bulk billing “is at the discretion of the doctor”, despite being paid to handle these requests on the doctor’s behalf.
There are peers who’ve smoothly transitioned to fully privately billing, who declare others just lack the gumption to do likewise; others express dissatisfaction with their choice in general practice as their chosen speciality.
Yet others have jumped ship into salaried jobs independent of Medicare, including ED work (which I am currently doing) with an hourly wage, or aesthetics, citing relative ease and happiness in these areas.
The problem I have with all these ventures is summed up in a tweet by psychologist Natalie Martinek: “The grass is always greener until everyone discovers it and bring the old culture into the new one. What are people prepared to do and be differently to prevent contributing old culture values into a new setting?”
The grass is always greener until everyone discovers it and bring the old culture into the new one. What are people prepared to do and be differently to prevent contributing old culture values into a new setting?
— Nathalie Martinek PhD (@NatsforDocs) November 19, 2022
GPs who make a change risk taking with them a pathological unwillingness to talk about money, preferring to undersell themselves.
With the jump to gap fees, there is anxiety around money – often, I suspect, because people may not have done their maths. I had a discussion with a friend and colleague about to make this move, and it took some concrete examples to show her why, even at 50-75% booked days, even with 75% of those still bulk billed, she’d be further ahead than at present at a 100% UBB practice.
I’m seeing more and more FRACGPs moving into aesthetics. Many are joining chains of unfellowed doctors who set up these practices soon after internship and who appear to operate on the premise that if you are 18+ and can pay the fees, you’ll be treated. Many who are starting out of their own GP practices, with aesthetics as a side hustle, intend to start at prices to match the laser chains and switch to higher prices once busy and established. Sounds like those who begin by bulk billing intending to switch to gap fees once busy.
The above two examples may well be legitimate business models, but I’m disheartened and alarmed by the sheer number of people who seem to think that non-GP is where the fun and profit is.
The truth is, for many if not most non-GP specialities, it takes an average three to five years to become established and to be regularly busy, especially if they’re not bulk billing.
I know friends who are surgeons who qualify and then have no jobs to step into unless they move regionally or rurally and face big costs in setting up private practice.
I know others who’ve left non-GP speciality training at a late stage because of the paltry number of jobs available post-fellowship, their fields being full of elderly consultants with no imminent plans to retire.
If you want to be in demand literally from day 1 post fellowship, general practice is one of the best specialties, especially if you’re in a UBB. With the current and worsening shortage of GPs, it’s a service provider’s market: you can easily charge and select for people who will pay if they can when the alternative is to wait hours in ED.
Many of us share the opinion that it is not our job to rescue anyone else when we need to rescue ourselves as a speciality. Nothing will change as long as many of us hold on to an idea that we must continue to work for free at point of access even if it means subsidising patient care from our own pockets. With that mindset, I fear our speciality will simply disappear.
Often we can feel sad, mad and bad about a situation and we can make some noise about it and hope to effect change. But after a certain point, people simply stop listening. It’s boring to hear the same “woe is me in general practice”, and certainly in parts of social media, it can seem like an echo chamber in which we all sit on our pity pots for far longer than is helpful or healthy.
Years ago, when I was a solo mother on my own raising four very young children and training full time – I studied after they were in bed – every day was bad, sad, horrible and worse. But I had a rule that I learnt from my psychology upskilling training: I was allowed to sit on my pity pot for 10-15 minutes; I was allowed to whinge to a trusted friend about how crap and unfair it was.
Then, I had to get up and get on with it.
I had to look to see how much I was contributing to my own misery through repetitive behaviour, and poor choices that helped me stay stuck.
I had to recognise that no one was coming to save or rescue me, and that I was it.
I had to let it go and recognise that the next day was a fresh chance to do better/different.
Rinse, repeat.
Almost 12 years later, life is so much better. I began the move from bulk billing in 2013, the year the government froze the rebate, even though I didn’t know it then.
I just knew that I was frantic, I didn’t enjoy the work as it felt unsafe, I wasn’t making enough to pay all my bills and that I was an excellent doctor who deserved more. There was no real plan, just a desire to have more and complain less without expecting anyone to rescue me.
So I made a plan. I did the maths. I calculated average billings fully booked in a universal bulk billing clinic. Then I calculated average billings if I moved to gap fees for all patients over 16, which might be only 20% of my appointments going forward (I encouraged patients to see one of the UBB doctors in the same practice rather than drop my fees); the remaining 80% that I continued to bulk bill would carry me through this time.
The owners warned me I’d lose patients and be deathly quiet. I was prepared for that. I told myself and them I’d give it three months then reassess.
Then I did it. And I never looked back.
Does it take gumption? Yes!
Does it take planning? Also yes. The last practice I was at, which closed during covid, was 100% private billing and it took me around two years working two to three days a week to be 75% booked most days. But it was still better money than in universal bulk billing. Do the maths.
A well run mostly privately billed general practice with well trained staff still earns me more than lucrative locums. And locums aren’t general practice. I love the relationships we forge in this speciality so I had to find a way to get comfortable talking about money with patients and charging appropriately for my time and my skills and expertise even if it meant some discomfort. And like all new skills, it does get easier with time.
Otherwise, the mass exodus into other work risks bringing the same culture of discomfort around discussing money, discounting and far worse, an erosion of ethics and dangerous practices that do not belong in health and in medicine, into our lives.
We can do better. It won’t be easy, or comfortable, but if I was well established in a private billing practice and had successfully made the transition, I’d be focusing on changing my mindset rather than switching to another area. Self-fulfilling prophecies (“it’s a doomed speciality”) have a way of coming true if the issue all along, is not with the speciality of general practice, but with the people in it including us.
Dr Imaan Joshi is – at heart – a Sydney GP; she tweets @imaanjoshi.
