Variety, flexibility, salary: the GP reimagined

With a fresh perspective after stepping back from day-to-day general practice, Dr Joshi has a wishlist.

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It is no secret I’m taking a break from general practice for some time by doing ED locums in rural areas.

While I was initially nervous about it, and upskilled by doing the ALS2 and with some caveats in place initially about my comfort zone, it has been a surprisingly easy transition into working in busy EDs where, I hope, I’m largely a help and not a hindrance to my FACEM colleagues as they do their work and oversee junior doctors.

Having now experienced both Fast Track (often the sole FRACGP rostered on) as well as main ED, I can honestly say it is an enjoyable experience for many reasons I’d forgotten about, having left hospital medicine in 2012 for general practice.

What we are all seeing, obviously, with the rapid shortage of GPs, is more and more non-acute presentations to ED for minor as well as acute problems, which well stocked and funded general practice is ideally suited for.

The biggest challenges at present for general practice:

1. A lack of adequate funding for anyone who relies largely/entirely on bulk billing. This results in shortchanging both patients and practitioners alike.
2. A lack of time to teach the next generation of trainees because we can’t afford not to be seeing patients. There is no payment for notes outside of consults, for phone calls to family and other providers or for teaching trainees, so many bypass this, or subsidise the cost out of their own pockets.
   Juniors and medical students end up bored and feeling isolated. Would you choose a speciality in which you sat in a corner and watched a new patient come in every 10-15 minutes with little discussion, teaching or involvement? A colleague who left GP training cited this as her reason for leaving – being sat in an isolated small room, feeling out of her depth and being required to see more patients per hour than she was comfortable with, with minimal teaching, in a universal bulk-billing practice.
3. A lack of time to do CPD, for the same reason as above.
4. In many practices, a lack of resources to adequately fund all the things we know we can do, leading over time to deskilling and referral to more expensive non-GP alternatives to do the work at a much higher price. I’ve left practices that didn’t stock eye drops, or instruments for suturing because they’re not cost-effective. I’ve seen patients referred to ED because the GP could not fit them in to commence a NOAC for a DVT or did not offer suturing for a simple laceration.
   These scenarios lead to the self-fulfilling prophecy of GPs being seen as just glorified referrers for “real” doctors who are worth paying for.
5. Low morale and a sense of inferiority thanks to the lack of variety through poor choices (see 4) coupled with paltry pay (work for a 53% discount, anyone?). This leads to FRACGPs leaving for greener pastures, often bringing the unhelpful mindset of “I must be cheap” unless they’ve trained in other specialities such as aesthetics.

So, how would I refashion general practice based on what I’ve learned in my early experiences in ED? If I were to dream big, what would I imagine for us, apart from healthy boundaries and the ability to discuss money and to say no?

If Health Minister Mark Butler were actually listening and wanted to help, and granted me three wishes – except it’s a big job so let’s make it six – here’s what I’d say:

1. Salaried roles for at least some FRACGPs at parity with hospital specialities and benefits with a tier tied to continuity.
2. Trainees tied to hospitals and clinics where the salaried FRACGPs are paid to supervise them, advise them and even see patients with them as needed. Likewise, medical students allocated to these, as well as a term during internship in general practice in one of these clinics to allow all junior doctors to see what community medicine looks like, and how it differs from hospital medicine.
3. The option of flexible shifts for these doctors: days when they see some of their own chronic, complex patients, who could be referred by privately billing GPs in the community; days when they see only the walk-ins and acute presentations. This would mix up the caseload nicely for those of us who see mostly complex chronic patients and need regular mental health breaks in the form of non-complex patients.
4. Paid teaching roles for the FRACGPs, with med students, interns, GP trainees all rostered on at various times for exposure to general practice.
5. Scope for expanded clinic hours and days. Some FRACGPs would see the referred patients with complex care needs, and others see the walk-ins with acute needs. Hours could be 7am-10pm seven days a week to take some pressure off emergency departments.
6. Because the FRACGPs are all salaried with pay parity, patients can all be seen for free, with no Medicare billings involved. The rest of the general population can continue to access privately billing GPs and pay gap fees for their care subsidised by dwindling Medicare patient rebates if they don’t wish to wait to be seen.

On the surface it may seem hard, but I think it can be done, with some careful planning and thought behind it.

Unless the government is committed to revamping Medicare, I think it is time to accept that a substantial rise in the patient rebate is unlikely, and therefore the dream of everyone having access to timely and free healthcare is dead.

So how can we look at retaining the GPs we do have, attracting more GPs to this speciality and rebuild ourselves without cutting out the most vulnerable among us?

Not everyone who believes they qualify to be bulk billed will be, and I don’t believe it is any of our jobs to be the arbiter of that decision. The fee we charge is the fee. People can choose to pay or go elsewhere. At present, that elsewhere is the ED, which is not a viable longterm solution. Urgent care clinics, however, set up to support GPs longterm, are a more feasible option.

Can general practice be saved with some tweaking?

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

Note: edits have been made to this piece since publication to remove errors introduced during the production process.