15 February 2022

We must teach our patients boundaries

Comment KnowCents

Giving away our time for free trains them to take advantage of us. This is why, without change, we will run out of GPs.


Last week RACGP president Dr Karen Price tweeted that we were in danger of running out of GPs. 

In response, a fellow GP posted a thread on the reasons she, and others like her, were making their way out of general practice and, in some cases, out of medicine altogether. The thread is worth reading: 

It was striking to me, even pre-pandemic and more now, the degree of angst, burnout, exhaustion and lack of validation that my colleagues and I regularly face in our day-to-day work. 

No wonder there is so much deflation and desire to leave the general practice community – because the grass seems greener anywhere else. 

But we, and those who trained us, are in a small way to blame for how undervalued we feel. Poor funding from the government is compounded by our own tendency to put the patient first at our own expense, and effectively to give too much of our time away for free. 

I switched to general practice training with two years left to my chosen path to an FRANZCOG. I left because I had been trapped in an abusive marriage for eight years with many years of abuse yet to come, and chose general practice because, with four young children aged three months to five years, I could not do the requisite overtime and weekends to complete training.

In the years between commencing GP training in 2011 and today, 11 years later, I have had to do a lot of work on myself and regroup – for myself, my kids and ultimately my patients. The bulk of my GP work was obs- and gynae-related work (including sexual health, contraception, menopause and infertility) and mental health. Not six-minute medicine. 

I learnt very quickly that with a niche skillset I was frantically busy very fast, in a way that left me feeling unsafe, burnt out and still taking home very little pay by accepting the patient rebate as full fee for my extensive services. So, I forayed into charging a gap in a bulk-billing practice, then moved to a mixed-billing practice, and eventually a high-end private-billing practice (until it closed because of covid). 

I’ve had to learn boundaries the hard way, through doing the uncomfortable work and being willing to look at what I gain by remaining silent and resentful, or even, quite simply, by underestimating a patient’s willingness to pay. 

As healthcare workers, our training focuses almost without exception on patient-centred care. First do no harm; do what is in the patient’s best interest. Go out of our way to do this even if it’s unreasonable, is the message we are often told during training. 

In general practice, the added message I heard from supervisors was “if we say no to bulk-billing, they’ll simply go elsewhere”. 

Yet around us, we see pharmacists charging for homeopathy and pushing to diagnose and treat diseases they have no training in, and patients willing to sign up and to pay for the convenience. 

GP training impresses upon us that we must be “free at point of service”, and providers are afraid to have the conversation around money and the value of our time. But when we fail to do this, we fail to advocate for ourselves and our own care, and thus begins the decline in our own enjoyment of the work we do, our happiness outside of work (because we often take these resentments home) and our quality of life. 

I have colleagues who do heavy mental health consultations, including on their days off, and spend more than an hour with patients, but thanks to the limitations upon telehealth, charge only for a 20-minute consult. This is not generosity, it’s a recipe for burnout due to a lack of boundaries. They’ve also trained the patient to expect this next time and every other time after that. 

When I have pushed the practices I’ve worked at over the years for changes in billings, or to simply advise patients of possible extra fees when booking, I’ve had pushback. Practices, whose bottom line is often “some money is better than no money at all”, are largely happy with maintaining a larger throughput when a smaller number could provide the same revenue. This is a McDonald’s or Pizza Hut type of care, rather than that of a café or good pizzeria. 

But while the revenue may be the same, everything else is worse. The margins are often thin, staff turnover is high because everyone is exhausted and burnt out, and ultimately the very patients we purport to help by being cheap (that is, free) suffer because they do not get the continuity and care that they need. 

I personally know so many colleagues who have fellowed and then given up on working in GP practices because of the working conditions. They instead look for other – preferably salaried – options or, like the author of the Twitter thread, locums with less responsibility, less continuity, travel and better money. All of this is great for the doctor, and a loss for the community and especially the patients with complex care needs. 

By cheapening ourselves and what we give in the name of patient care, we ultimately end up disadvantaging the patients themselves. 

But we can change the way we practise. 

Will it be easy? No.

Will it take time, effort and a mindset change? Absolutely.

Will it seem easier to quit and return to the status quo? Yes, often. 

But will it be worthwhile? I believe so, yes. If you provide value for the money they pay. 

Dr Imaan Joshi is a Sydney GP; she tweets @imaanjoshi

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13 Comments on "We must teach our patients boundaries"

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Philip Hall
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Philip Hall
2 months 27 days ago

There is no surprise to me that government is keen for pharmacists, nurses, midwives to take over the roles of doctors

We are a dying breed.

yu yu chit jellinek
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yu yu chit jellinek
2 months 28 days ago

it sound like me. .
The more I gave the time, the more lists I got from the patients . It is endless. The medicare always on our back. I am happy to keep up with endless list, medicare won’t let us do that also. I am leaving GP soon.

Dr Aletia Johnson
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Dr Aletia Johnson
3 months 4 days ago
This seems to be a big trend at the moment. If covid taught me one thing, it’s that I’m not indispensible. If I take time off, the patients will manage. If I’m sick, still working from home will exhaust me, make me take longer to recover and won’t pay me very much in the end. After 18 years as a GP I’m finally learning to set boundaries and put my own needs first. And I don’t feel even a little guilty about it. I practice ‘slow’ medicine. It’s all chronic multisystem disease, mental health, chronic pain and trauma counselling. It… Read more »
Sarah
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Sarah
3 months 5 days ago
I am from the UK originally and grew up believing that healthcare should be free at the point of delivery. I still do…but unfortunately our healthcare system does not allow me to practice what I believe in: I have been a GP here for almost 20 years, and like everyone else trained long and hard to get here. I work long days and work in my own time to get done what needs doing for my patients best interests. Much of this work is unpaid – we do this because, like the teachers, like the nurses, we care. However I… Read more »
Andrewp
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Andrewp
3 months 6 days ago

You deliberately avoided gp work duringthe pandemic? No work = no pay. What happened to your patients?

Imaan Joshi
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Imaan Joshi
2 months 28 days ago

Who are you addressing here Andrew?

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