18 June 2021
Why the tears keep falling
It had been another tiring day as a practice manager, with one stressful moment after another.
I had come home, once again weary and washed out, and logged on to Facebook and I started reading some of the comments left on our Community’s Facebook page and my heart started to sink.
Yet again I was noticing comment after comment criticising our region’s medical centres, complaining about certain doctors by name and generally taking to the Facebook platform to ask the same questions, only this time the questions and comments were turning nastier, angrier and had a more intense level of desperation attached to them.
Questions such as: “Why does my doctor keep leaving?”, “Why do we only get ‘foreign doctors who can’t speak English?’,” and “Why can’t I find a practice that takes new patients and what am I supposed to do now?”.
Seeing the obvious confusion and desperation, and outright anger, not only towards medical centres but also specific doctors who were having their reputations trashed, and knowing that many of these same doctors (both at my practice and many others) would be reading these comments (without having the ability to defend themselves), I decided in a fit of frustration to answer all those questions to the best of my ability.
I was naturally expecting to get hurled with abuse as a result as, given my line of work, this is almost expected as part of my regular working day. What I was totally not expecting was to find that Facebook post would get read by other doctors and practice managers, and shared across Australia (and subsequently reprinted in this publication).
What was totally unexpected was the incredible outpouring of solidarity and support from doctors I had never met but who read my piece and contacted me in private and public; and from practice managers, nurses, receptionists and admin workers in health care who all said: “Thank you for saying what we couldn’t say”, “Thank you for being a voice for us” and “Thank you for valuing our work enough to defend us the way you have”.
For an unimportant practice manager in a small country area who generally shows up each day ready to “crisis manage” and “get through another day”, I found that sharing my voice and getting so much strength, encouragement and appreciation has given me the extra push of energy I need to not only “get by” but also to try to understand and facilitate change across multiple levels by bringing awareness to many of the frustrations and stressors that we, as bulk-billing, privately owned general practices, have on a day-to-day basis.
By sharing my thoughts and having the unexpected support of so many people, I came to realise that that there is power in being heard. And even if just one other person hears the message and it causes an impact for them, then that is the start of change because without collective thoughts pushing our voices together, we won’t be heard and we cannot get the help we need. So, for now, my goal is to gather support and awareness on behalf of all those people that have reached out to me because if we all make enough noise our message may be heard and we may get the help and financial renumeration that we deserve.
Along with the many Facebook replies/personal messages/phone calls and emails that I received (and am still receiving every day) I found that I seemed to be a safe sounding board for many other health care providers to share their stories, thoughts and challenges.
This got me thinking about so many of the common themes I was hearing from GPs and practice managers across Australia. The huge truth that rang through all their comments and conversations with me was the absolute exhaustion and desperation in so many of their voices. Many were hopeful that I might be able to help them in some way. Others shared that they simply didn’t know if they had the strength to continue going on anymore but felt that by sharing their story with me, they were at least speaking to someone that could understand and empathise, and who understood the intensity of the hopelessness they were feeling.
Having done my job as a practice manager for nearly 10 years, I can say that there are obvious themes and challenges we all face. Doctors, nurses and admin staff burn out dealing with: abusive and aggressive patients; doctors that leave unexpectedly; the ongoing struggle for more remote areas to attract and retain GPs, especially those without DPA classifications; fewer GPs signing up to do general practice training; the impact and stress of managing covid and the huge expenses that many privately owned GP practices have to incur in order to keep their doors open; issues with ongoing frozen Medicare rebates and the struggles of many bulk-billing practices to continue to operate while having genuine fears for the communities we serve, and knowing patients simply cannot afford private consult fees.
Before our day begins, we have to make sure we are all insured, and compliant, regulate all the ways we have to adhere to practice accreditation guidelines, do our best to stay out of sight of the ombudsman, AHPRA, FairWork Australia and to stick to NTCER guidelines. My phone beeps from 6am and it’s doctors, nurses or admin calling in sick, a day of patients needing to be shifted and not having anywhere to shift them to, or a text to say there has been a power failure and our immunisation fridge temp breech needs to be reported, a day where our phone system gets cut again as Telstra are doing “further works” (six weeks and counting) and we want to cry and scream in rage and its only 7:15am.
The joke (except it’s far from funny) is that we do all of this – for what? We started a practice to serve our local community but also to make a successful living after all the many years of study and devotion. But the shockingly poor renumeration, and huge practice expenses plus ongoing red tape and ridiculous government bureaucracy, has my husband and I looking at each other every single day bewildered and frustrated and asking one simple question: “What are we doing this all for?”
Most people go to work, get their work done and then come home feeling tired but generally satisfied that they did the work they got paid to do. Owning a privately run GP practice that is open 7am to 5:30pm Monday to Friday seems like a great idea in theory; however, what has eventuated is that my husband as principal GP and I, as practice manager, end up doing almost 14-hour days seven days a week. My husband (GP and skin doctor) is booked out for seven months currently and, yes, practice staff take a beating every time a patient of his rings for an appointment.
This in itself should be stressful enough for a doctor, to manage to ensure that he is providing effective care to his patients, that he runs on time, he is clinically managing them to the best of his ability and that errors and mistakes are minimised for every consult. However, the problems start way before he walks in the door to see his first patient of the day. Our days and weeks AFTER hours are not spent with our three children but are spent constantly worrying about cash flow, looking at the huge wage costs, worrying about consumables spending, counselling exhausted doctors, lending moral support to burnt-out admin staff, trying to figure out if we have the ability to keep all our staff that we are so fond of in jobs. We also worry about how we will keep all our staff employed after our registrars have dropped off the training program when we had budgeted staffing needs around this, if will we have enough money to pay the practice mortgage for that month and how much of our overdraft do we have left to use if it’s another bad month.
How did this happen? How did our combined 12 years of university education and training lead us to feel panicked every single day just by showing up to do our jobs? Something has gone very wrong and owning a practice has always been stressful but in the past few years that stress had escalated to the feeling of having extreme anxiety every single day and often moments experiencing outright panic.
The panic doesn’t come from my doctors not practising good medicine or not being wonderful to work with or in not treating their patients with excellent clinical skills. It comes from the fact there are not enough of them working in our area and we have to knock back on average 80 phone calls a day from patients desperate to get in for an appointment.
If we were a Distribution Priority Area (DPA), we could hire more doctors but we are not and are therefore stuck in this desperate situation where every day feels like a war-zone, triaging cases who are most clinically urgent and turning all other patients away. We have had patients sign petitions begging the Department of Health to change our DPA status.
We have featured on local and national news three times, we have written to Health Minister Greg Hunt and we keep getting generic answers such as: “Statistics show there are no doctor shortages in your area”
WHAT statistics? The statistics where many patients are left without a GP to care for them? The statistics that mean we cannot get a patient in with their GP for two weeks at a time? The statistics that mean we have to send patients to the emergency department only to get ED calling us to say “stop sending us your patients, we are an emergency department and these are general practice issues”, so now we have ED doctors angry at general practice doctors and vice versa, all really fuelled by the fact that we are all doing the best we can but that our best is still not good enough.
I now speak confidentially on behalf of all those doctors and practice managers that have reached out to me about the fact that our current DPA classification system is a joke. The bulk-billing renumeration our doctors get paid for the years of their training and experience is pathetic at best and embarrassingly bad at worst.
To add insult to injury, our region (four hours from Brisbane) does not qualify for our doctors to get rural incentive payments, and we cannot hire doctors other than FRACGP qualified and not subject to 19AA/19AB restrictions. Bonded university doctors cannot work in our region because we are not a DPA and that really only leaves us with registrars (who hardly come through anymore) and if it’s a good year and we are lucky enough to get one, they all leave 12 months later.
Why is this getting so hard and how can it be changed? That is indeed a complex question but answers do exist. The bureaucrats in government all scratch their heads and ask themselves: “Why are fewer doctors deciding to go into general practice as a specialty each year?” They ask these questions but they don’t seem to really want to know the answers.
How do I know this? Well because so many people are telling Minister Hunt on his own Facebook platform, on which he remains completely silent. On his latest “boast post” about the high percentage of bulk-billing statistics, there are cries from more than 400 GPs and primary health workers begging for his attention and help, and yet his voice is deathly silent.
The $38.75 for a standard consult is not acceptable for the years of training and experience that our doctors go through, especially those that had to migrate and start from scratch – either by needing to retrain to Australian standards and who had to be paid non-VR rates ($31) for many years.
After paying the practice their percentage, and paying medical defence insurance and for ongoing training for QICPD points, not getting rural incentive payments despite being in a rural area is not good enough. Turning away 80 patients every day because we cannot see them all because of a doctor shortage issue is unacceptable. Losing seven doctors from our area in the past three months and having four practices having to shut their doors is horrifying and puts more pressure on the ones left standing.
We deserve the opportunity to at least be able to hire more doctors without the DPA line forcing us back in our box. We deserve to be paid for the hours and effort we put in. We deserve recognition for the fact that we service our community of highly disadvantaged patients at a bulk-billing rate because we know they are desperate and struggling, and have highly complex health care needs.
We deserve for our doctors and nurses to get a 30-minute lunch break instead of begging them to fit in more urgent cases, we deserve appreciation and financial recognition for the fact we employ nine staff and take on the risk of running a business – with all the stress, costs and responsibilities that that involves.
Raising the Medicare rebate for GPs would be a start. Giving areas such as us our Rural Incentive Payment back should be a given, to reward those doctors who don’t move to CBD areas.
Listening to the desperate practice owners close to crumbling and who are begging to have their DPA status reviewed and actively making changes to this in our favour means we save more lives and more importantly save ourselves.
The sad reality is that there is only so much pressure any person can take before they break. My husband and I would be OK. As a FRACGP who is a qualified skin doctor with a seven-month wait list we would make a success of a small GP practice and skin cancer clinic if we decided to throw in the towel. We could pack it all up, stop worrying about the 80 patients a day we have to disappoint and move into the CBD sunset, which would be a private-fee practice and be far more lucrative, but if we “saved ourselves” then our practice would crumble as my husband as supervisor for our international doctors would mean they lose their ability to continue to practise.
Having the pressure of genuinely caring about the people we employ because they are an amazing team, and knowing these are mothers who have children and fathers that have sacrificed everything to give their families a fresh start in a safe country and all whom have mounting debts and bills to pay, forces us to have to think with our hearts and not our heads.
We don’t want to let our patients, our staff and our international doctors down because we no longer have the strength to keep going as the obstacles just keep getting thrown at us, and before you fight through one obstacle after another, beating us down to exhaustion and desperation.
There are workable solutions but the problem is they are not in our hands to solve and we have to rely on the people at the top of the health care chain to use logic and common sense, as well as “statistics”. We are all drowning and are begging for someone to throw us a life raft.
The bigger question is: will they throw us the life raft before we sink?
Carrie Norval is a practice manager at the Family First Medical Centre in Urraween, Queensland