The landscape of general practice in australia
TL;DR: My recent locum as a GP in Victoria (where I was seeing new people for very short, back-to-back appointments) reminded me about the problems with the traditional GP system – created by the way Medicare is funded. This system means it is much harder to facilitate the things that are vitality important – time, depth and understanding. This experience reinforced my decision to do things differently and offer extended appointments in my private practice. I’ve now expanded my offerings to include holistic health assessments that meet the needs of patients who want more time to ask questions, explore issues and dive deeper. I’ll be talking about this more in upcoming weekly emails this month.
I’ve recently returned from doing a four week GP locum in a rural Victorian town. Locum roles usually help ‘fill gaps’ when local GPs are on leave or if there aren’t enough GPs to support that community. It is an essential role for many rural communities and it was an opportunity for me to keep up my use of my other clinical skillset.
It has been a long time since I’ve worked as a ‘regular GP’ and I had a lot of fears about what it would be like! Would I remember what to do? Has much changed about treatment? What if I can’t keep up?
I am really grateful for this opportunity, and was even lucky to connect with a clinic that was well run with excellent support staff and a great system of care. Even with these things in place, it was a strong reminder about how differently I practice medicine now.
These days, my private practice is structured so that I see people for 60-minute appointments, with 30-minute breaks in between to make notes, go to the toilet, answer questions from Bel and keep up to date on work-related tasks.
I offer these extended appointments and avoid stacking my bookings to benefit the people I work with and my own wellbeing.
If you come to see a clinician and their nervous system is ‘wired’ or agitated, it is difficult to feel settled within yourself. So it is important for me to work within a structure that is healthy for me in order to do the best for the people I work with.
In my recent locum, I was working within existing booking structures in the usual model of GP care. This meant seeing new people to me, in a new community, for back-to-back 15-minute appointments.
It was very difficult. And it reminded me of the importance of time in medicine and why I choose to do this work.
Why are most GP appointments so short?
When you are treating an entire community, access and affordability are highly important. This means that General Practice systems are set up to reflect what is available for patients in regards to federally-funded Medicare rebates.
These rebates are woefully inadequate for the cost of providing health care, because the longer a doctor spends with a patient, the less rebate there is.
Because of this, General Practices have adopted a model where seeing people for short appointments (<15min) more frequently is the norm.
It means less out of pocket costs for the consumer and more appointments available each day, but it also means less time with a Doctor.
This is difficult for everyone, for many reasons.
Why is more time needed?
You might not have considered it before, but 15 minutes is not a long time to have with anyone – let alone a clinician involved in your healthcare.
There is not enough time for questions. Or answers.
It is just enough time to deal with one simple problem or have a brief discussion about an ongoing issue, results or a referral.
There is not enough time to work through emotions, or to consider or understand complex points of view.
It is a structure that is essentially doctor-centric or health-system centric.
We make a diagnosis, give results, suggest a plan – you take it or leave it. If you have a complex problem or have more questions, come back next week. And the next week. And the next week. Until you have had enough appointments to sort out the issue or have your questions answered.
Although it was created to be efficient, in terms of long-term issue resolution and whole-person health, from my perspective, both doctors and patients are unsatisfied with the current status quo.
Yes, it does give you time to think in between appointments, to receive results, or for inquiry, research, googling, and speaking to friends or family.
But the time involved in returning to care again and again is not just the time you spend in the appointment.
It is:
Time off work to attend an appointment during work hours
Travel time.
Time spent waiting in the clinic waiting room.
The time either side of your appointment to account for the possibility your clinician is running late.
Time to have blood tests, pay the fees and find your way back to your car.
From a clinician’s point of view it is also deeply dissatisfying.
During my locum, I felt like there was only enough time to ask a few questions, provide brief information and suggest a plan. There was not enough time for negotiation, understanding complexities or even to discuss alternative options in detail – the way I really love to practice medicine.
It is a system based on risk stratification – what needs to happen now, within a week, within a month or within a year?
That question you asked – can we talk about it later? There’s not enough time now – let’s stick to the urgent thing that needs to be solved. Your non-urgent questions will need to wait.
To me, working that way is not necessarily ‘hard’ because I was trained to practice that way. We all are. We are trained to work ‘quickly’ and ‘efficiently’. To curate clinical conversations in a way that maximises efficiency.
In fact, during medical training, many of our clinical exams are at six to 10 minute ‘stations’ where marks are partly based on how well we are able to keep on task.
That means we won’t be distracted by questions or go down rabbit holes (which I would argue are just as important as whatever the diagnosis or presenting issue is).
Working quickly is not the way I dream of practicing medicine. It’s not conducive to healing.
For years, the Royal Australian College of General Practitioners and the Australian Medical Association have been lobbying successive governments for investment into primary care.
We know that people need more time. That the best care takes longer.
For years there has been very little response. Token funding. Token gestures. Breadcrumbs.
Now our system is failing. Hospitals are feeling the crunch.
Many GPs, like me, are leaving the system because it is a moral injury – it is against our values to practice in that way.
For the community, it is hard to find a practice taking new patients. It is difficult to get in and see your usual GP because they are booked for weeks. Clinics across the country are closing. Clinicians are burnt out. Communities are frustrated.
My passion took me towards holistic and complex care that included considering someone’s personal experience.
When I was working in General Practice, in a system of funding care that is outdated, I felt like a round peg in a square hole.
I could not sit by and wait for the government to finally invest in primary care. So I created a different structure.
I spent many years accumulating qualifications to support this legitimacy. I went through my own process of healing and understanding health in a holistic way internally.
To consider complexity, I had to unlearn a lot of my training.
I needed to learn to respond to body-based non-verbal cues, inquire just that little bit more, sit back in my chair, be curious, and regulate my own nervous system throughout the day.
When I first opened eluceo, I needed to focus purely on Psychological Medicine alone – restricting my practice to working primarily in therapy only.
This year, I’ve decided to expand my offerings – to supplement what is not available within General Practice.
Not as a replacement. As an extra. As a solution when more time is required, needed, or yearned for.
These will be multi-session packages for the holistic assessment of lifestyle, sexual, reproductive or women’s health issues.
And I’ll be going into detail about how they could work for the most common issues I hear about, in my next blog.
If you want to support the efforts of the RACGP and the AMA:
The AMA has made it very easy to flick off an email with issues and recommendations for changing the funding of Medicare. Sending this to your federal MP helps advocate for appropriate rebates for you and supports the development of primary care in the right direction – keeping General Practice the cornerstone of healthcare in Australia. You’ll find that here.