Pearls and Irritations

I’m a recently retired specialist doctor and I keep an eye on medical affairs. They affect all of us, especially as we get older, and people still ask what I think.

Two young female friends of mine have recently finished their medical degrees and both have sought my advice on their careers. They are each in their mid-to-late twenties, and both have partners. They’ve worked in Sydney and Brisbane teaching hospitals respectively, and in general practice, on country and city rotations.

The Sydney couple has bought a swishy apartment, the Brisbane pair has bought a ‘fixer-upper’. The Sydney couple are Australian-born and educated, and there are multiple doctors in all the living generations of their two families; the fixer-upper couple come from struggling immigrant families, and they are first in each of their families to go to university. This couple are also supporting the extended family in a war-torn nation far away.

Both couples want to have children. The two women are facing a big decision: what career path to choose?

My young friend from Sydney is adept at cutting and suturing, and making things neat, tidy and better. She has spent time with a country surgeon, and she loved it. She likes to feel in control, to be the one with the solution, to make a diagnosis and cure the problem. No surprise that she’s thinking of applying for a surgical training position.

My other young friend is a UK graduate who was allowed to come here to fill a hospital emergency department position, and then commenced GP-training (General Practice training program). She was destined to be sent to a remote GP practice for up to ten years. But rules have relaxed since Covid, and the postcode obligations are not as strict, and a place in a specialist training program could be a possibility for her, if she wishes to apply.

I tried hard to think of any useful information I could give them to help with their choice, because once you’ve made that crucial decision in your second year after graduation it’s very hard to change tracks. The stage has been set; the die has been cast.

I fell back on my own recent experience, both as a specialist, and as a patient. I also have the recent experience of having to find a new GP.

The previous group practice I attended, and the one where I also took my four kids and my parents for twenty-seven years, was always wonderful. This bunch of well-trained, conscientious GPs had also referred many patients to me in private practice. They were kind, compassionate and gave lots of time. My kids and parents loved them. The GPs enjoyed their jobs, you could tell. Their referral letters to me were always succinct but comprehensive – typed, with just the right amount of information. They’d trained at the same Catholic teaching hospital I worked at, and the stamp of the nuns was writ large on their foreheads.

After many years, these doctors had decided to sell out to a for-profit company. At about the same time I moved house and I never experienced their new set-up. However, my parents continued attending this practice and I heard their comments: “always looks stressed now”; “always rushing”; “hardly has time to type on the computer”; “I think I was in for 7 minutes”.

Since I moved I’ve had to find another practice. I tried out one which has a name like ‘AAAAA Health Solutions’ and is a franchise. I attended for a flu vaccination from a GP I had never met before. I thought, “She’ll be happy – quick consultation, single issue”. Yes, quick all right. No sentence was exchanged. I’ve never met anyone in any field less engaged, less interested.

“I’ve just come for a flu vaccine please. I’m actually a retired doctor.”

No response, none at all. After all, words do cost time and time does cost money.

So what should I or anyone else expect of a general practice? The Care Quality Commission in the UK, in its excellent little book for patients ‘What Can You Expect from Good General Practice’ lists five expectations patients should have of their GP’s practice: it should be safe, responsive, effective, caring and well-led.

There is a rider here: the little booklet assumes that clinics actually exist. We can no longer make that assumption in Australia.

In 2021 Australia was in a situation of perfect balance between supply and demand for GP care. However, demand is now starting to exceed supply and the gap will worsen dramatically in the next few years, according to Cornerstone Health and Deloitte Access Economics. These two private sector parties have modelled GP services in Australia for the next ten years. By 2032 demand will have increased by 47 %, but supply will have decreased by 15%. So, just eight years from now, in 2030, according to this study, Australia, particularly Australian cities, and particularly the outer fringe suburbs, will be massively short of GPs – 9,298 full time GPs short to be precise. Even if some assumptions prove incorrect, the conclusion is still staggering.

And don’t forget, much as it pains all of us to speak the ‘P-word’, that it won’t take too many more pandemic curtain calls (and there will be curtain calls), before young people (or their parents) decide that medicine is not such a great career choice after all. Who wants to spend a life in PPE and then contract an awful disease anyway? The potential for a backlash against medical careers has not been included in the modelling and could make the shortfall even worse.

But what are the antecedents for the predicted shortage? Is it just a gross failure of medical workforce planning, or is it specific to primary health care? Is GP practice becoming less attractive to medical graduates?

The modern landscape of general practice has certainly changed things. 50% of GPs are now women, women who may need to take maternity leave and may want to work part-time. Many male GPs also wish to participate more in caring for their children. If Australia is to attract and keep GPs, it must address the needs of GPs who are parents or are contemplating parenthood. 9298 GPs is not the same as 9298 full-time GPs anymore.

In addition, GPs are retiring and ageing, registrars are dropping out and some GPs are going into fields like cosmetic or complimentary medicine. Retirement, deaths, leakage and dropouts will outnumber numbers of new registrar and overseas graduates within a very short period of time. Australia will have to make visionary changes to maintain even a semblance of an adequate workforce.

Changes to recruitment of doctors will need to be made in two stages: firstly, we need changes which will increase numbers of doctors across all specialisations, and secondly, changes which will increase numbers of good GPs. Changes in the first category might include the following: 1. Recruitment of more overseas-trained graduates, with a ramp-up of the examination and accreditation system. 2. Allowing and encouraging older healthy GPs to practise longer, which will mean turning around the AHPRA (the medical regulator) culture of subtle discouragement. It will mean assisting such GPs in tangible ways to work part-time and yet to be able to afford Continuing Professional Development (CPD). 3. Expanding medical student intake and opening new medical schools. 4. Re-examining the university fee structure and HECS debt. 5. Re-structuring medical school curricula and placements so that students can maintain part-time jobs and introducing scholarships which provide living allowances and HECS debt relief. 6. Enabling new roles such as physician assistants and others, to allow doctors to offload some tasks.

If we are trying to bias students and young doctors towards choosing primary health care as a career, we should look at what attracts doctors to primary health care in the first place, and what puts them off. A recent European qualitative survey of GPs from 34 different European countries looked at both negative and positive factors which influence job satisfaction. The top three negative factors about GP practice were: mental strain; heavy workload; and loss of autonomy, followed by: burnout; complex patients including the multiply disadvantaged; conflicts at home over domestic-professional balance; administrative duties; and patient expectations. The positive factors, the ones most likely to keep GPs at work, were: income commensurate with hours and stress; autonomy and independence; compatibility with family life; the challenges of a broad medical practice; ability to practise holistic medicine; ability to employ an individual approach to people; social support; and feeling of belonging.

We must take heed of the factors listed in the aforementioned studies and be forward-thinking in devising solutions. Here are some suggestions which might make primary health care a more appealing and viable option than is currently the case.

Firstly, and most importantly, GP fees should be increased significantly, with no increase in out-of-pocket expenses to the patient. If you baulk at this, just consider the current pre-tax, post-overheads-deduction salary for an average GP – $116 per hour. GPs should be remunerated so there is a much smaller gap between GP and specialist. Training programs may not be the same in length, but the responsibilities shouldered are similar.

Secondly, GPs could be supported with paid CPD conference expenses and salary, as is part of the employment agreement for hospital specialists.

Thirdly, childcare could be subsidised, and progressive solutions for rostering within school hours could be sought. All GPs should be able to take leave without pay, and work a shorter year (e.g. a 48 week year) to enable them to spend school holidays with their families.

Fourthly, the workflow within a consultation could be managed better. GPs could be given more paid time for paperwork. Better still, an individual GP might become a mini-team, with a GP-PA, who sits alongside the GP and assists with documentation and paperwork. Models for such teamwork exist in legal settings. The team approach would mean that assistants could do BP checks, blood test ordering, referral writing, phone calls, typing of notes, preparation of mental health plans, authority prescriptions, and more.

Consultation times should be lengthened, so stress on the GP is reduced.

There should be regulation of corporate practices, to ensure good conditions of work for GPs, and a good standard of practice for patients.

And, finally, there are initiatives which would increase positive experiences for students within general practice. The medical course could be turned on its head, so that students start in general practice, in “Educational Clinics”, and spend three years as an apprentice, learning algorithms and red flags, much as a paramedic might, with specialty surgery and medicine and hospital exposure provided as rotations towards the end of the course. Universities have already moved this way, but the glamour of the hospital still seems to have overshadowed the community-feel of the general practice. Educational Clinics could be glamorous too, if properly constructed and equipped. Camaraderie and continuing education could take over from corporatisation. They could be the new teaching hospitals, and the Senior Teaching GPs who choose to serve there could be the best of the best. The course could be shortened by a year for GP vocational students with a final paid Intern year to be spent on location.

Minister Mark Butler has just announced a $750 million “Strengthening Medicare” initiative, with a Taskforce to match. Nurses, allied health practitioners, consumers, health economists, health policy experts, GPs and others will meet to discuss how to make health care more affordable, accessible, and integrated with allied health. All worthy objectives, and overdue. However, I wonder if the Cornerstone/Deloittes modelling hasn’t caught the minister on the hop. For what is the point of these changes when there simply isn’t a GP within coo-ee of Cranbourne or Caboolture? Where are they going to find the GPs to provide the after-hours care, to diagnose the chronic diseases or provide relief for hospitals (all items on the task list)? They just won’t be there. Under supply of GPs will be a defining issue of the 2020s, and urgent steps are needed. The first step will be to nail the issue onto the top of the agenda of the new Taskforce. The second will be to populate the Taskforce with more appropriate people to come up with a plan to train many more GPs. Quickly.

So what did my Sydney friend decide? She knows she’ll be always on call for her patients, and it will be stressful, and things will go wrong. She hopes her career satisfaction will be compensation. She’s got maybe five or more years of training to go, but she’ll be paid well during all that time, and her eventual income will likely be double or even triple that of a GP. She’s going to be a surgeon, and the swishy apartment will one day make way for a solid brick family home in one of the harbour side suburbs, with room for the nanny.

I tried to persuade my idealistic young ‘fixer-upper’ friend from Brisbane to become a specialist. I pointed out the income, the fact that, as a specialist, you don’t have to know everything. Just everything about your bit. I said that her income as a GP will be effectively capped at maybe $150,000 per year at very best, and there will be long hours in a very stressful responsible job. She already knows that what she will be expected to do in each 15-minute consultation with her patients is almost beyond human capacity. She’s supposed to be able to think, talk, type and write at breakneck speed all at the same time, not to mention fill in a few forms, check for allergies and drug interactions and follow endlessly changing guidelines. Oh, and be compassionate, and communicate with the patient. Never interrupt and maintain eye contact.

But she also knows she’ll be participating in the great journey of life with her patients and be there with them from go to woe. She’s never worked for a corporate – she hopes she can avoid working for such a company and wants to work for a high-quality group practice.

“I just want to look after people and families,” she said, “for the long haul. I don’t want to be the expert. I’m happy to manage the simple things and I hope I can recognise the serious things. I want to be part of shared care obstetrics, but I don’t want to be up all night doing the deliveries. The main thing is I want to be able to work part-time, because my family will always come first.”

She’s going to be a fine GP, and the ‘fixer-upper’ is coming along.

Katrina Watson MBBS MPH FRACP OAM – Katrina is a retired gastroenterologist and writer.