People like to use the terms coalface and frontline when they’re talking about the work GPs do, as if its immediacy and seriousness can only really be understood by likening it with war and, for some reason, mining.
The pandemic could change that, now we’ve been forced to acknowledge healthcare as essential above all else. It’s also becoming obvious that those who provide it are under great pressure, not only from Covid-19, but also because of the systems in which they operate.
“The viability of general practice has been an issue for quite a few years now,” says Dr Ayman Shenouda, acting president of the Royal Australian College of General Practitioners (RACGP), the peak body for general practitioners in Australia.
Covid-19 has just made matters worse.
“We are trying to respond to the demand of patients. We are trying to respond to the needs of our communities and the needs of our country for the future. And that creates a big load on general practice,” he says.
Dr Marina Kang has run a small practice in Kingsford, an eastern suburb of Sydney, for around 30 years.
She makes sure to leave time between patients who are still coming in to see her so that she can clean the surgery between visits.
“Even though it is more respiratory borne, we have tried to stick to the recommendations,” she says.
It takes barely a minute of conversation for Dr Kang’s focus to drift away from the impact Covid-19 has had on the way she runs her practice, to how her patients have been affected.
“The older ones who are probably on the verge of dementia, with the social isolation and the stopping of a lot of the activities, they have been impacted more in their clinical status, their cognitive functioning. There’s more confusion, and the services services haven’t been available to them.”
When it’s pointed, she laughs and says the biggest changes to her practice are all about what’s happened to them.
“Patients who used to be fairly stable, solid, single older ones who live at home, now if I ask them a pilot question they’ll break down. They’ll cry, they’re emotional. It doesn’t take much for them to decompensate, and I’ve never seen that before.”
Dr Kang can think of several examples off the top of her head.
“I’ve had a patient who just had a very simple skin thing, but I probed a little bit and she was, instead of being the happy person that she was, she was just not coping with being away from family. Her children are interstate. Another one has had to put off surgery because of the whole Covid thing and she had a bowel tumor.
“So just the nature of the treatments, of the conditions. Often the chronic conditions were exacerbated by the Covid shutting down of clinics and things. But also newer things that you would imagine that patients were coping okay with, but the mental health status of these patients was just very fragile.”
GPs are in fact still doing what they’ve always done—looking after the total health of their patients. But Covid-19 has increased the number of complex issues they’re seeing every day, like mental health and domestic violence, for instance, that take more than 15 minutes to address.
“You need to, we call it in general practice, to peel the onion. The core of the problem is not up-front. You have to engage and ask those questions and then you peel the onion until you reach to the core of the problem. And that’s what GPs do very well, but it requires time,” says the RACGP’s Dr Shenouda.
He says the organization has been advocating for higher patient rebates for longer consultations, so GPs aren’t forced to choose between doing less for their patients than they’d like to, and going out of business.
“When [the pay is too low] you end up with less quality, because you need to see more patients to keep your general practice viable,” he says.
“So, in a period when you need to spend more time with patients you cannot achieve that because if you do that the business is definitely going to fail.”
And that includes work done for patients outside of the consultation.
Dr Kang says she spends a fair bit of time after hours organizing for patients to see psychologists and linking them with various appropriate services, all of which adds up to a lot more incidental admin work. Naturally, it’s not something she’s remunerated for.
“No, we just do it. But because I have seen these patients for so long, they are almost like family. It’s hard to see them having to deal with these extra things. But, I mean, I can deal with it. The GPs can manage, generally.
“But I can imagine that burnout would be a major [issue]” she adds.
Dr Shenouda says GPs are often, in one way or another, providing services out of their own pockets because they are “very passionate” about their patients and because of the special GP-patient relationship.
And that relationship, he says, is part of the reason why many GPs have continued to bulk bill widely even after the mandated bulk billing of telehealth consultations for all patients vulnerable to Covid-19 during April and May was amended, and the temporary doubling of the bulk billing incentive ended.
“A lot of GPs understand that this is a strange time for patients, so they don’t bill them at this time,” he says.
But Dr Shenouda doesn’t think any practice can survive in the future if they only bulk bill.
Bulk billing patients during the pandemic has had a noticeable impact on Dr Rebecca McGowan’s bottom line, particularly during April and May when she was working entirely from home, providing only telehealth consultations.
Dr McGowan serves the regional area of Albury, on the border of New South Wales and Victoria. She lives on the family farm where she grew up, in the foothills near Beechworth “where Ned Kelly hung out”.
After expenses, Dr McGowan says she ends up with between $9 and $11 in her pocket per patient when she bulk bills.
“My income dropped massively because it was 100 per cent bulk billing at that stage,” she says.
Pre-Covid, around 80% of her patients were privately billed, paying $40-$50 above the Medicare rebate. When she explained what she received from the $80 handed over the front desk, they were mostly very understanding.
But she has always bulk billed some patients, either because they belong to lower socio-economic groups or because she’s known that their financial situation at the time warranted it.
“And that’s a thing that I love,” she says.
“Doctors love being able to pick and choose who we bulk bill, or who we privately charge. That’s the lovely thing about my billing situation.”
She says at first it was difficult to accept having that decision taken out of her hands.
“But you know, the whole thing is—and here I’m going to get philosophical—if you can’t change something, you change the way you feel about it.”
And at present she’s continuing to bulk bill, instead asking patients to “pay it forward”.
“Which means donating to a charity that you know of that’s helping people in these tough economic times, or passing the kindness on,” she explains.
“It’s just the vibe of the thing. It could be helping someone get some wood, taking a little old lady’s bins in, shouting someone a cup of coffee, or leaving that dollar coin in the trolley at Aldi.
“And it’s completely changed my practice because I’ve let go of it, and the love and the beauty that comes back has just been amazing.”
For now, that’s working out.
“I’m not sure how this is going to go in the future,” she admits. “I probably will start to have a little fee. I say I’m bulk billing for the time being.”
During April and May, Dr McGowan worked exclusively from home, consulting with patients via phone or video.
Like many others involved in the great work-from-home transition of 2020, she had to navigate the various physical and technological requirements to make it possible.
“There were numerous things. I think it was probably close to about two grand to set up my office appropriately because it wasn’t set up to do things like that,” she recalls.
And, like any other industry, there were requirements that suddenly became much more onerous.
Pharmacies, for instance, often need an original script. In many instances they were still using fax machines.
“Our practice just became so overwhelmed with this massive amount of scripts. I had to send sometimes 30, 40 scripts each day. So that was another cost, postal. And the time! Sitting beside a fax. I just couldn’t believe it. But now I try and scan and email most of my scripts to the chemist.”
Her payments to the clinic in town also continued.
“Even when I was working from home and patients were able to bulk bill online for the tele-consults, and I was doing everything else, sitting by the stupid 90s fax machine, waiting for it to go through, they were still [taking a] percentage. And that was a really big expense.”
Dr McGowan says the income drop associated with the combined elements of that shift also fell largely on other female GPs.
“Many of us women went home, especially in April and May, the first lockdown, because we had school-aged kids. The men were still working at the office. So they were still getting the patients coming in, private billing, because patients were seeing them face-to-face.”
Some “bigger Medicare-ticketed items” are only available in person, she explains, and working from home in that period also meant missing out on income generated by flu clinics.
On top of the economic consequences, there were the disparaging comments.
“One male doctor wrote in the local newspaper about how telehealth is not real medicine and real medicine is seeing a patient face-to-face and holding their hand like our forefathers did when smallpox came,” says Dr McGowan.
“That’s the attitude—we were soft. It’s really gendered.”
Telehealth has, in fact, been seen overall as a silver lining.
The Australian Government has stepped up to the plate and extended Medicare coverage for telehealth until 31 March, 2021. (The temporary doubling of the bulk billing incentive has ceased as part of that extension.) More than 30 million consultations have taken place so far.
Dr Shenouda says the RACGP has strongly advocated for telehealth to continue, both for the benefit of patients and doctors (who, he points out, may be equally at risk of Covid-19), and the organization is very appreciative that it’s been extended.
“Hopefully it will be part and parcel of the future of general practice,” he says.
Dr McGowan says GPs have always provided telephone consultations, unpaid. At the end of most of her days there would be five, eight, sometimes 10 phone calls made to patients.
“So we were doing all this work for free, and we weren’t getting paid for it. So when telehealth consults came in I think collectively we all said, you beauty, we’re going to get paid for things that we always do,” she says.
Telehealth works for Dr Marina Kang too, because she knows her patients well.
“So I don’t have to go, well who are you? I don’t have to go through all that. I have all their files. I know who they are. I know their voice. I’ve seen them for years and years. So I don’t have to cross the hurdles that other GPs have had to cross. My patient profile is sort of static.”
However, it has not entirely made up for the income shortfall caused by the drop in the number of people accessing GP services.
“We’ve always said that general practices are safer than supermarkets, but the idea is not out there,” says Dr Shenouda.
“Telehealth has improved [things], but still not to the extent of patients coming in face-to-face as they should.”
Putting off GP visits is going to pose even more problems for patients—and, by extension, their doctors—during the post-pandemic recovery phase.
The downstream impacts are particularly great for people with chronic health issues and for those whose illnesses have not been caught at an early stage because they weren’t screened during this period.
On top of this, GPs will also be seeing an increased number of people for mental health issues— “at least 30% of patients we see in general practice are there for mental health,” says Dr Shenouda— as well as playing a central role in a mass immunization program.
And preparing for this imminent future is where Dr Shenouda says efforts should be focused. He says general practice can be a vehicle for returning to normality if the profession has the support to do everything that’s required.
“General practice will be in the center of all of this. But if we don’t invest in that now, it’s going to be a problem.
“If you don’t have investment in primary care, then there’s no way you’re going to be able to afford the future demands of health—all the research around the world supports that.”
Dr Shenouda says general practice can be a vehicle for returning to normality if the profession has the support to do everything that’s required.
But that’s not where things stand.
“It’s about the healthy nation that we want to have. But part of the equation is the viability of general practice. If we don’t have a viable general practice, how are we going to achieve that?”
Right now, he says, Australia is headed the wrong way, because it’s difficult to attract young doctors to a specialty that’s not financially viable.
“If you are a young doctor trying to decide on what you want to do in the future, would you choose a less complex specialty that pays you more, or a more complex specialty that pays you less?
“In a time where you need more generalists, you need more GPs to address the future needs, it’s the other way around, we are getting less.
“In Australia it’s phenomenal actually, that the number of specialists is more than the number of GPs.
“We’re paying people with a very narrow focus, whereas people who are doing the whole thing, like general practice, where you do public health, preventative health, you do obstetrics, all the routine things to do with child care, aged care, palliative care, mental health—so, a very complex specialty—we’re paid the least of all the other specialists.”
He says GPs need to be seen as specialists in their own right, and the funding model has to support a team approach to primary health, with GPs remunerated for using their expertise to coordinate care as needed.
“The majority of GPs are sticking to their work in this very rough, unpaid environment because of that passion for the profession and their communities and their patients,” says Dr Shenouda.
The question is, how long can that passion sustain them? And can things shift before it’s too late? For better or for worse, we will soon find out.
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