Whats your point John? Actually John the actually study time for a NP looking at your info is still only 6. The first is 3 years full time and after that they can be working (actually they NEED to be) while doing the other 3 years. Most NPS are excellent but lets deal with actual facts and not get into a ‘who studies more’ scenario. Required experience time does mean its a longer degree….it just gives you the necessary experience to attend the degree and subsequent responsibilities. GPS are not saying that NPs should get less, they are simply distressed that the Government values their services so little that they are trying to either pay them considerably less, or make their valued pts pay considerably more. Just like NPs, GPs come with their distinct areas of specialty, interests and past experiences before choosing General Practice as a career. Why would medical students consider heading down this past when they can earn 4 times or much more by choosing a different specialty?
To loose more GPs to other areas of medicine, deter future GPS from entering the speciality or encourage highly experienced GPS into early retirement would be devastating to the medical system.
I’ve been watching TV adds tonight deterring patients from going to Emergency Departments with conditions that can be treated by a GP and in the next program there is more information about Medicare Rebates being cut for the same conditions if they go to the GP. The Government can’t have it both ways and something has to give.
Actually to become a nurse practitioner you require:
3 year undergrad nursing degree
1 year post grad diploma in nursing speciality (ie general practice)
5 years experience in this speciality
2 years studying the masters nurse practitioner.
1 years as a nurs practioner candidate
Strangely enough cones out at 12 years?!]]>
Agree fully with Maureen. She is a great Doctor - has saved my life a few times!
How can these politicians sleep at night knowing that there are now people who will not be able to afford to go to the GP. ?
What medical student will bother to go into General Practice if they are paying more out to their rent and office staff than what they are making?
LNP you are being fooled by the cigar smoking accountants. (. Who is going to treat them when they get cancer?)]]>
On 19 Jan 2015 the Abbott government will bring in changes to Medicare which will make it impossible for me to continue my current medical practice. Complying with Abbott’s changes would force me to practice in a manner which would remove all joy from a currently perfect working lifestyle. I am not Abbott’s donkey.. I will not comply .. he will have to ride other donkeys to the next election.
The changes have absolutely nothing to do with any co-payment. These are fatal challenges to the cornerstone of General Practice .. aimed at the fee structure and time constraints relating to the standard consultation. The first 20 minutes of a GP-patient interaction is ground zero for medical practice. This is where it all happens. On the dynamics of this 20 minutes we create our business models, organise our lifestyles, determine our levels of debt, set our overheads, employ our staff and so on. The current organisation of General Practice has been carefully crafted over the past four decades. It is the result of a continual dialogue betwen government, GPs, political parties, bureocracies, and the community. For the Abbott goverment to strike a lightening bolt into ground zero on a political whim is amateurist and stupid.
My situation is not typical because I have spent my working life creating distinctly unique style of work within a rural scenario. For that reason, in the context of the wider political ramifications of Abbott’s changes, I am irrelevant and politically impotent. I will just have to make my own decisions and the only people who will suffer the consequences are my own patients and other local GPs who will suffer flow-on effects from my departure.
However I believe that the same changes which make my practice impossible, will also cause a breakdown in the business model of corporate medicine. The corporates are huge organisations employing thousands of GPs. A savage cut to their business model will be impossible to absorb or work around. My belief is that the Abbott changes are not workable and will result in a collapse of Austrailan medical system.
I am gobsmacked that the Abbott government will introduce a change which directly rewards inefficiency and time wasting and punishes efficiency, experience and flexibility of work practice.
The change involves two basic elements.
1. Firstly the rebate for a short consultation will be reduced so drastically (it will be a dog’s turd not a fee) that GPs will have to abandon short consultations.
2. Secondly the time required in face-to-face consulting required before a “standard consultation” fee cuts in will be doubled to 10 minutes.
Addressing the corporate model:
I have no direct experience with Corporate Medicine having always been self-employed .. so this discussion is a bit speculative… however …
The corporate sector now dominates Primary Care. It is big business. It has created a system of general practice medicine which hinges on efficiency. Its business model depends on experienced, efficient, smart GPs delivering no frills, bang-for-your-buck medicine.
There is a myth floating out there that “6 minute medicine” is bad medicine. Rubbish. Sure there are issues such as mental health where a GP just has to drop everything else and spend quality listening and counselling time ( this can be an hour or more).. or times when one needs to spend considerable time setting up a complex illness plan, or dealing with patients who come with a list of complaints.. but for each of these longer scenarios we are adequately rewarded.
The reality is that the bulk of actual health needs is well managed by GPs who can cut the crap and focus on the issue of the day. Even complex care patients are managed well by a series of shortish conutations once an overarching health plan has been established.
There are some GPs who routinely take longer time with their consultations. These include young GPs who are learning the trade, chatty GPs, some special interest GPs, and GPs who simply find it difficult to control the time chewed up by chatty or dependant patients. Some of these GPs think they are practicing “superior” medicine, when in fact they are often just pandering to their patients or their own needs to turn a medical consultation into a social event. This may seem harsh but why should the time-wasters be rewarded and the efficient doctors punished. I thought the whole point behind the Abbott changes was an attempt to make better use of a limited tax-payer’s dollar. So he is doing the exact opposite isn’t he.
These changes will drastically alter the rationale behind the corporate business model. Efficient consultations will be rewarded with dogs turds. Slowing up the process to tick consultations over the 10 minute threshold will involve thumb twiddling and idle chat. Efficient doctors will be encouraged to become sloppy time-wasters. Not only that but the numbers of patients seen per day will fall in such a way as to eat away the corporate’s profit margin. I hazard a guess that the drop in Corporate income from reduced patient throughput will be impossible to absorb. Corporates caput.
Because of the dominance of the corporate sector, this is where the politics is going to be played out. Abbott can totally ignore me. But he will have to mix it with the big boys.
Addressing my own personal situation.
It is hardly worth explaining my situation except as a matter of human interest. I am totally irrelevant to this issue. Individuals have no power.
Because this is a human story .. more an issue of lifestyle than an issue of finances .. my decision to quit medical practice can only make sense in the context of the history of my medical career and my peculiarly individual life choices. I had aways hoped that my pathway though life had some relevance to the perennial issue of “how do we attract GPs to the country”. But I’m not convinced. The lifestyle solution which I have pursued is one individual’s solution… it can never attract mass appeal.
As long-time rural spokesman Dr Ras Simpson from Oatlands has pointed out a painful number of times (to the deaf ears of his arrogant colleagues) .. the solution to the rural workforce dilemma is simple. That is … restriction of provider numbers on a geographical basis (as per pharmacies).
We have the shameful situation of resorting to employing desperate overseas-trained doctors in rural Australia at a time we have excess doctors in the cities. The countries they come from need them more than we do. A rich country’s gain is a poor country’s loss.
The failure to impliment obvious reform ie placing our own doctors in areas of need … doesn’t say much for the so called leaders of our medical profession. The RACGP clearly feels guiltless and in no way embarrassed to have forced most GPs into a stranglehold of its own rules, registers, accreditations, PIPs, the in and the out, VR vs non-VR and countless other Lee Quan Yu style peer-control regulations, yet they cry crocodile tears and fein rage at the suggestion that the people (through their government) might dare restrict medical practice location. Such hypocracy is mind-numbing. I would rather have a government attempt to tell me what I must do … I can then fight back (like now). To have had to suffer the (not so) benign dictatorship of a peer organisation whose leaders revel in exerting power over their own kind (well chooks can be cruel to each other too) has been the bane of my life. Abbott may be a fool. The RACGP is scary. Novelist George Orwell described beautifully the way the middle class controls its own. The RACGP is truly Orwellian.
My greatest fear is that Abbott will find an ally in the naturally right-leaning RACGP and AMA and come up with a compromise solution which will become status quo on the pretext that “the doctors have been consulted”…. that they have come to an agreement with ” their representatives” ‘
I hope the RACGP and the AMA will butt out of this argument and allow the democratic processes exert their influnce unblemished by “representative organisations”.
My own story in brief
Born in Hobart and educated at Friends’ school where I was strongly influenced by Quaker humanitarianism.
Brought up in an atheistic intellectual family who took no prisoners and suffered no fools.
Medical school at Uni of Tas in a period of social unrest and rebellion where “being different” was seen as a virtue.
I am relentlessly individualistic (with a determination to accept no master) combined with a strong social concience and a traditional left wing idealism.
During 2 years working as a junior doctor in Launceston General Hospital I discovered my future life direction as a Rural GP thanks to a 3 month placement in the Longford Medical Practice.
I moved to Cygnet on the invitation of the then secretary of the Tasmanian branch of the AMA in 1981 who said the town was desperate for another doctor.
I set up a solo private practice, the first ever in the history of the district.
I worked solo for a couple of years, then took on a series of partners, Dr Lewinski, Dr Skeat, and finally Dr Dubetz who stayed on as a town GP until his retirement in 2014.
In the first few years the district was small enough for Dr Dubetz an I to manage on our own.
We shared the workload in a unique way which allowed Dr Dubetz to follow his interest in travelling the world in search of adventure, and me to raise a family, build a home, explore the Tasmanian wilderness, home-school my children and pursue a passion for sea-kayaking and bushwalking, furniture building and gardening. I still live in my perfect house on the waters-edge in Cygnet.
Cygnet was rapidly becoming an attractive retreat for young alternatives and retirees seeking a rural lifestlye.
The steady influx of newcomers eventually broke the back of our combined ability to sustain our perfect arrangement.
Recruiting more doctors proved a thankless exercise.
Our working hours increased to the point of becoming a burden.
In 1994 I spent a 4 month stint on my own, working 14 hour days, 7 days per week plus on call, trapped in a single consulting room. I lossed track of time and perspective. At the same time Dr Dubetz developed the first symptoms of a devastating arthritis which eventually changed my friend and ally from a human dynamo into a physical wreck. I had developed a heart complaint as a direct result of working excessive hours. Clearly the increasing pressures caused by an ever expanding population had caught up with us.
I unilaterally abandoned the practice and spent 3 years as a locum providing medical relief for the Bass Strait Islands, Aboriginal Centre and the Tasmanian East Coast.
Locum medicine had it’s own limitations and after 3 years I was stuck with a dilemma of what to do next.
I was continually under pressure from the Cygnet community to resume rural practice in my home town.
Under no circumstances could I contemplate spending the rest of my working life trapped again in the four walls of a doctor’s surgery, working ridiculous hours.
That prospect remains a nightmare to me. Under no circumstance can I contemplate a return to that sort of practice.
I came to the country for a lifestyle, not to spend every waking hour in a sterile room never seeing the outside world.
This remains a central reason why I cannot find a solution to my current predicament.
However in 1986 I read James Herriott’s “All Creatures Great and Small” and after the laughter stopped I was left with an inspiration for the lifestyle of this country vet who combined his life as a town-based vet with a daily journey around the farms and villages of his district in Rural England. Soon after I spent an evening drinking a lot of very strong exotic coctails with a god friend Richard Parry whose father had run a rural practice in James Herriott country and had done just that.. a 3 hour morning surgery then 6 hours on the road. After the alcohol wore off the idea still seemed fantastic. I had found my answer.
Coincidently at this time Telstra announced its intention to bring mobile phone coverage to the district. Communications solved.
At the same time my daughter Amy won an Apple Computer in a writing competition. I discovered Apple’s Hypercard programming language, played around with it, and wrote a suite of medical software. At this time there was no established medical software. The designer of Medical Director was just putting his first hesitant ideas onto disc.
Writing the software took me a year or so and gave me something to do during far-flung locums. It was ready at the time Telstra opened up mobile coverage in the Huon. I was set.
My home-visiting medical practice started as an experiment but soon established itself as a viable, enjoyable way to work. It has allowed me to sustain a long-term full-on rural medical practice which at the same time is a lifestyle in its own right. My involvement with the community is truly in the vein of my inspirational James Herriott. It is so interesting and so rewarding that I don’t want for anything else.
True I still work long hours. My average day is 11 hours minimum Mon-Fri and 3-8 hours each weekend day. Plus I am on call 365 days per year.
True I don’t have any holidays .. two of my three breaks from work have been spent in ICU .. once with a heart complaint, the other with a spinal tumour.
In recent years, most of my remaining hours have been spent helping out with the local football club. (club doctor, barman, licencee, cleaner, committeman, website manager, facebook page manager and so on). That has just come to and end. I have 8 going 10 grandchildren under 6 years old and new priorities are taking over. The football club has had 34 years of my time .. enough’s enough.
The current dilemma
As I have described, my willingness to sustain a serious medical practice long term is dependent on being able to make it sustain an enjoyable lifestyle.
Back to the dilemma of how to attract and retain GPs in the country.
Rural towns are under doctored. There are always more patients and more demands than can be met by the resident medical workforce.
Rural districts want and need GPs who actually put in serious hours of work.
GPs who settle in rural towns for “lifestyle reasons” often spend more time on the lifestyle and less time on the doctoring. In some respects “lifestyle GPs” are more of a nuisance than a benefit.
So trying to attract GPs on “lifestyle reasons” fails on two grounds… 1. the Doctors who are willing to put in the hours actually needed are unable to enjoy a real rural lifestyle and 2. the Doctors who truly enjoy a rural lifestyle are unwilling to put in a worthwhile doctoring contribution. Part time GPs tend to ignore the plight of their overworked fulltime colleagues.
My answer to this dilemma was to create a style of medical practice which was also a lifestyle. For me it has been an outrageous success. I really don’t want to stop.
So how does Medicare and Mr Abbott fit in all this.
Simply put, the previous fee and time structure has allowed me to “hive off” a whole proportion of my daily work .. away from the patient encounter and into my home. It has allowed me to generate a normal income from the (reduced time) face-to face encounters on the road.
My working day is divided into.
1. Three to four hours in my home office in the morning ( 6am - 10 am) .. writing up the previous day’s notes, thinking about each patient, planning what is required, researching, writing reports, writing extended referrals, faxing and emailing, phoning specialists and hospitals, phoning patients to discuss issues and so on and so on.
2. Two hours in a room I hire in the town to see patients who have moved too far away to visit on that day.
3. Five to Six hours on the road doing home visits.
4. One hour back in my home office dealing with results,correspondence. Phoning patients etc etc.
So much of the essential work required to deal with my patients’ needs is done at home. This is quality lifestyle time. My home is a delight. I do my work with views of water from both sides of the room (I live on a point). My wife and garden and TV and music and pets and all are around me … all nourishers of the soul. Quality lifestyle time.
Much of my out-of-home work is my “All Creatures Great and Small” experience. Quality time.
So what is the problem?
Well.. Medicare only pays for the actual face-to-face time spent with a patient.
Currently, under our traditional Medicare system, short consultations are paid well and the standard consutation (ground zero) has a very forgiving time structure. Essentially I can generate a standard fee for face-to-face of anywhere between 5 and 20 minutes. By hiving off all those other components of my health delivery which do not demand actual face-to-face time, and transferring them to my home-time, I can maximise my patient encounters, maintain my income and maximise my work-satisfaction.
Much of the non- face-to-face components of my practice are actually practically very difficult, in fact impossible to deliver in the “on-road” scenario. Writing and faxing, phoning , waiting for return phone calls etc etc involve needing a formal office setup or involve delays which are incompatable with travelling from house to house. For example a simple phone call to a specialist may entail a wait of between 15 minutes to several hours for a call-back. I just have to move on. Mobile phone and wireless internet coverage is so woeful in this district that it is not fair to frustrate hospitals and specialists with frequent communication-failure. It is best done from home.
So in the end, I spend time on the road mainly on the face-to-face component which inevitable sits somewhere in the 5-20 minutes time allowance, but the majority are well under the magic 10 minutes (non-chat time). The subsequent time spent at home on the other essential elements of the consultation may be anything from a couple of minutes to over an hour. I accept the losses incurred when my actual (total) time blows out. Medicare does well out of me.
The Abbott changes however make face-to-face times up to 10 minutes financially unviable. The drop in fee will be $37.05 to $16.95, ultimately to $11.95.
As an experienced and efficient older GP I can deal with most of my patients’ needs well inside the 10 minutes timeframe. So for the majority of consultations I will receive a woefully inadequate fee.
For the more complex consultations I am faced with a situation where I cannot create an income without shifting my home-work back to the face-to-face encounter environment. That will be simply to increase the face-to-face component of complex consutations .. up past the 10 minute cut-off.
And since that is practically impossible in the home-visit scenario (no formal office setup and no ability to cope with delay), then one simple change to the dynamics of the standard consultation makes my current working model unworkable.
My only solution fotr that sort of work would be to set up again in a formal office and spend my 11-12 hours there. I’m not going to do it. End of story. In 1994 I had had enough of that.
I have calculated that I can earn a better living doing two days locum work than a full 7 days work in my own practice.]]>
Mike, love the graphic! I’d have stolen it had I known!
Sharing this! Thanks for the link!]]>
Good for Maureen ! I think all GPs but particularly those who own their own practice are furious. The only thing is that the 11.95 doesn’t come in until July . Having said that getting 16.95 for something the day before I received 37.05 is equally insulting!]]>
The new Health Minister, Sussan Ley’s contact details are at www.aph.gov.au/S_Ley_MP