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JumpingTurkey on GPs in Canberra

By johnboy - 13 August 2010 26

In our recent discussion on Labor’s proposed GP Super Clinic for Canberra “JumpingTurkey” made a lengthy post worthy of its own thread.

So here’s a GP on GP services in Canberra:

#18 JumpingTurkey
11:51, 13 Aug 10

As an existing GP I have a few comments.

1. Building a huge builing to the tune of several million dollars is going to do absolutely nothing to address the GP shortage in Canberra. GPs are not going to be suddenly lured to Canberra to work in these new super clinics.

2. Issue of how to get GPs to work in Canberra is complex. I think it has to do with the fact that GPs generally don’t stick around in cities and places that they did not train in or grew up in. Until very recently, Canberra did not have their own medical school, except for students who rotated from Sydney Uni. Hopefully when ANU starts pumping out graduates, (and they are now) then this will address some of these issues.

3. You say that there are incentives for GPs to work in Canberra. I’ve never heard any details of these incentives. And I read through most medical newspapers / journals regularly. If it does exist then the government is not doing a good job of promoting this, are they?

4. You’ve got to stop blaming GPs for not bulk billing, but blame the government for not increasing medicare rebates. If you are an intern or a resident in the hospital contemplating your next career move – whether to specialise or enter GP training, and if you know that the government pays specialists double or more compared to GPs, and if you know that the training time for most specialties is only 2-3 years more compared to General Practice (and of course you earn an income as a trainee too, so its not as if you are paid nothing), then why would you enter general practice?

If you feel that your GP bills too much, then do you feel that your accountant who spent 3 years at Uni, followed by 2 years doing his CPA (compared to your GP who spends 10-12 years studying and training), charges you too much? What about your lawyer who charges you $50 for a couple of phone calls?
As a GP I’ve never dreamt of charging people for phone calls that I make to them, or bill them for the time it takes me to check their blood results or pathology results as they come through, or to call and talk to specialists or hospitals to discuss a patient’s case.

The money that you pay GPs need to pay for the surgery expenses, including rent, including electricity, phone bills, staff wages, and all sorts of expenses needed to keep the equipment sterilised, and also for medical indemnity insurance that protects you as a patient in case anything goes wrong (its not that we try to practice dodgily, but we are humans too and you’ve gotta be deluded to think that we never make mistakes).

The fact is that what medicare covers seems to rise in the order of 1% of less per year. Compare this to your electricity charges, or even the inflation that goes up at 3-4% per year. Or even your own salaries and wages that goes up by at least that amount per year.

5. Many GPs that I know will bulk bill patients who are in genuine financial difficulties. For instance, I bulk bill some of my patients – e.g. those with mental health issues, because I need to follow them up closely, and I don’t want money to be a barrier in them coming to see me frequently. Also we bulk bill those folks in nursing homes who are extremely fragile and often in the last few months to years of their lives.

6. I think having nurses working with GPs is a great idea. However you’ve gotta be kidding me if you think that nurses can replace GPs or do 80-90% of their work. What even makes you think / or what qualifies you to think that this is the case? As a GP, I can confidently tell you that 20-30% of my work is routine – i.e. coughs and colds, and issuing scripts and so forth. Around 40% are intermediate – they are things like people presenting for scripts but they actually need to be properly reviewed to make sure everything is okay – e.g. people who ‘thinks’ that they can come in asking for more scripts for diabetes tablets, without realising that they did not have a blood test for that in 12 months, or had their blood pressure checked, or does not realise that the sensation in their foot is slowly dying off due to diabetes, or their vision is silently going etc. That’s when I have to actually tell them that its not a simple matter of giving them scripts, but I have a responsibility to make sure that they are properly assessed again.

The other 30% of my work are diagnostic dilemmas. e.g. funny skin rash, or abdominal pains, headaches that persist, or dizziness etc etc. These are not ’simple’ things and they need extensive history taking, examination and investigations to get to the bottom of things.

Now, I think a well trained nurse would be able to do the routine things. They might be able to do parts of the intermediate things, but they will always need a doctor to check to ensure that nothing was missed. Often during the course of routine BP check, I often discover things like a mole, or funny irregular heart beats. And this kind of stuff only comes with years of medical training, not years of nursing training.
There is no way that nurses can deal with diagnostic dilemmas or the harder cases.

The fact of the matter is that nurses are NOT trained to be diagnosticians. Diagnosis is the most difficult part of health care. The rest – how to get you better – is easy – you just look up a book. For instance, if you KNOW that what you have is a skin cancer – treatment is easy – cut it out or burn it out (depending on the type). But getting to that point is difficult and requires specific training.

Nurses are good at ‘nursing’ people to health. Once they have a diagnosis, they are very good at taking good care of them, and monitoring their recovery to ensure that they are back to their health. With further training they become good at technical tasks – e.g. as scrub nurses who assist surgeons, or ICU nurses who are very good at looking after patients in critical conditions and become good at protocol-driven management of people’s airway, breathing and circulation issues.

However nurses are not trained to be diagnosticians and will never become good at this because they lack the broad medical training.

Remember 20 years experience as a nurse is not the same as even 2 years experience as a doctor, given that what you are doing is so different. this is same as thinking that a dental assistant working for 20 years will be able to do the job of a dentist – although they spend a lot of time looking after patients, they are simply not involved in making diagnosis or taking on the heavy responsibility of patient’s care – so how do you expect them to be the same???

What’s Your opinion?

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26 Responses to
JumpingTurkey on GPs in Canberra
JumpingTurkey 8:26 pm 14 Aug 10

@jethro: you are absolutely right,I think that the requirement for the employers for their employees to have med certificates is in most cases a waste of time. And I think most GPs agree with this and most of the time it is a waste of everyone’s time.

The other problem is when someone comes to see me and says that they have a cold or a diarrhoea (and who knows whether or not they had diarrhoea – there is no objective test or anything that can prove or disprove whether someone has gastro except what they tell you) and says that they feel crook and cannot go to work, then how can I refuse their request for a med certificate?? Yep – if you’ve done this before and if you are reading this, then yes we know what happens – but we cannot accuse our patients of lying without having any proof so we go along with it.

So med certificate is mainly a way for employers to discourage their employees in taking a sickie. Only the most daring ones would chuck a sickie when healthy and go to their doctor and pretend that they have an illness to get a certificate. Most ‘honest’ people would probably be discouraged in doing so.

On the other hand, I am not so sure it is wise to let a pharmacist or a nurse (let’s stay away from the nurse practitioners, but just nurses) give out medical certificates. This is because even though 95% of the cases when a person thinks that they have a cold will have just a cold, 5% will not. And can you imagine a pharmacist actually examining you before issuing you with a medical certificate? Imagine in a busy pharmacy with other people watching you, your pharmacist pulling out his stethoscope and trying to listen to your chest… (not to mention that s/he has never been trained to examine people, or to make any form of diagnosis) Do pharmacists even have medical records where they can record down what happened in a consultation?

So I think it will be far better to scrap this requirement for medical certificates and make it compulsory only if one needs to take more than say 2 days in a row, or takes more than 10 days in a calendar year.

As for pharmacists and nurses issuing medical certificates – I really don’t see any point in it – they are not adding any value and I don’t see how they will be much better than you in picking whether or not you are sick enough to actually go to a doctor.

I suppose if they set up a consulting room and keep proper medical records and get trained in properly examining people for coughs and colds, then let them go ahead! I’ll train them myself (provided that my indemnity insurance covers it, and I get paid for it). But this seems to be far too complex a system when we can do away with this stupid system.

Jethro 6:40 pm 14 Aug 10

Since I seem to have the opportunity to quiz a GP on all things GP-ish, I have this lump on my knee….

No, really, I actually want to bring up the topic of doctor’s certificates and:

1. The fact that since its almost impossible to find a bulk-billing doctor these days, I need to fork out a bunch of money to be told I have a cold and to stay home and rest when I clearly already knew that.

2. The fact that by me going to the doctors, I’m taking up an appointment space for something that is very minor and not really in need of any medical attention, other than the need that I get a doctor’s certificate so that I can prove that, yes, I do have a cold

3. There seems to be a shortage of doctors in the ACT, so often I need to call 3 or 4 doctor’s surgeries before I can actually find one with an available space for today, and now someone who may actually need to see a doctor is missing out. (I have had a few occasions where a request for an appointment was met with a ‘We have a space open next week’). Also, this means I’m not visiting my personal GP, which I always feel a bit bad about because he’s such a good GP and knows my medical history, etc.

So… why do we have this requirement to get doctor’s certificates? Is this something that doctors agree with? Surely, this is a case where a nurse or a pharmacist should be able to certify that I am sick.

It really does seem to be a massive waste of 1. my money. 2. a doctor’s time 3. an appointment space for someone else who might actually need it.


JumpingTurkey 6:23 pm 14 Aug 10


Yes in the end, it doesn’t matter what field (nursing or medical) that one comes from, it is the ability to provide effective care that is important.

But in your situation, shouldn’t your title change to reflect your skills and status?
I am a bit intrigued: if you are capable, trained and experienced in diagnosis, then why are you still called a nurse? For instance, if you and I were working side by side, and if I asked you to do something that is traditionally nursing, then you’d object to it, wouldn’t you, given that you would feel that your skills would be better used. And also you already object to being classified in the same way as traditional nurses as is evident in your post?

To address any problems and misconceptions, why don’t Nurse Practitioners change their title? Physician assistants are an obvious example but this is a problem given that in US and also in Australia we have physician assistants coming out from 3 to 4 year university courses.

Or perhaps there should be a pathway that will allow someone like yourself to become a fully qualified doctor – in a shorter time given your experience and training already – maybe 18 months to 2 years to upskill on basic and clinical sciences – and fully funded (say at $50 to 60K per year).

GuruJ 6:09 pm 14 Aug 10

Genuine question to either or both of MrNurseRatchet and Jumping Turkey:

What practical differences are there in the training that a nurse practitioner receives vs a GP?

Presumably you both get trained in basic medical science and diagnosis … is the main difference left that a GP will have trained in surgical techniques as part of their basic MD degree, whereas an NP gets trained in patient care?

MrNurseRatchet 4:02 pm 14 Aug 10

Hi Jumping Turkey et. al:
With all due respect (and I really do mean that) I must heartily disagree with your take on nurses not being able to work autonomously, independently, nor have the ability to be “diagnosticians.” I’m not talking about “advanced practice nurses”, “general practice nurses” or other variants when saying that they can treat 80-90% of what a doctor can. I am speaking of “Nurse Practitioners” being able to safely, appropriately, efficiently, and effectively treat 80-90% of those diagnoses pertinent to their specialty field when compared to their physician colleagues. There is a WORLD of difference in this country between an “advanced practice nurse” and a “nurse practitioner” and I believe that you are blurring the distinction between the two.

I am a nurse practitioner from overseas that has been trained, through my extensive advanced education and experience, to BE a diagnostician. I agree with you that nurses are not traditionally trained to build differential diagnoses…but we’re not talking about traditional nurses anymore, now are we? Nurse Practitioners are able to very effectively work with those easy and intermediate cases…and many of the “diagnostic dilemma cases” as well. I was trained as a generalist NP, did heart failure for a brief stint, and then worked side by side with a cardioaortic surgeon for a while. He did the surgeries and as soon as they were extubated I did ALL of the medical and nursing management from that point on. The medical and surgical management of these cases was quite complex, and yet our NP-collaborative cardiothoracic surgery service had PROVEN decreased morbidity and mortality compared to traditional physician-directed models.

With respects to your epiglottitis example: Please. I have a lifetime’s worth of examples demonstrating the exact same thing but in the reverse: plenty of careless physicians making mistakes that, if it weren’t for my advanced clinical assessment, reasoning, and diagnostic skills, would have resulted in significant morbidity and mortality for patients. It goes both ways: there are bad nurses just like there are bad doctors.

Anywho: I definitely agree on your points on the GP Superclinics. I say devote more money to the existing infrastructures and find more creative means of providing services to the community. (Like hiring some NPs to work alongside with the GPs at the community centres!) It’s in my very strong opinion that the most beautiful, effective, and powerful healthcare occurs when nurses and GPs work side by side.

JumpingTurkey 2:24 pm 14 Aug 10

@ Sasquatch Sam

I see your point, but the reason why 20 doctors came down was only because the condition is so rare and serious so they needed a lot of people’s input on how to tackle the situation.
The point of this story is that nurses didn’t really know that such things could happen or that is a possibility.

Look nurses are fantastic at common things and things that are routine. For instance if you go into emergency with a gastro bug then they’ll be the ones looking after you really well, and you’ll be lucky to see an intern for 5 minutes who’ll just come in and ask you a few questions and then leave. They are lot more thorough than medicos, and often know their protocols really really well. So things like setting up IV lines and giving medications, and reassuring patients, they are really good at.

JumpingTurkey 2:18 pm 14 Aug 10

Vg, of course you could argue that GPs are already paid too much and don’t need more incentives than any other skilled shortage.
But what you don’t realise is that people think that health care is a right.
If you don’t have more programmers in Canberra, people aren’t going to die.
If you don’t have more public servants or lawyers in Canberra, then people aren’t going to die.

If you run out of dentists or GPs or nurses, then people will suffer.

The fact of the matter is that GPs aren’t coming to Canberra. And the fact is that this is causing a lot of problems for Canberrans.
The solution is to find ways of attracting more GPs.
In this capitalist society, you can’t “force” people to go anywhere, so you need to offer them incentives – in our society, it is money.

Sasquatch Sam 1:40 pm 14 Aug 10

Astrojax, epiglottis appears to be something nurses will have learnt about as well (eg I think the nurse in this example didn’t do their job well (tonsils and epiglottis are completely different bits + drooling and tonsilitis just sounds painful, swallowing spit all the time, painful even for a Tongan). Thankfully JT was there to pick up this other induvudals slack. I don’t think this very old anecdotal evidence supports the idea that nurses working indepentely is a bad idea though.

In fact … maybe if his profession didn’t have this kind of objection people like JT would have time to time get up to date with the ACT health website and would be aware of things like the grant DTC mentions.

(I have nothing to do with nurses by the way, I’m in IT, I just think the DR lobby group are overly powerful)

justin heywood 9:02 am 14 Aug 10

vg said :

Why do doctots need ‘incentives’ to work in Canberra any more than other skilled shortages.

When the AMA’s own data indicates the average GPs salary is around $300,000pa you can cry me an effing river

Doctors DO earn a lot of money – that isn’t the issue though. If we have to pay them more to get them to Canberra then I’m all for it.

astrojax 8:40 am 14 Aug 10

Sasquatch Sam said :

The epiglottis example points more towards your thoroughness doesn’t it JT, more than the inability of nurses to act independently (given everyone else thought it was nothing presumably including other docs, and then it took 20 doctors to confirm what was going on)

well, his thoroughness and his additional training to that which nurses undergo – which was turkey’s point, no? presumably, twenty – fifty – nurses would all have contrived to send home, and so kill, our epiglottis sufferer…

Sasquatch Sam 7:00 am 14 Aug 10

The epiglottis example points more towards your thoroughness doesn’t it JT, more than the inability of nurses to act independently (given everyone else thought it was nothing presumably including other docs, and then it took 20 doctors to confirm what was going on)

vg 8:12 pm 13 Aug 10

Why do doctots need ‘incentives’ to work in Canberra any more than other skilled shortages.

When the AMA’s own data indicates the average GPs salary is around $300,000pa you can cry me an effing river

“imagine going through 8x that number!!!”

At $65 a head

JumpingTurkey 5:07 pm 13 Aug 10

Yeah that is lot of $$$ they are offering…
I wonder why they did not assemble a focus group of GPs (in Canberra and in other cities) to see what can be done and what can entice those GPs to come over, and then based on their views formulate a plan to spend $15 million accordingly?
I wouldn’t imagine many GPs sitting there writing up proposals and filling out forms for this sort of thing – as slack as that sounds – partly its because you get a bit brain dead after seeing 30-40 people each day… if you are in the corporate world or work for the government and feel zonked after seeing 5 new clients that day, imagine going through 8x that number!!!

JumpingTurkey 4:46 pm 13 Aug 10

@dtc: you are right – I find that you sometimes need routine stuff to give you some downtime during the day. Different kinds of practices have different mix of routine stuff to more complex stuff. I remember a practice where routine to complex ratio was something like 30:70 split, because this was a long-established practice that privately billed in a sea of bulk-billing medical centres churning through gazillion people per hour. That was tough work, let me tell you.

But I don’t think I’ll mind doing more complex work and hand over more routine stuff to nurses or other HPs, provided that I am satisfied that patient care is not being jeopardised. To be honest, even when doing routine stuff, I am always a bit paranoid about not missing anything or uncovering bad stuff masquerading as simple stuff.

A case in point: a long time ago when I was a junior doctor in the hospital I was asked to see a patient with a sore throat. A triage nurse had seen the patient and made the diagnosis of tonsillitis, and thought that he could be seen quickly and sent home with some oral antibiotics and some pain killers. He had been sitting in the waiting room for a couple of hours at this stage. Pressure was on me to see him quickly and send him home. When I saw him something was funny about him – the fact that he was sitting there drooling from his mouth, and this was a large 120kg tough 25 year old man from Tonga who decided to come into emergency with sore throat??? When I examined him I thought that he had a very subtle stridor – a noise that people make from their airways when they are taking a breath in (as opposed to wheeze that occurs when exhaling). Reaching into my medical school days, I decided that he might have potentially life threatning condition called epiglottis (meant to be very rare due to vaccination against the bacteria haemophilus) and called the staff specialist over and arranged urgent transfer to a resuscitation bay. Everybody thought that I was an idiot and overzealous and no one (among non-medical staff) could understand why I was so concerned. Well 2 hours and after 20 doctors from all sorts of different specialties came down to have a look at him, his life was saved after getting an emergency airway from an anaesthetist up in the operating theatre and indeed he had epiglottitis that would have surely killed him if he was sent home.

Now I didn’t write that to gloat or to say how superior doctors are. But rather it is to illustrate the point that nurses are extremely efficient and good once diagnosis is known; or with common illnesses. However their training is simply not broad enough in medical fields to cover rare possibilities (some of which could have devastating consequences).

This is why I strongly believe that nurses would need to work under medical supervision, not as independent practitioners. Even GP registars with 6 years of medical school training and 3+ years of experience as doctors need to work under supervision of qualified GPs, so I wonder why many nurses desist the idea of working under our supervision?
I am all for nurses billing medicare for their consultations, and for taking on greater role in patient care. But they need to be working with existing GPs, under their supervision, perhaps clearing every patient with the GP, at least verbally, before they can be sent home.

dtc 2:46 pm 13 Aug 10

since I made the comment about ACT health incentives, you might want to check out here and apply for a $50,000 grant:

As a genuine question, friends of mine who are GPs say they like the routine stuff because it gives them a break, some ‘downtime’ during the busy day. Sure, over winter the 50th person wanting you to diagnose them with something more than a cold gets tiring, but overall its a time not to think too much. So giving this work to nurses results in GPs having to work harder.

What do you (OP) reckon?

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