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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
(Newbie)
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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JumpingTurkey on GPs in Canberra
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Drzaius 2:22 pm 11 Sep 10

Just a quick comment with regard to nurses and diagnostics. A source at The Canberra Hospital tells me that just today some nurses received a test result for a patient whose nasal cavity is positive for commensal S.aureus. Firstly, they didn’t know what S.aureus was so proceeded to look it up on Wikipedia, next they didn’t know how to distinguish between commensal S.aureus and antibiotic resistant S.aureus and so assumed that the patient has Golden Staff despite the results stating otherwise, finally, they’ve put this poor patient in isolation and are treating them like an infectious disease patient. Through all of this they didn’t think to ask the registrar for any advice!!

I won’t be trusting nurses with my healthcare thank you very much! I completely agree with @JumpingTurkey.

MrNurseRatchet 8:30 am 16 Aug 10

@JumpingTurkey: A very good question! I can only speak from my experiences receiving my training abroad but this is how it works: first and foremost you have to have several years of nursing under your belt before you are even allowed into most NP programs. I think here in Oz the minimum time before you’re allowed into a NP master’s curriculum program is after 5 years of practical nursing experience. A significant portion of those 5 years requires you to be working in an “advanced capacity” and you must have received some type of advanced degree in your specialty field during that time. (ie: graduate diploma in emergency nursing or rural and remote nursing). Once you are in your master’s degree program you receive plenty of didactic courses pertaining to advanced physiology, pharmacology/pharmacotherapeutics, physical assessment and pathology. At least in my program, many of these courses were shared with medical students. You also receive a host of other importance subjects such as qualitative/quantitative research and other professional development courses. Finally, we had several clinical placement courses that required us to spend 1000 hours working side-by-side with physicians and NPs in various clinical settings (unpaid, of course). Since my two Masters degrees were in Adult and Geriatric Health, the vast majority of my clinical hours were spent in rural and metropolitan primary healthcare centres. One entire semester was spent in a nursing home. During this time you are working to obtain those skills you’ve mentioned above. By the time I got out of my intensive 2-year curriculum I was working at a level of an NP. Then, when I entered into my professional life as a NP I was surrounded by NPs, physicians, surgeons, and PAs who worked collaboratively with me and the learning process continued. Interestingly enough my primary care experience was what was instrumental in making me such a successful cardioaortic surgery NP. The surgeon I was working with back then knew I was trained in primary care but wanted to see what mixing the two specialties would result in. So he essentially undertook me as my mentor to show me the acute surgery side of things. I guess you could call it my “residency.” The fact that patients were getting a holistic view of primary care during their surgical stay is probably what lent to the success of the model.

JumpingTurkey 10:33 pm 15 Aug 10

@MrNurseRatchet
This is a genuine question: I am curious as to how the master’s program equips one with a full set of diagnostic and examination skills? Do you get attached with a doctor who demonstrates these skills to you? I found in medical school that I still struggled to perform a competent examination and get correct diagnosis even after spending 3 years in clinical years attached to various subspecialty teams and getting numerous clinical tutorials? I only truly acquire these skills after a couple of years as a junior doctor…?

JumpingTurkey 10:27 pm 15 Aug 10

@VG:
So you think our teachers and firies and police officers ‘just get on with it’?
Then why do NSW teachers go on strike almost on a yearly basis? Why do police officers go on strikes? Why do ambulance officers go on strikes?
You’ve also got to realise that training time for teachers is 4 years. Training time for police officers (depending on what type) maybe 3-4 years. Ambulance paramedics are the same. Training times for nurses are 3 years.
For doctors to qualify to practice independently it takes a minimum of 10 years. The time that you spent earning money and time you spent on leisure time, doctors or would-be doctors were spending studying and seeing patients. Many trainee doctors would pull 70 hour weeks – and these are 70 hours not spent on a desk, but spent running around on your feet. Let me tell you that stories you hear about intern and residency work being tough is all true and more. Around 50-60% of interns will actually break down and cry on their first 14 hour overtime shift due to the overwhelming workload.

I hardly think that it is unfair that doctors are paid highly given this amount of self sacrifice and dedication. Please note that most doctors are well into their 30s by the time they finish their training. I don’t know of any other profession or occupation that has such a long training time.

@Leinna
I agree with many things that you say but I don’t agree with your view that GPs just deal with coughs and colds and refer on anything that is puzzling. Let me tell you – if you practiced in this way (i.e. referring everything that you are not sure), then you will quickly find that your patients will return very very annoyed. Imagine if you are sent by a GP to emergency department to only end up waiting 4 hours to be told by an intern that it is nothing to worry about, and sent home? And imagine if you refer someone with a puzzling rash to a dermatologist, and then the patient will return telling you that there is 4 months waiting list, and they would really like something done about it before then?

Leinna 10:23 am 15 Aug 10

I should also mention that is often a lack of respect by specialists for GPs. When you’re training in a hospital, the only senior doctors you deal with are specialists. Therefore you tend to get a one sided opinion of what it is like to be a GP.

Leinna 9:11 am 15 Aug 10

As a specialist in training… (whose father is a GP)

When I was deciding what I wanted to do with my life, I was considering specialist training versus GP training.

In summary:
1) GP training is just as long (if not longer) as specialist training
2) Specialists make AT LEAST twice as much as GPs, and if you work privately you can often earn 1 million/year
3) Most specialists have equivalent insurance premiums (with the exception of O+G)
4) Specialist work is often more interesting, as GPs have had a lot of their skills taken by specialists. GPs are left to sort out coughs and colds, and when they get something interesting (like a puzzling skin rash) their main decision is whether to refer on to the appropriate specialist (dermatologist)
5) GPs need to be a ‘jack of all trades’ and master of none. As a specialist, you focus exclusively on one area and become a master of that. Just don’t ask me about something unrelated to my speciality!
6) As a GP you don’t have to put up with the hospital politics, references, and so on. You can pretty much just say “I want to be a GP” and the GP college will accept you.

I think we need GPs as they can manage the multiple illnesses a person may be having. I also think we need to make working as a GP more attractive to medical students and junior doctors. The few colleagues of mine who have decided to GP often do so because they are sick of the hospital system / politics / crazy hours.

In my case, I had just about given up on getting a specialist position and was considering being a GP. Mainly because I wouldn’t have to worry about petty politics between and within the units, and so I could spend more time with my family. But it was definitely a ‘second choice’ given the benefits of specialist training.

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