Driving patients into the arms of quacks

7 minute read

Sometimes it’s not charging gaps that loses you business.

Multiple times in clinic this week a patient said something along the lines of: “No offence to general practice, but I’ve given up on finding a good GP.”

They say they don’t blame us, they know general practice is in crisis, there’s only so much you can do in 15 minutes especially if you’re also expected to bulk bill. “So I’ve booked an appointment to see an integrative doctor. I am happy to pay for someone who’ll take the time, address my concerns, listen to me and advise me.”

They often ask if I could allocate a day for just privately billed services, as they’d be happy to pay for care.

This is what happens when we bulk bill, undercharge and rush patients through to make ends meet. We fear driving patients away by charging gap fees, but if we can’t give the patient the time they want, they go to someone who’ll happily take their money.

I reflect on whether general practice as a speciality recognises that many things we are currently unhappy with are things we have the power to change.

There are more than enough people, at least in the cities, able and willing to pay for good care. I’ve worked in some of the consistently low SES areas in Sydney and live in southwest Sydney and have privately billed since 2013.

When they cannot get into a GP in a timely manner, one who’ll allocate the time they want, these patients simply take their business elsewhere.

If they want time, attention and reassurance, for 30-60 minutes, they go to a naturopath ($450/hr, booked out till mid May), an integrative doctor ($350-600/hour, booked out till June) with their list of concerns. Some (or much) of which care may not be evidence based.

The appetite for alternative medicine is not abating. A TikTok has been making the rounds on how rosemary oil is equivalent to 2% minoxidil for hair regrowth – this study is flawed, yet clocked up some 864 million views on social media and has been touted even by other healthcare workers as effective.

At a time when everyone seems to think they have what it takes to do our job, and many of us are failing to do our jobs the way we are trained to due to time pressure, burnout and worry about finances and viability, what will it take to get us to rethink our current stance?

Patients who are unable to access good primary care will simply find someone else equivalent enough to do the work they want to order. People buy on emotion first and credibility last. This is why advertising is so effective.

Years ago when I entered aesthetics I was publicly ridiculed on a doctor social media forum for my choice.

Yet, not too many years later, many FRACGPs are jumping ship and looking to compete with chains in aesthetics and sliding into my DMs looking for advice on how to get started.

Universal bulk billing leads to corner cutting. I’ve left practices in the past where we didn’t offer basic suturing because that would cost money in consumables, or referred to ED for a foreign body to the eye due to a lack of basic equipment, or referred because we were afraid of being audited if we cobilled two item numbers.

With such common practices seen as the norm, is it ANY surprise that our speciality seems to be a mockery at present? Throw in the most recent letter from the RACGP regarding means-testing fees to include non-doctor-related revenue, and it feels even more of a joke.  

Who in their right mind would choose to work like this, or choose this speciality as it stands?

And why would anyone willing to pay for good care choose any of the people who work like this, except for possible convenience – the “just a script” type of medicine that is dissatisfying to the provider and patient?

I see colleagues still begging the government for crumbs, instead of using this as an opportunity to build a practice that works for them, for their ideal paying patients. If they want to give back, they can regularly give back pro bono at a designated time or place to the vulnerable left behind by government and the public.

Charging most people allows me to do my pro bono work on my terms. It allows me to care for my patients the way they and I want to.

It allows me to earn enough to justify the years studying medicine, as someone who doesn’t come  from generational wealth and had student debts to repay.

It allows me to save for my retirement, to have a decent standard of living and to not feel resentful of my patients when they tell me about their renovations, their upcoming trips and other expensive plans, because they’re paying my fees, showing up to their booked appointments and grateful for our therapeutic relationship.

Late last year I briefly worked with a telehealth company offering menopause services to women. Like so many other services, they offered complimentary, i.e. bulk-billed, GP services that then acted as a conveyor belt to other paid services with naturopaths and dietitians. Appointments were 15 minutes each and I was flooded each week with women who said “My GP doesn’t know anything about menopause” “My GP is too busy to talk about this with me, I’ve got more important things to discuss by the time I get an appointment”. Most women were incorrect in their self-assessment of needing menopausal care, for a variety of reasons. Many expected me to spend more than 30 minutes for a Level B equivalent rebate. In the end, I quit because I wasn’t “converting enough people to the paid services”.

When we stop listening and referring appropriately people don’t stop asking. They simply find someone else to pay their money to, to sell them woo.

So many of us are hesitant to talk about money and have such shame around fees that we’ve abdicated all responsibility for this to others. We regularly say we “shouldn’t have to talk about money” with patients, that it’s reception’s duty, while still wanting pay parity with our non-GP peers.

While I agree it’s a systems issue that needs to begin with consistent messaging at reception, the fact remains that as contractors, we can’t have it both ways – if we don’t want to talk about money, we need to accept what we are given and make peace with it. Even if that’s bulk billing.

The iron is hot right now, and it’s a provider’s market. Like my foray into aesthetics at at time when it was still taboo back in 2016, we are now doing the same with the potential to restore our speciality to some respect, attract young minds and have quality of life while providing excellent care.

Whether we rise to the challenge remains to be seen. Until then, we will continue to see fragmentation of our specialty by non-FRACGPs, enabled by people with the means to pay, but not necessarily the ability to understand scientific rigour, nuance and so much more. And our speciality will cease to mean very much to anyone at all.

When we, as a specialty and our college doesn’t take enough pride in who we are, why should anyone else?

Dr Imaan Joshi is a Sydney GP; she tweets @imaanjoshi.

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