We have a mental block when it comes to money

6 minute read

It shouldn’t feel shameful to talk about billing, but GPs have been subsidising patient care so long we’ve never learned how.

I’ve been revamping my website recently, and the process of defining what image I want to convey has been revealing.

On the one hand, it needs to “sell” my image and the work I do, and attract people who would be able and willing to pay for my services. On the other hand, I don’t want it to scream “I’m dripping diamonds and Louboutin.”

My website guy said to me: “So … you want to be for everyone, but not really, because they give you headaches when they ask for a discount at the end of the consultation.”

And there it is, my money mental block.

He went on: “You know, when I began in this business, I had this thing about dentists; I thought they went into business to just help save the world from cavities and dental caries. Imagine my surprise when they talk about money and tell me that they don’t see people who can’t afford them!”

I’ve been mulling over that, and how it applies to the current crisis of general practice, the way the general public views us, and why they are so angry now more and more of us are charging gap fees.

I am sure most of us didn’t enter medicine to get rich quick (or for many, even at all). All through med school, the topic of money, of running a business successfully as a self-employed person, was never covered. Money magically paid our wages when we worked in hospitals.

Then we entered GP training, or private practice, and suddenly, earnings were dependent on many other factors: how efficient with our time we are; how many patients we see; how we bill; whether we charge gap fees; how effective our boundaries are.

Add to that what I refer to as our saviour complex – the desire to rescue people even when they’ve not asked us to – and it is possible to see how we have landed in this hot mess of our own collective making.

As I said to my website guy, I am mindful, daily, of my discomfort in charging gap fees. In an ideal world, the me that is a doctor would triumph over the me that is a businesswoman by circumstance. And at the same time, if I allowed Dr Me to win, I’d not be able to pay my bills, contribute to my superannuation, pay for my kids and have nice things in life – which I’ve worked very hard to achieve – and eventually I’d quit medicine out of a mix of resentment and burnout, letting down not only the patients who can afford to pay to see me, but the handful who cannot, whom I still choose to discount and do pro bono work for.

At some point, most of us, public included, has landed on this black and white thinking that medicine can go only two ways: you can either give and give and give until you’ve nothing left, but be lauded as a wonderful GP. Or you can charge and be a #greedygp. There’s no middle ground.

Some of our peers feel so strongly about this that they pick up other work to be able to continue to bulk bill their patients. Others post about how they feel that as doctors we are already in the top X centile in terms of wealth while the average Australian is on $70,000 a year, etc.

While I can see their point, I don’t agree with it. My guilt over charging and talking money does not mean that I give in and provide free care to every person who asks for it. My kids and I also have a right to a decent income, a lifestyle that we enjoy and a decent retirement on some kind of parity with other peers in our speciality. A rested doctor who is not worrying about paying bills is a healthier doctor to care for others, to advocate for them and on occasion, to give her time and skills pro bono to the care of the genuinely vulnerable and needy, on her terms.

For decades we have relied on the Medicare patient rebate being adequate, we’ve never learnt to talk about money, which we do in every other area of life. Equally, patients have got used to never getting their wallets out at the GP’s, never considering that we are personally subsidising their care.

In many ways I think the dentists and the psychologists and Allied Health have it right, or are lucky: they’ve never been allowed to get so complacent on relying on the patient rebate alone that it’s automatic.

The evidence over and over suggests that patients value what they pay for better, and are generally more compliant when they have skin in the game. I accept that certain vulnerable and disadvantaged groups may struggle with this and genuinely need help, but that’s been extended to everyone for decades, leading to resentment and burnout among us.

How many times have we heard from patients talking about their home renovations or annual trip to Europe while we sit there thinking of the outstanding bill on our beaten-up Toyota?

I didn’t sign up for medicine to be poor and resentful, any more than I signed up to be a billionaire. It is not shameful to want to earn a good living in order to be well rested and happy enough to provide excellent care for our patients, while doing pro bono work, if we choose to, to a small handful who genuinely needs it.

As to the people who think we are greedy, selfish … let them.

My website guy confided that when I was giving him my brief, he thought I was “money hungry” (his words). Then, he said, as he got to know me he realised “you want people to be clear on what they have to do to get results and one appointment won’t do it. They have to invest the time and the money to get results, and you don’t want to waste any of their money if they’re not likely to proceed.”

And that in a nutshell is it for me. Certain services such as psychotherapy need ongoing commitment and involvement for results. They’re also time-intensive and a no-show can have a significant impact on the running of a business. It’s not greedy or “money hungry” to be clear about our boundaries.

I recognise my money block, and since change takes time, I know it’ll take time for me to change my outlook and mindset, but each time I sit with my discomfort, recognise my block and do the hard thing anyway, there is new rewiring that will make it easier for me to eventually be more comfortable talking about money, feel less resentful and burnt out and serve my patients better.

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

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