Why are private billing GPs looking to ED locums?

7 minute read

The logic may not be immediately obvious, but for some GPs there are good reasons to look to the hospitals – if only temporarily.

In the weeks since I announced my plan to take a temporary break from private billing general practice to do some ED locums, I have been inundated by DMs from FRACGPs with questions on how it all works.

If I’m honest, I’d say there are too many DMs to answer individually, but I recognise many of the names – all people I don’t personally know – from several other social media fora, many of whom have successfully moved to private billing everyone in their GP practices in 2022, some rather aggressively if I were to be honest.

So it begs the question, why are they looking into ED locums and why now, when presumably they’ve successfully navigated the holy grail of peak general practice – to charge everyone, no exceptions, and still be fully booked most days?

To answer that question requires, I dare say, some reflection.

I left the last two private billing practices I was at for similar reasons (although there are, no doubt, others):

  • Autonomy – while GPs are, in theory, contractors and free to run their own small business, the truth is often that most of us have had to push hard to be able to bill as we please, especially against clinic owners who are loathe to lose “customers” by stopping bulk billing.
  • Uneducated floor staff, including receptionists and nurses as well as practice managers, who often do not understand that every single staff member costs the business money – and that the fee charged by the doctors is the only revenue generating step – but who actively undermine billing practices by undercharging, overriding billing and asking for patients to be bulk billed.
  • Advice given to patients who ask to be bulk billed, even at a private billing practice, to “ask the doctor, it is at their discretion” instead of simply saying, “We are a private billing practice and do not offer bulk billing.” This thereby passes the burden of a difficult conversation onto the doctor, often at the end of a consultation, when they are gazumped by this question from a patient.
  • Money aside, most of us show up to work at least a half hour early to go over results and action follow-ups and fit-ins for the day. We usually run into our 30-minute lunch break seeing patients, chasing results and with unplanned phone calls and fit-ins in time to begin our afternoon session on time. Many of us then also stay back an extra hour or two because we ran late or have notes to finish up after all patients have been seen for that day.
  • Lastly, on the groups, helped in no small way by the constant fear of nudge letters, PSR audits and “exposés” without any real basis, such as the recent ones by the ABC/Sydney Morning Herald, there is a real weariness in the community, amounting to “why are we bothering if this is what the public and media thinks?”
  • Despite all of this, the most significant reason for my taking a break from general practice for the time being was the encroachment on my personal time. The last two practices, amidst covid, saw a creep on my personal time and space, possibly due to the disruption. Staff would text me on my phone out of hours, on my days off. I’d get texted and asked for advice on managing non-urgent issues instead of the doctors who were on being asked. The final straw was a practice nurse texting me during my planned 4 days of leave to ask about non-urgent results so she could book patients in for follow-up on my return.

By contrast, as I’ve posted many times over on ED locums, with no disrespect to my hospital colleagues:

  • There is an hourly wage paid me regardless of whether I am busy or (rarely) quiet. I get paid this whether I see 2 patients an hour or 20 a shift or 80.
  • There is a large pool of patients waiting to be seen, and we all work at our own pace such that no one is specifically waiting to see me if I’m caught up with a tricky patient or a case.
  • The work is less isolated, and there are others around to bounce ideas off and get help from if needed.
  • Patients are used to waiting. Most are grateful to get 5 minutes with me to be reassured and sent home, even if they’ve waited 2-3 hours. In general practice, if someone waits more than 20 minutes, there are usually mutterings.
  • When it’s time for my shift to end, I hand the patient over and leave. There is no follow-up, no chasing results, no intrusion on my time off – nothing.

So yes, I work my butt off in ED when I’m on, choosing to work 10-hour shifts to maximise my time on these locums. I work hard, but when my shifts are done, I also have zero responsibility and no way of being contacted. Right now, it is the antithesis of everything I love about general practice and I’m loving it because I want to be uncontactable when I’m not rostered on.

And yes, in many ways the money is similar to what I could be making in GP work that is entirely privately billed, especially in my niche areas. But as we have been seeing, there is a mass exodus of junior, unfellowed doctors and FRACGPs into the aesthetic space, with the promise of easy money and fun work – till it’s not, because I see so many carry the same lack of boundaries and cheap prices into these areas.

ED locums now seem like an escape from the drudgery of general practice brought on by systems errors, inefficiency and lack of boundaries, coupled with undeserved anxiety about audits, the PSR and nudge letters, and a basic lack of understanding among FRACGPs themselves of how it all works.

Most of us therefore choose to exchange the anxiety-provoking exercise that working in general practice means for us at present (even when 100% privately billed) for a similar wage, coupled with minimal responsibility and a complete disconnect from Medicare.

So, as we see more and more people choosing to flood EDs for non-ED presentations – because they’re unable to get into their GP’s in a timely fashion, even if they can afford to pay to see one – perhaps it’s appropriate that we should have FRACGPs, designed to assess and manage such presentations, flood EDs as locums to help our FACEM colleagues out.

Mostly, the younger cohort of FRACGPs aren’t OK with accepting a 53% discount on every consultation as “fair pay”, nor to be told by the public or the media and government how much we should work for free or be called greedy. Many of us have decided it is not our job to decide who to bulk bill and who to charge and have simply moved to charging everyone and letting patients work it out with the government. And if we are in practices that won’t support this, as I was, then we leave for a while till we work out our next steps and take a break.

A FACEM friend suggested I look into ED training so as to be able to do this long-term, but honestly, I do not see myself belonging in EDs long-term. My heart is still in the long-term therapeutic relationship and these locums are a breather while the system is in flux. I hope to be back, and I sincerely hope that for those looking to take a break from general practice in ED, that they feel similarly.

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

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