General Practice in the headlines... again...

I'm inspired to write my first post in years on this blog by multiple news reports over the last couple of months about the state of General Practice. To paraphrase Shakespeare, something is rotten in the state of General Practice in Australia and it is nothing to do with the efforts and skill of the local GPs on the coal face of healthcare.

Concerns over the ongoing financial viability of General Practice were raised again recently, culminating in a summit on the future of General Practice held a month ago in Canberra. The dire straits of General Practice funding come as no surprise to those working in healthcare, as the impact of years of indexation freeze and partial indexation of Medicare item numbers comes home to roost. 

Unlike other areas of healthcare in Australia, General Practice is almost completely run as private businesses that utilise Medicare funding, with no equivalent service provided in the public, state government funded system. This means that there is more pressure on GPs to bulk bill their patients as there is no public funded service to provide care for folk unable to pay private fees. This leaves General Practice particularly vulnerable to the vagaries of Medicare funding. This has resulted in a direct impact on our GP workforce - the proportion of medical graduates choosing to go into general practice has reached an all time low; GPs near retirement age are bringing forward their retirement; experienced GPs are quitting or reducing their hours and picking up other work. These workforce pressures are felt the most in rural and regional areas which have always struggled to find GPs, but even General Practices in metropolitan areas are struggling to find doctors now.

In a recent news report, a small country town in Queensland (Julia Creek) was offering a $500K package for a GP to work there without luck. Dr Michael Mrozinski, a GP that does rural work, has summed up well the reasons why recruitment is such a challenge on his TikTok. Spoiler - it's not about the money.

And talking money... What about those ABC reports on the 8 billion dollars leaking from Medicare due to poor billing practices by doctors? First a quick fact check - the figure of 8 billion dollars is dubious according to the ex head of Medicare's PSR and the MJA. Undoubtedly there are some doctors intentionally billing Medicare poorly, and even fraudulently, but the actual cases are miniscule compared to the errors in billing related to the ever increasing complexity of the Medicare schedule. The myriad of separate item numbers with specific clinical and administrative requirements, which have little relevance to actual clinical care, increases the likelihood of billing errors. So complex, in fact, that if you contact Medicare for advice because you have difficulty interpreting the clauses in the schedule the person you speak to is equally as unlikely to know the answer and will basically read back to you the same passage that you have just been struggling with. Rhetorically - how much simpler would it be if  item numbers were simply time based? How much easier and cheaper would it be to audit a time based schedule? Does a Medicare bureaucrat really need to know if I have mental health issues or was late for a PAP smear? My GP's time is as valuable whether they are checking my blood pressure or treating a sinus infection; and none of the clinical details need to be visible to non clinical folk who sort out the billing.

The simple solution would be for GPs to stop bulk billing and start setting the fees that would make their practices viable. This would probably help maintain the viability of General Practices, but would also leave less well off patients at higher risks of falling through the cracks

Coming to Australia...

There have been a couple of articles in the local paper (1, 2, 3) recently about the difficulties facing doctors trained overseas wanting to work in Australia. Undeniably, Australia does depend heavily on recruiting doctors from overseas, and the issues discussed are therefore important ones.

For a clear and rational discussion of medical migration, the issues do need to be separated out somewhat...

Firstly lets look at this pesky moratorium. Under the 10 year moratorium rule, overseas trained doctors or foreign graduates of accredited medical schools who either gained residency or were first registered with an Australian medical board in 1997 or later must work in an area of workforce shortage for at least 10 years. What this basically means is that doctors who are allowed to migrate to Australia in order to address our workforce shortages (which is what skilled migration is about I guess) are obliged to work in those areas where the workforce shortages are at their worst. As a general principle, this does not sound unreasonable and I don't have a problem with the moratorium as such.

In the spirit of informed consent, it is important that the moratorium is clearly explained to applicants before they start the application process. If the Australian Governments own website, DoctorConnect - which supposedly disseminates information for doctors thinking about coming to Australia - is anything to go by, the informed consent process may not be all it is cracked up to be. I mean... "OTDs and FGAMS who are subject to section 19AB are generally required to work in a DWS for a minimum period of 10 years"... I know about the moratorium and I find that hard to understand...

The requirement to pass knowledge and skills assessments as well as English language assessments before being able to work surely cannot be argued with. Our medical schools may not be perfect, but we do have reasonably high standards which the Australian people rightfully expect. In spite of the arguments about Australia being a nation of migrants where many people speak other languages, and how the English language limitations should not be a barrier to working as a doctor in Australia, Australia is an English speaking nation. The majority of the population (and therefore the patient group) speaks English, and English is the language that our laws and formal communications use, and the colleagues that we need to communicate with will mostly use English. The necessity of requiring overseas trained doctors to pass threshold assessments is self evident.

The key thing that makes it difficult for doctors trained overseas to work in Australia is the sheer and utter complexity of the migration system for doctors. I did try to search through the regulations for the different types of visas that can be applied for by doctors and found at least 5. Each different type of visa has different requirements, and the medical registration requirements can vary also. If a doctor's circumstances change, he/she may need to change the type of visa that they come in under, which may or may not in turn change the registration requirements.

To put things simply:

• If Australia is allowing overseas trained doctors in to address workforce shortages under a skilled migration process, then it is surely reasonable to ask the applicants to work in the areas of greatest workforce shortages. 
• If we wish to maintain standards, then there has to be an assessment process for the skills and knowledge of doctors applying to work in Australia. 
• English language skills are important. 
• The migration system as it relates to medical migration is overly complex and lacks transparency.

A good news story from an innovative school program

Engagement in education and retention in schooling are a key component in the wellbeing of young people. Kids who stay in education do better - even aside from academic achievements which can create further opportunities, the social connectedness and supports that exist within a school environment can help to build life skills and emotional resilience. This is why programs that promote engagement in schooling for teens who are at a high risk of dropping out, like the program for young parents at The Canberra College in the ACT, are such a good news story.

As a community, we are becoming more aware of how disadvantage can become entrenched in families across generations. Children growing up in a home where there is no role modelling of the positive aspects of education an employment will be more likely to drop out of education and not find stable employment as adults. If we can encourage teen parents to stay at school, not only are the teens more likely to do better as adults their children will see the benefits in the next generation as well.

The Canberra College has a history of innovation and providing programs that deal with the social determinants of health. Several years ago when I was living in Canberra, I was involved in a "full service schools" project at The Canberra College. This was a project which brought in several services (including primary health services, alcohol & drug services, sexual health services, employment services, pastoral care) into the school as a colocation model. The idea was to bring the services to where young people were in order to overcome the barriers that teens may be faced with in trying to navigate some of these systems in the community. It was fantastic working with a school that was enthusiastic about supporting the wellbeing of their students, and willing to innovate.

I'm not surprised to see that The Canberra College are still "kicking goals" for their students. Good on them!

not enough jobs for junior docs (part 4) ...and yet more Medical Schools...

"CURTIN, Charles Sturt and the University of South Australia will press ahead with their plans to create new medical schools."

In the midst of concerns about intern positions for medical graduates, 3 universities have announced their intent to move forward with plans for more medical schools (and more medical students). Australia is apparently not training enough doctors.

It is undeniable that there is a shortage in the medical workforce, especially in rural areas. However, the bottleneck in training is not at the medical school level. In order to produce doctors that are able to work independently and service areas of medical workforce disadvantage we need to create the supervised junior and training positions to provide vocational training.

Without adequate resourcing of junior medical positions, including indemnity (which is potentially a barrier for moving training into the private sector), and adequate resourcing of the time needed from senior doctors to provide the supervision that junior doctors require, bumping up the number of medical graduates does very little to improve workforce shortages. It makes absolutely no sense to increase the number of medical schools and thereby increase the number of medical students, until the issue of adequate supervised junior positions and vocational training is resolved.

Senior medical folk associated with the universities need to seriously consider wisdom of creating new medical schools at this point in time. If the unit you work in is unable to accommodate any more junior doctor positions (due to funding or availability of adequate supervision) then the rationale for increasing the number of medical graduates is probably difficult to justify.

not enough jobs for junior docs (part 3)

This week, The Australian again reported on the lack of intern places for medical graduates. It is encouraging to see that the various interested parties (students, deans of medical schools, professional organisations) are starting to reach some level of agreement about what needs to happen. Now if only the people who make the decisions will listen...

Creating intern positions involves more than just putting aside money to pay their salaries. Medical interns are just out of university - they have a fair amount of book learning but don't actually have the context with which to use this knowledge safely. They need a hell of a lot of supervision. In order to have interns working safely, there needs to be training and infrastructure to support the senior doctors providing supervision, money to pay for supervisors' time, and adequate senior staffing levels so that supervisors can provide adequate oversight. I haven't heard any murmurings of this happening any time soon.

The Problem With Acronyms

At some point, haven't we all stopped and looked at a clinical record or a discharge summary and been completely confused about the multitudes of abbreviations? Is "BSE" bovine spongiform encephalitis or is it breast self examination (getting that wrong could be a mite embarrassing)? "NFR" could mean not for resuscitation of no followup required... maybe not so different after all.

Here's a story I heard from a colleague recently... Once upon a time there was a hospital of reasonable size which had all the usual bits that hospitals do including A&E, critical care, orthopaedics, cardiology, renal medicine, etc. It also had an inpatient mental health unit that had an acute unit and an attached longer stay or chronic care mental health unit. Working in this hospital was a psychiatry registrar who was doing the psychiatry on call shift one particular evening.

The registrar was called by a cardiology colleague in relation to a consult request.There was a patient who was in recovery from bypass surgery with a history of depression, and the team was worried that it may take a turn for the worse following surgery. The psychiatry registrar obligingly offered to go and have a chat with the patient in the coronary care unit (CCU) - he informed the nurses in the inpatient acute mental health unit that he would be "in the CCU" if needed as he realised that his mobile phone would need to be turned off in the monitored area.

Unfortunately, in the world of mental health treatment, the term CCU refers to Chronic Care Unit. An incident occurred within the mental health unit that evening, and the nursing staff tried to ring the registrar... the phone was switched off. They contacted the Chronic Care Unit... the registrar hadn't been there the whole evening. The poor registrar had a complaint made against him for not being contactable whilst on call.

It is easy to rely on acronyms as they are much quicker to say and easier to write... but there are risks...

not enough jobs for junior docs (part 2)

The AM Program onABC Radio this week discussed how "Medical Deans lament [the] lack of internships" in Australia.

Surely the availability internships should have been a consideration when the deans and senior folk within the Universities were considering starting up the medical schools or setting student numbers in th the first place.

...and surely when the numbers of graduating doctors could have been anticipated (not that hard considering that people can count how many medical students there are in the medical schools years ahead of them graduating) we could have had years of developing models to provide junior jobs instead of going "oops we forgot that they needed internships to get qualified" when they are just about to graduate.

There is now a very short time fram in which to try and build the capacity of the health system to supervise junior doctors. It is all well and good to say - lets put them in private hospitals and general practice. The reality is that interns do require a significant amount of supervision and unless there is funding available for the time of senior doctors to do the supervising, adequate medical indemnity provisions to cover the junior doctors in non traditional settings, adequate scope of pathology and clinical exposure to ensure an adequate training experience, and appropriate administrative support for the private sector to take on junior doctors, this is not going to be a satisfactory solution.

not enough jobs for junior docs

Unsurprisingly, the media is reporting on a shortage of junior doctor jobs for the 3000 or so medical students about to graduate from Australian medical schools.

Lets go back in time to the '90s... all the rhetoric in the early '90s was about the oversupply of doctors. The Medicare budget was blowing out, and the clever bean counter types looking at the supply and demand equation were convinced that this was due to too many doctors spruiking for business. There were 10 medical schools in Australia and there was a rumour that there were plans to decomission one of them bringing the number back to 9; the government of the time put caps on vocational training places (particularly in general practice). This, of course, was a bit of a surprise to the doctors out in the commuity who were having diffculty recruiting other doctors to work with them and hadn't had a holiday for years because of lack of cover.

It didn't take long for the real truth to emerge in the numbers. Far from an over supply of doctors, there was actually a shortage. This was brought to a head by the limitations in training places. All over the country, communities were reporting difficulties accessing medical care (general practice and specialist). Demographers started to pay attention to the aging medical worrkforce.

Lets fast forward a little - a decision was made to open up medical school training places. This would supposedly produce all the doctors we need to fix the shortage... The universities were more than happy to put their hands up to run medical training; after all medical schools are prestigious things for universities to have. More and more universities started announcing medical schools, and the number of medical graduates has more than doubled.

Somebody forgot to consider that, for doctors to be able to work in unsupervised in the community where they are needed, a they need a period of vocational training in supervised jobs. So here we are in the ludicrous position of simultaneously having ongoing medical shortages in the community and a shortage of supervised junior medical jobs.

The sad thing is that this was not unexpected. For several years there have been senior doctors expressing concerns about the rapid expansion of medical schools in Australia and the capacity of the system to take on junior doctors.

What's the best way forward?

The government is keen on expanding training outside of the major public hospitals. As a concept this is laudable - the test will be putting it into operation and ensuring that the quality of supervision and the adequate safety measures are not compromised. Will smaller private hospitals (the bigger ones already take junior docs) and nursing homes have sufficient numbers of medical staf around to ensure adequate supervision? Will the breadth of clinical presentations and scope of practice provide enough valuable experience for junior docs? Will there be enough support for training within the infrastructure of these organisation?

Time will tell.

It is a difficult time to be a new graduate. My thoughts and sympathies are with all my junior colleagues out there about to take on the big adventure of meidcal practice.

Midwives, Professional Indemnity and Homebirths

I have been reading a lot of comments in the media recently about how new requirements for professional indemnity for midwives will make homebirths illegal and drive them underground.

One of the key sources of angst voiced by midwives is that the federal government pays for the indemnity for obstetricians and GPs, but will not pay for midwives. This is either a clear lack of understanding of how indemnity works or a deliberate attempt to mislead the reading public.

Doctors who deliver babies in the private sector pay for their own indemnity insurance and the premiums that they pay are substantial. The government provides a guarantee for claims above 20 million dollars, they don't actually pay the indemnity insurance premium.

The reality is that, if people highly value the homebirth option, then they will pay the midwifery fees that are commensurate with what the insurance organisations charge the midwives as premiums.

Nobody is "picking on" the midwives, they are simply expecting them to operate under the same, responsible framework of practice as everybody else. The move to national registration for all health professionals (medical, nursing, physiotherapy, pharmacy...) will mean that all health professionals will need appropriate indemnity cover to be able to practice. Surely that is a good thing.