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02 Dec 2019

BY DR SANDRA HIROWATARI, CHAIR, AMA COUNCIL OF RURAL DOCTORS  

Last month I became an Australian citizen. It was a long but worthwhile journey (special thanks to my fellow GP and AMA ACT President Dr Antonio di Dio for coming along to the ceremony). Though I am now an Aussie, I will still be an international medical graduate. The AMA has been a great support for me as an IMG and will continue to be.

Long before I came to Australia, I built a solo general practice. A private business complete with all the books and ledgers, the constant struggles to find locums, arranging the staff payroll and leases. This was time consuming, but I loved my job and my practice and my community.

I was a do everything family physician providing provided cradle to grave care. I had hospital privilege, visited nursing homes, made some house calls to palliative patients, obstetrics to 36 weeks, I did all the childhood immunisations and if my patient was taken to surgery, I insisted that I be the surgical assist. IUDs, lumps and bumps were routine. I worked late – to 8 PM to accommodate my patients’ work hours. I took my own after hours call and also was on a call roster as a sexual assault forensic examiner.

My business failed.

I am not trying to pass the buck, but my business did not fail due to lack of effort or hard work on my part – it failed because of the market, or lack of one.

I failed as a business owner because: 

  1. I spent too long with each patient. To break even, one needs to see about one patient every 10 minutes, nonstop. To make a profit, that time needs to be cut down to six minute medicine*.
  2. I provided full services, many not compensated for. I did this because I was a doctor who wanted to provide the best care my patients needed. It was charity.
  3. I spent a lot on equipment and outfitting a practice – very expensive when not shared.
  4. I was on governance bodies (like our GP Colleges here), subcommittees of mental health and immunisation protocols. This was essential work, but it was not paid.
  5. My morning hospital rounds barely covered the cost of fuel for my car to get there.

This happened to me in Canada, but the experience is not too different from many that I hear when I speak with rural GPs – running a private practice is not financially viable. Years of the Medicare rebate freeze really hurt rural GPs who have populations that are less able to pay the gap. There are few solo and small practice GPs in rural Australia. Private businesses. And they are dying. This has been overlooked in most of the recent efforts to increase the rural medical workforce, such as the National Medical Workforce Strategy, and that needs to be changed.

Consider this scenario: You are a doctor finishing your intern year considering rural generalism because you had a great time on your rural placement and want an exciting career. You look at your options down the path and see post-fellowship the opportunity of buying into a general practice, but that general practice is failing. The town needs a doctor though. What do you do? Do you take on the burden of a struggling business just to have the privilege to work in this town? Or do you look for another way?

There are other considerations for doctors considering going rural. The cost of running a business is more than monetary, it absorbs your time, keeping you away from family and a work-life balance. Young doctors and medical students see this – general practice, particularly rural, is not seen as providing a work-life balance that the new generation of doctors want. The financial compensation is the same with fewer hours and smaller sacrifices in your personal life in a non-rural location.

Yet we need private businesses, it is this private business that is the foundation of the family doctor. We need a medical home with the mandate of primary care. This is what patients need. A Norman Rockwell family doctor.

Primary care needs to be treasured, especially in locations where the health differential is greater. Thorough, preventative, continuous care is what counters loss of follow up, preventable hospital admissions, increased rural morbidity and earlier rural deaths.

How can we recognise these treasures, the struggling GP in in a private business?

We can begin by acknowledging that many private general practices in the country are unlikely to find another GP or rural generalist to buy in to the practice. The AMA’s Easy Entry Gracious Exit position statement is a potential solution, but there are other options to help support these practices, and we would like to see them discussed in the National Medical Workforce Strategy.

What do you think about these? 

  • rural differential MBS Billings;
  • increased Rural incentive payments;
  • tax-free infrastructure grants;
  • equipment subsidies;
  • paid holiday time off;
  • retirement Savings contributions;
  • indemnity assistance;
  • subsidised CME;
  • housing, electricity, transport subsidies; and
  • allied health and specialist support.

 

* In Canada it is illegal to charge a gap. The billings are not time-based.


Published: 02 Dec 2019