Transcript of Feature Story - ABC Radio National 'Background Briefing', with Stephen Skinner

ROMEO: It was actually only yesterday there was a serious case came into hospital. The lady was having a heart attack, and she went into a funny rhythm of the heart; she was conscious but she needed urgent attention and she needed to be temporarily anaesthetised so that her heart could be shocked. And she came through, and today she's feeling great.

SKINNER: Rural Australia needs more doctors like Joe Romeo. We've all heard about the shortage of GPs in country towns, but now it's spreading to many regional centres and fringes of the capital cities as well. The flipside is that many inner suburbs of the big cities have plenty of doctors, both GPs and specialists.

Welcome to Background Briefing on ABC Radio National. I'm Stephen Skinner.

There are all sorts of cultural shifts going on in Australia, and if we're going to get a more equal distribution of doctors and medical care, money alone won't do it. There's also stereotyping about life in the outer suburbs and rural areas to overcome, and romance comes into it, too. All too often trainee doctors in the city fall in love with other young professionals in the city, and stay there.

And within a decade, the majority of doctors will be women, and women don't want to work 80 hours a week. In Wagga Wagga, anaesthetist Dr Judy Killen.

KILLEN: It seems to be assumed that every doctor wants to work full time. I don't see why we should be the only profession that's expected to work full time no matter what. I would love to be able to work 30 hours a week, devoting myself to the patients in that time, but able to have a balanced family life for the rest of my life. It seems to me that everyone assumes that if you're a doctor you're going to work 60 hours a week. It's not safe, it's not desirable, and I think it's discriminatory. If I were a shop assistant I would be part-time.

SKINNER: Vice President of the Australian Medical Association, obstetrician Dr Trevor Mudge, was a little late into the ABC studio in Adelaide because he was held up doing a caesarean. He says there are important debates to be had about medical care in Australia. For example, how much doctoring is really necessary?

MUDGE: The whole problem is how do you define necessary? Especially in an age where none of us want to take any risks -- medically or otherwise we're not encouraged to accept risk for ourselves much in society now. So that even if little Johnnie is crying and has a temperature, in 999 cases out of 1,000, that will be a common upper respiratory tract infection which will have absolutely no implications for life or limb, and in one in 1,000 it'll be meningitis, or meningococcal septicaemia, and it'll be life-threatening. And the problem is, what level of risk do we take? Do we say that the doctor should see immediately every child who has a temperature just to save the one in, well I guess it's one in 10,000, not one in 1,000, just to save the occasional one? And then I suppose if we say yes, that's only reasonable, we live in a society that ought to be able to afford that, then we have to say to ourselves well, how do we afford that reduction in risk, because I think the crisis in public liability insurance and medical indemnity insurance should be teaching us that reduction of risk comes at a cost. And again, what are we as a society prepared to pay for what level of risk reduction? I don't have the answers to those (questions), but I think we need to have the debate.

Phone Ringing

Deanne: Deanne speaking, how may I help you? For tomorrow evening? All I can offer you is 7.30 tomorrow evening or 10 past 8.

SKINNER: The big new issue in all of this is the shortage of GPs in many of the fringe suburbs of capital cities. A report for the AMA by consultants Access Economics earlier this year, concluded that these areas are about 500 doctors short around Australia. The Federal Government disputes that figure, but acknowledges that there is a problem.

Ken Dowd: So how are we going, Jenny? I'll call the next patients in, in just a minute. All right, so I won't keep them waiting much longer.

SKINNER: Dr Ken Dowd works in a large medical centre with a dozen other GPs near the main street of Melton, a satellite town of Melbourne, 40 kilometres west of the CBD.

Ken Dowd: Are there any appointments tonight, Jenny? Or are they all fully booked?

SKINNER: Dr Dowd enjoys solving the wide range of problems he attends to as a general practitioner in Melton. He knew early on in his student days at Melbourne University that he didn't want to become a specialist.

DOWD: I can remember back in medical school when I received a lecture from a specialist in anal-rectal surgery, and he gave us a tutorial on how he could detect the personality of a person by what their anal sphincter looked like, and I thought to myself at that time, I don't want to specialise that much.

SKINNER: Dr Dowd has plenty of variety in his work, especially as the nearest critical emergency ward is at Footscray, near the CBD.

DOWD: General practice affords you the opportunity to do all sorts of things, and certainly out here in Melton, because there is no hospital, we do a lot of fairly critical emergency work. We often get the ambulances dropping in here because either they haven't got time to take the patients to the hospital and need some critical intervention; we often have done resuscitations out in the car park; and because there is no emergency treatment centre, often people come to us with chest pain, with severe asthma, with bad lacerations, because there is no hospital for them to go to. Whereas most places in the city, people would tend to go to the emergency department first, because that's probably just as close as their local GP.

SKINNER: Dr Dowd's problem isn't the variety of work, it's the fact that there's just too much of it. Melton's a fast-growing area, but the number of GPs hasn't kept pace with the population growth. In Australia on average there is one doctor for every 1,400 people. At Melton there's about one doctor for every 2,500 people. But try as they might, the two large medical centres in Melton can't get doctors from the much better supplied wealthy inner suburbs to move out.

DOWD: The doctors in those areas might disagree, but we look with envy towards the eastern suburbs, the areas of better socioeconomic status, be it Toorak, South Yarra, even Kew, Brighton, Hawthorn. I think that those areas, because they're desirable places to live, and a lot of doctors would live in those areas, and of course would prefer to practice near where they live, and especially women doctors, especially if they've got young kids and want to put them in cr che and be able to pick them up from cr che, of course want to live near to home. And so that always presents a problem. I mean of the doctors at our practice, there's only one who lives in Melton. So everyone else commutes from places like Moonee Ponds, St Kilda, Carlton, which all take us, yes, 40 minutes or more.

SKINNER: Ken Dowd says one of the reasons it's hard to get GPs to practice in Melton is that it's a bulk-billing area. The doctor only gets the standard Medicare rebate of $24.50 for a consultation of between five and 20 minutes. GPs are saying that's not enough to make a good living these days, unless you push the patients through like sausages. In the wealthy suburbs, a GP can charge $20 on top of the Medicare rebate and still have plenty of customers. The Melton GPs are tossing up whether or not to ditch bulk-billing, because they say Medicare rebates are just not keeping pace with costs. They say increased insurance premiums are just the final straw.

DOWD: At some stage the way things are going, we will have to change our billing policy. A couple of years ago we decided to privately bill on weekends, but we've tried to stick to bulk-billing during the week.

SKINNER: Why is that? Because according to the laws of supply and demand, you could have started private billing years ago, when there's such a shortage of doctors here.

DOWD: Well part of the reason I suppose is that Melton is so socio-economically disadvantaged that there would be so many people we would have to make exception for -- with regard to those with Healthcare cards who are on disability pensions, old age, or just generally suffering financial hardship -- that we felt it would almost be hard-hearted of us to. So we have tried to, well, keep the best of both worlds and provide a service to the community and still try to maintain a decent living out of it. But it gets harder and harder.

SKINNER: The Royal College of General Practitioners estimates that GPs who bulk bill earn an average of less than $50,000 a year before tax. The Federal Government says the figure is more like $100,000 a year before tax. Both city and country GPs who also charge the patient an added fee, would make a lot more.

At Deer Park, 15 k's west of the Melbourne CBD, Dr Peter Rankin runs a small general practice with a partner.

Surgery sounds

Woman: Just let Dr Peter touch your tummy.

Peter Rankin: She's got gastro. Yes, there's a fair bit of gastro going round, she's got it, poor love...

SKINNER: Dr Rankin is Chair of the Western Melbourne Division of General Practice. He calculated on the back of an envelope that the average full-time GP in a wealthy suburb of Melbourne can earn about $170,000 a year before tax for seeing about four or five patients an hour. He estimates that's roughly $60,000 a year more than the average GP seeing the same number of patients in a bulk billing area.

RANKIN: The problem with the outer suburbs, particularly the outer west and northern suburbs, the other industrial low socio-economic suburbs, is that we're a bit of a Cinderella area. We don't get any of the publicity or any of the kudos that perhaps pertains to the bush, and as a result, we tend to be neglected. The situation in the outer west of Melbourne is in some parts, as bad as it is anywhere else in Australia.

SKINNER: And why don't GPs want to work in the outer western suburbs of Melbourne?

RANKIN: My division is the highest for bulk billing in Victoria, and as a consequence it's very difficult to attract doctors to work here when they can get more money -- ironically they get more money often going to nearby rural areas, where there's quite a high rate of private billing, and for not much further travel they can get a lot of incentives that aren't available to doctors in my division.

The other problem is that very few doctors life in the western suburbs of Melbourne. The dilemma is that doctors are recruited -- particularly in Victoria, but also in other States as well -- recruited from the more affluent areas. They go to private schools, and when they set up in practice, they tend to obviously choose to set up a practice near to where they grew up, rather than somewhere that is quite different from them.

SKINNER: Dr Rankin grew up in the bayside suburbs of Melbourne. He says there are plenty of positives to working in an area of greater need like Deer Park.

RANKIN: I guess for me why I enjoy working here is the fact that I can provide comprehensive care for my patients. My patients respect what I'm trying to do; they don't just come in asking for a prescription or a referral, they actually value my advice, they're more likely to want to embark upon a plan of care in a joint fashion. Certainly for me, I like dealing with the children, paediatric areas, and generally with counselling, and there's oodles of paediatrics and oodles of patients needing counselling, and those sorts of areas really appeal to me as a doctor, and certainly I find it very rewarding if at times a little stressful and frustrating, to work in an area like this.

SKINNER: All of that sounds a lot more satisfying that ramming them through at a rate of knots just to get your bulk billing fees up.

RANKIN: Oh certainly. Why did I become a doctor? I mean obviously we want to help people, and the need and the ability to help people is fantastic. I mean obviously nobody who works in this sort of a clinic in this sort of an area, is in it for the money.

SKINNER: The Federal Government is wrestling with various plans to get young doctors from the inner city to work as GPs in the fast-growing outer suburbs of the big cities, even if they only work after-hours shifts. It's a balancing act though because if the incentives are too generous, they could undermine the carrots being offered for GPs to work in the country.

The Chair of the Doctors in Training Committee of the AMA thinks some of the draft plans for the GPs will work, and others won't. Dr Joseph Sgroi is a 27-year-old trainee physician based at the Alfred Hospital in the heart of Melbourne. He's about to do a stint as a registrar in the rural city of Shepparton. Specialists like him are also in short supply in both the country and suburban fringes.

SGROI: Going to Shepparton is a secondment from the Alfred Hospital for a selected term of 13 weeks, and it's to advance my training, it's to give me the exposure of being a medical registrar, being a senior registrar in a hospital and having a bit more responsibility than I would have in a major teaching hospital like the Alfred Hospital. But at the same time, it's for a limited period, and certainly the exposure of medicine that I get in that area, and the training that I get is probably not as broad as what I would experience if I was in a metropolitan hospital. And so one way of potentially attracting doctors to these regions, is by providing very good training programs in these outer metropolitan and rural regions, and hopefully attracting and retaining those doctors to those areas.

SKINNER: Having got them there, the challenge is to keep them there. And there's no better way than love and marriage.

SGROI: If you provide adequate training to junior doctors in rural regions, then the potential for them to meet a partner in those areas, fall in love, marry and have children, is highly likely.

'A Country Practice' Theme

SKINNER: Human nature being what it is, romance is an important part of the equation, and young doctors are loath to go and practice anywhere where they think their chances of meeting a life partner are slim. But 20 years ago, a wedding in Wandin Valley practically brought Australia to a standstill. In the serial, 'A Country Practice', young city doctor Simon proposed to local girl, Vicki.

Simon: From the first day that I arrived in Wandin Valley I, oh hold on.

Vicki: When you first set eyes on me...

Simon: Yes. I've loved you from the very moment that I saw you.

Vicki: No, Simon, in your own words.

Simon: But it's true, that's the way it was.

Vicki: Simon, was it?

Simon: Well you know it was. Vicki, will you marry me? Please?

Vicki: Oh Simon.

Waitress: Is that a yes?

Music swells…

SKINNER: Most city-bred doctors think they've got a better chance of meeting Mr or Ms Right in the social whirl of the big city. Dr Joe Sgroi grew up in the eastern suburbs of Melbourne and he intends to stay there.

SGROI: At the present moment my partner works in Melbourne in a major office block for a major company, and the potential that she could move into a rural area and perform the same duties is somewhat limited. This is one of the things; we've moved from 20, 30 years ago where most doctors were male, and generally speaking their wives were domestic technicians, and we've now moved into a spectrum whereby doctors are marrying professional people who have very high-powered jobs and much as with everything, the whole business community is centralised. And so that unfortunately has placed some restrictions on doctors moving to those areas.

SKINNER: Nevertheless, Vice President of the AMA, Dr Trevor Mudge, says a lot of the shortage of doctors in many rural and outer metropolitan areas does boil down to money. Earlier this year, Access Economics finished a study for the AMA reporting that GPs are averaging less than $50 an hour after costs. That's before tax, and less than lots of other professions without as much responsibility and training involved. And the GPs work on average, a 50 hour week.

Dr Mudge says that if society wants to keep Medicare, the system must get more funding.

MUDGE: What's happening at the moment is that Medicare is failing to do what it was brought in to do, and that is to provide equal and equitable access to health care services, particularly for those who can't afford to pay, in fact irrespective of means. Universal health insurance, access to quality health care for everybody. Well, the Government's failure to support Medicare rebates across a whole raft of services, not just general practitioner rebates, although of course they're the most frequently accessed services, has meant that over 15 years the Medicare pot is now worth in real terms $1.5-billion a year less than it was 15 years ago. On the Government's own figures. They're not ours, they come from the relative values study, which the Government set up seven or eight years ago with the co-operation of the profession.

SKINNER: The AMA recommends that GPs should stop bulk-billing and charge $45 for a 15-minute consultation, which an increasing number of them are doing already.

The Government has increased Medicare rebates by more than 14% in the past couple of years, but it rejects the AMA's calls for sharply increased rebates across the board. It says this is an inefficient way of getting the best outcomes for patients. Instead it's gone for what are called practice incentive payments, worth $250-million. These are designed to encourage doctors to spend more time with such time-intensive groups as the mentally ill, the elderly, children needing vaccination, diabetics and asthmatics. But there's a lot of paperwork involved in this, which the Government has pledged to cut back.

On the maldistribution of doctors, the Government says big across-the-board increases in Medicare rebates is too blunt an instrument to get doctors into the areas of shortage. Instead it's pledged to spend $80-million on other ways of attracting doctors to the fringe suburbs of the big cities. It's already spending almost $600-million on all sorts of programs for rural medicine. They include practice nurses to do a lot of the routine work such as vaccinating children and advising people with chronic conditions such as asthma and diabetes. The programs include scholarships for undergraduate medical students and incentive schemes for trainee GPs. Federal Health Minister, Senator Kay Patterson says the number of GPs in rural areas increased by 4% last year, signalling a turnaround. But she concedes there's still a long way to go.

PATTERSON: The workforce issue isn't something, a tap that you can turn on and off very easily. You have to work over a long period of time. If you look at the number of young people from rural areas who were in medical schools when we came into government, eight percent of medical students came from rural areas. It's now 25 percent. We've had all sorts of schemes, assistance to universities to assist in selecting young people from rural areas, and assistance to encourage medical schools to take in rural students, and we don't think all those young people will go back to rural areas, but they're more likely to. We've had a series of scholarships to encourage young people from rural areas, and there are three types of scholarships, all of which have different conditions on them, to encourage them. We've got incentives for young people if they're training in a rural area, that they will get HECS relief if they train in a hospital in a rural area, and then if they undertake GP specialist training in a rural area, they get HECS relief for each year that they're in that training, and they get a $10,000 bonus in their first year of training, $20,000 in their second year, and $30,000 in their third year. So we have a large number of incentives to keep rural doctors back into rural areas.

SKINNER: There are all sorts of debates about other financial means of enticing doctors into areas of shortage, such as having different Medicare rebates according to where the doctor is practising, or how well-off the patient is. But the Government is worried it would be electorally unpopular to, in effect, have a means test on Medicare.

Underpinning Medicare for decades has been bulk-billing. That is, the patient pays nothing directly, the doctor just charges the Government directly. The fee they get is $24.50 for the standard consultation, and these days that's not enough, says the AMA. But if they want to, doctors can charge the patient what's called a 'co-payment'. This means the patient pays the doctor's bill of, say, $40, or $45, and claims the $24.50 Medicare rebate back from the Government.

AMA Vice President Dr Trevor Mudge says rebates are too low to ensure a decent living for doctors without them having to race patients through as fast as they can. And he says co-payments from patients have the advantage that they help keep demand on GPs down. He says if something has no upfront charge at all, like bulk-billing, people will want unlimited amounts of it.

MUDGE: The AMA has always said that bulk-billing is inherently a problem because demand for it is bottomless, and what we predicted really is what's happened, that the quality of practice falls and the time that doctors are able to spend with people falls. And there is an increasing demand, on an increasing number of services. And the big argument is how big the pricing is, but even if it's small, even if people pay $1 to $5 - I guess in today's money - to go and see the doctor, maybe they think twice about how necessary the visit is.

SKINNER: But there are some potentially big negatives for doctors who give away bulk-billing and charge their patients direct instead. The patient might not pay their bill; there's extra secretarial costs involved; and if there's tough competition from bulk-billing doctors in the area, patients might go to them instead. That helps explain why the proportion of GP consultations bulk-billed in the cities is about 80% but the average of bulk-billed consultations in the country is only about 50%. That's because there are bigger shortages of doctors in the country and therefore much less competition between them.

Dr Trevor Mudge says the other difficulties with charging co-payments in poorer areas are the doctor's compassion; and trying to work out who can afford to pay and who can't.

MUDGE: The major problem is that charging a co-payment gives doctors a pain in the heart, it really does, in a disadvantaged area. Charging a co-payment in the leafy suburbs doesn't give them a pain in the heart, and so that's why they shift to the leafy suburbs.

SKINNER: So you're not advocating co-payments in the disadvantaged suburbs?

MUDGE: Oh yes, we do. I think that we have said to general practitioners for a long time: 'Value yourselves, charge what you think you're worth, and don't blame yourself if the patient can't afford to pay. Instead of blaming yourself for it, become politically active and advocate for society to give the disadvantaged a better deal so they can afford it'. But part of the problem is that doctors are probably very poorly placed to assess a patient's capacity to pay. Any economist will tell you that a person's capacity to pay for a service can be measured only by the rate at which they consume that service -- not by a doctor saying: 'Well Sue Smith, really I know she brings the kids in every week, she really can't afford to pay $5 every time she comes in'. But of course the figures show that the Sue Smiths of this world spend far more than that on chips and Coca Cola in the supermarket. Chips, Coca Cola and cigarettes are the three biggest-ticket items in supermarkets. But of course that doesn't take place in front of us. It is just very difficult I think, for any of us to measure capacity to pay.

SKINNER: Many doctors compromise by charging co-payments from patients who work, but bulk-billing patients on government benefits.

Studies in the US and Australia have shown that having to pay an upfront fee out of your own pocket does not stop trivial use of GPs by the better off, but it does hit people from poorer backgrounds. That's the view of the Dean of Medicine at the University of Sydney, Professor Stephen Leeder, who's dead against co-payments.

LEEDER: I could take you to parts of western Sydney where asthma, an eminently treatable disease, is poorly managed. Why? Because people cannot afford the cost of preventer drugs. So giving them a co-payment is not going to straighten out their morals so they become more responsible users of the health care system. The co-payment argument is actually a subterfuge for people with an ideology that says people should fundamentally be rapped over the knuckles for using the medical care system. And anybody who's worried should think three times before they go to see a doctor. Whereas the best primary care is practiced when people go to see the doctor when they're worried about something, and get immediate treatment for it. The whole argument behind Medicare is that payment at the time that you're ill is not good for your health. And it won't solve the problem of maldistribution, and it won't solve the workforce issue; it's not where the answer lies.

SKINNER: Professor Leeder says this is also true outside the big cities, where the doctor shortage is even more serious.

Joe Romeo: Squirt a little bit of gel on that for me, put it on there.

Gel sounds

SKINNER: Dr Joe Romeo bulk-bills pensioners and health care card holders, who make up two-thirds of his patients. He's the senior doctor in Narrandera, a scenic town on the Murrumbidgee River in southern New South Wales. Dr Romeo is one of a dying breed, a GP who also does obstetrics and anaesthetics. He's a musician in his spare time; he's even got a CD out.

Song: 'Plain Simple Love'

SKINNER: Narrandera is in the worst category for rural doctor shortages. A recent Federal Government report concluded that small towns like Narrandera have 13 percent of Australia's population, but only five percent of its GPs.

Joe Romeo: So how do you feel now?

Man: I feel all right.

Joe Romeo: So did I increase your dose of insulin the other day?

Man: Yes, to 34.

Joe Romeo: And what were you on before?

Man: 28.

SKINNER: After his surgery consultations finished at 7 o'clock at night, Dr Romeo did his rounds of the mostly elderly patients at Narrandera Hospital.

Joe Romeo: What are we going to do with you, Henry?

SKINNER: This man with diabetes had collapsed earlier in the day.

Henry: Well why didn't I go bad yesterday?

Joe Romeo: I don't know. Things are not right for you, though. So we'll have to keep you in for a couple of days and see what your sugars do and get it right again.

Henry: That's alright Joe.

SKINNER: Then it was home to Dr Romeo's big house on a few acres just out of town at 8 o'clock for dinner with wife Liz, who does the books for his small practice. The couple's five children had already eaten, and most of them were watching TV.

Dr Romeo lived in rural Italy as a small child and even though he grew up in the Sydney beachside suburb of Manly, he always wanted to be a rural GP.

ROMEO: Once you do get over the settling in period, and once you've coped with a couple of emergencies, with all the adrenalin rush and the worry of how things could go wrong, when they actually go right, there's something really good happens to you, and your confidence suddenly goes up and you feel good about yourself being a doctor, you feel like you're a real doctor. And recently our trainee and I, it was actually only yesterday, there was a serious case came into hospital, and I could see that he was a bit iffy about whether he should deal with the situation, and I took a peripheral role, I just helped him make the decisions he was making, and once he did everything that was needed, he felt really good, and he told me he did. And I just know that he's now more likely to work in the country than someone else who hasn't been through that.

SKINNER: And he'd be less likely to have that satisfying experience in the city?

ROMEO: In the city that person would have been referred to Cas, and someone else, a casualty specialist, would have done what we did. GPs wouldn't normally have the opportunity to, for example, apply cardioversion to someone who's having a heart attack.

SKINNER: What was that case yesterday?

ROMEO: The lady was having a heart attack and she went into a funny rhythm of the heart. She was conscious but she needed urgent attention and she needed to be temporarily anaesthetised so that her heart could be shocked, and she came through, and today she's feeling great.

SKINNER: And that must make you and the trainee feel great.

ROMEO: It does, yes. It's a great feeling, it's hard to describe.

SKINNER: Being a country doctor is a bit like being famous on a very small scale, as one GP put it. It's a bit of a goldfish bowl. Dr Romeo says everyone in town knows him and his car.

ROMEO: Well I drive a beat-up old Corolla which used to be my wife's, and I hardly ever lock it up. In fact I've got a couple of patients that usually bring me some fruit if they come to see me, because they're orchardists, and before they see me, they see the car out the back, they open the door and put a box of oranges in the back seat for me, and then when they see me they tell me they've left some fruit in the car for me, which is fine by me. And when I'm on call, there's a lady that lives on the road between here and the hospital, and she knows the weekends I'm on call because she sees the blue Corolla drive past, so she's always the first one down there on a Saturday morning to see me, because she knows what time I start the surgery. But some days I ride the bike, and she asked me the other day, 'Have you been on holidays? I haven't seen that blue Corolla go past'. And I said, 'No, I've been on the bike'. So I know now how to avoid some of my patients by riding the bike. And I used to park in front of the hospital when I was on call, but people cottoned on that it was my weekend on, so I'd get extra outpatients at night, so then I started parking round the back of the hospital; they soon cottoned on to that one as well. So I try to either ride the bike or park the car somewhere unexpected when I'm on call.

SKINNER: So there are a few hypochondriacs around then?

ROMEO: I don't like to call them that, but people that like medical services, and the attention received from seeing the doctor. Same thing though, isn't it.

SKINNER: The most stressful part of Dr Romeo's life is being on call most of the time, either taking his turn on the general practice roster, or for anaesthetics and obstetrics. There are four doctors in Narrandera, serving a catchment population of 8,000. Dr Romeo says two more doctors are needed. He says the likely possibilities are doctors from overseas. He's pleased to already have a doctor couple from Iraq working in his practice.

On the day Radio National's Background Briefing was visiting, Dr Romeo worked a 12 hour day. Then at midnight he was woken and called down to the hospital to treat a teenage girl with suspected appendicitis.

Joe Romeo: Come on, don't move, here we go. That's the needle. Better?

Girl: No.

Joe Romeo: You haven't felt it, have you? Here comes the medicine, the medicine does sting.

SKINNER: At 5 in the morning, he had to go back again to the hospital for a difficult premature labour, and Dr Romeo ended up having to cancel the morning session at his surgery to concentrate on the woman. Concerned about her high blood pressure, Dr Romeo rang a specialist, as he's always able to do, and then gave the woman an epidural injection. A healthy baby was born, but the mother lost a lot of blood and had to be transferred to Wagga Base Hospital an hour away. She's fine now.

The specialist who taught Dr Romeo his anaesthetics at Wagga Wagga Base Hospital is Dr Judy Killen.

Judy Killen: This shouldn't be nearly as sore though, you know it's sort of a smaller operation.

Man: Yes, well they said the first two were the...

SKINNER: Dr Killen comes from a farm near Narrandera, and doesn't want to be anywhere other than in the country. After 16 years in Wagga, she loves it, but not all her family agree.

KILLEN: Well I've got a 13 year old son who thinks it's a hell-hole. My husband, who's a city person, and loves the beach, was a little slow, but he's come around to Wagga since joining the local kayaking club, and my younger son loves it. We live 15 kilometres out of town on 100 acres. We moved out of town because my garden was spreading into the back lane, and my husband thought it was ridiculous. We've got a beautiful outlook, and really we've built a beautiful house with all this glass at the front, and you can just sit there and look at the wide expanses every morning; I love it.

SKINNER: Dr Killen is happy with the schools, theatres, galleries and shopping available in Wagga, and her husband, who gave up his job as a computer expert to be at home for their sons, is happy to be in charge of the household and acreage. Dr Killen enjoys the variety of her work, but not the workload, which ranges from 50 to 80 hours a week, depending on how often she's called to the hospital after hours. There are seven anaesthetists in the city. The guidelines state there should be 11 or 12 to serve the 120,000 people in the catchment area. Dr Killen.

KILLEN: We can cope, sort of, when we're all here, but that allows for no holidays. As soon as one person's away, we can't in any way cater to the demand. We're getting a lot of help from locums at the moment, and we really appreciate that. But we need four more full time anaesthetists to come to town. So surgery at Wagga Base is going at about half flow; we've restored some lists by getting some help from GPs from Leeton and Griffith, but they don't do the full range of procedures that we're trained to do, and we have to sort of schedule them fairly carefully to appropriate lists. But next week for instance, I've rescheduled various lists, not only at Wagga Base but also at Calvary Hospital just from the shortage of anaesthetists. We really sort of are juggling all the time; this is the roster here, and you can see all the scribbles where we're trying to get people, to get the most work out of the people available.

SKINNER: Dr Killen thinks not enough anaesthetists are being trained to keep up with the growing demand for their services. The Australian Medical Workforce Advisory Committee, or AMWAC, advises the State and Federal Governments on how many specialists and GPs are needed in Australia. It's a very hard thing to get right. Improving medical technology alone has led to an explosion in the amount of treatment and surgery that's not only possible, but deemed to be necessary. For instance if a person has been diagnosed with bowel cancer, all that person's relatives must have a colonoscopy. Dr Killen believes the associated need for anaesthetists across the nation hasn't been fully factored in by AMWAC. She says many anaesthetists are working dangerously long hours.

KILLEN: In anaesthetics, the comparison is to pilots: if we do a night on, we should have the day off afterwards, to catch up on our sleep, and that hasn't been reckoned in to manpower planning. We should stop doing overtime somewhere round 55 or 60 -- as your diurnal rhythms get more exaggerated, you just shouldn't be up trying to watch a monitor at 2 in the morning, you're going to doze off and disaster's going to strike, sooner or later. So we need more people training, and if we have enough people, then people find the jobs that suit them. But so long as there's a shortage, even if you might be the sort of person that would like to come to the country where really the range of work is I think much more challenging, you know, one day you're doing a neonate and the next a 90-year-old; you're doing all specialties -- obstetrics, paediatrics, it's much more diverse and therefore interesting, from my point of view, than being a cardiac specialist in Sydney. And I think if there are enough people, the people who want that sort of work would come, in most cases. But at the moment there's not enough anaesthetists in Sydney, therefore there's no impetus for them to search more widely for work.

SKINNER: Wagga Wagga anaesthetist, Dr Judy Killen.

Doctor: We could give him some morphine I suppose, and we'll go from there.

SKINNER: Wagga Base Hospital is part of the new School of Rural Health run by the medical faculty of the University of New South Wales. Small groups of undergraduate students have long stints at regional hospitals across the State, rather than spending all their work experience in big city hospitals. Such clinical schools are also springing up for other medical courses across the nation.

Director of the Wagga Clinical School is Professor Sandy Reid, who spent 20 years at the University of Newcastle. Newcastle was the first medical school in Australia to depart from the easy method of choosing medical students simply by their very high school marks.

Professor Reid says many city-bred students have never been inland.

Reid: When I was in Newcastle I ran the Rural Health Club. Now this was students of all the health professions who were interested in rural occupations. I took 45 of them to Tamworth one year, and 18 of them had never been west of the Divide, and that was a group of students who were interested. So they were astonished at the facilities that Tamworth Hospital had; most people would be astonished to realise that we can do cardiac catheterisations, we can stick tubes into people's coronary arteries in Wagga and take pictures of it, that are just as good as pictures they take in Sydney. The facilities are excellent, and the way of practice is excellent, but people just don't think about it.

SKINNER: After graduation and specialisation, most young doctors seem to head for the best suburbs in the capital cities to live and practice. Perhaps the starkest example of this is that 85% of all the psychiatrists in Australia work in the capital cities, and most of them are in the inner city.

In some wealthy suburbs of the cities there's one GP for every 500 people, way above the rough benchmark for developed countries of about one doctor for every 1,000 people. This raises the extremely difficult and controversial concept of 'over-servicing'. Professor Reid says it's possible that there's over-servicing in many of the wealthy suburbs. He says some of his evidence for this comes from being a GP in Wagga for a short time.

Reid: I might see a patient needing a repeat of their blood pressure scripts who'se just moved here, and you talk to them, and you find out they've been on the same pills for the last five years and their blood pressure hasn't shifted much, and it's quite OK when I take it. So I would then normally give them a month's supply and five repeats, which lasts for six months, and I've had it said to me 'Oh but my doctor in Sydney always sees me every month to take my blood pressure'. Now I think that's a reflection that there may be over-servicing occurring in some places. There are, on record, and the Health Department knows about this, people who have about 500 patients who they regularly see. Now if you're going to make a living out of 500 patients, you've got to see them pretty often, and unless they're mighty sick, that's probably not justified. I have no evidence for saying this, I can only look at the figures and suggest that there probably is some over-servicing occurring.

SKINNER: There are no hard and fast rules and regulations for how often a doctor should see a patient. Patients expect to be seen when they feel they have a need, and there are strong arguments that the best treatment involves the doctor keeping a very close eye on medication and outcomes.

As well, many doctors are increasingly fearful that if they don't cover every possible contingency, ordering every test under the sun and referring to specialists to be on the safe side, a patient may be able to sue them. But that still leaves the issue of over-supply in parts of the big cities.

MUDGE: Well there's where we come to what's an over-supply, isn't it. One person's over-supply will be another person's under-supply. I think even in the leafy suburbs if a mother has a sick child, she would want the doctor to probably come to her house immediately, let alone being able to get an appointment to see the doctor she normally sees, or the family normally sees, that morning. And so a lot of it revolves around expectations. So that family would say 'Well there's a shortage, I couldn't get the doctor to come out when little Jimmy was very sick', or 'I couldn't get an appointment that morning before work, so I had to take the afternoon off to go and see the doctor'. So I mean, is that an unreasonable expectation of speed of service? I guess that's part of it.

SKINNER: There's also the fact that some people just like going to the doctor; they're not satisfied unless the doctor gives them a script to take away.

One solution to over-supply is for there to be Government restrictions on Medicare provider numbers. In other words, the Government will not give a GP a number which allows his patients to claim on Medicare if he or she practices in a part of the city that's already well supplied with GPs. This restriction already exists for the thousands of overseas-trained doctors in Australia. And a specialist can't just operate at any hospital he or she chooses. But the AMA is dead against any geographical restrictions on provider numbers and the Government says it prefers to try other ways first before considering such a drastic step.

Professor Stephen Leeder also disagrees with restrictions on provider numbers. He welcomes the Government's initiatives on rural health, but he says even more financial incentives are necessary to get doctors to where they're most needed. He says Medicare needs more funding across the board, and there should be higher Medicare payments for doctors in areas of shortage.

LEEDER: There are relatively so few people practising in the rural and remote areas that it wouldn't break the bank to increase the amount of money given to them. And Australia has to face the fact that despite all of the touching belief that people invest in politicians, who tell them that somehow or other there's no more money for health care. I mean, says who? We spend 8.6% of GDP productively in health care which means that 91.4% of the rest of the gross domestic product rides on the back of this relatively small investment in health. I mean, who says we can't spend more? If we wanted to, we could. It's a question of national priority, and running the national budget according to the will of the people. They haven't been asked whether they would tolerate a one percent increase in the Medicare levy. No-one's asked them, they just assume that everyone would say 'No'. It could be tested out, and a relatively small increase in the Medicare levy would cover incentive payments to practitioners in the bush and rural and remote Australia without blinking an eye. It would be a 30-second wonder.

Ends

Stephen SKINNER: Co-ordinating Producer, Linda McGinnis. Technical Operator, David Bates. Background Briefing's Researcher is Paul Bolger, and the Executive Producer is Kirsten Garrett. I'm Stephen Skinner and you're with ABC Radio National.