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JumpingTurkey on GPs in Canberra

johnboy 13 August 2010 26

In our recent discussion on Labor’s proposed GP Super Clinic for Canberra “JumpingTurkey” made a lengthy post worthy of its own thread.

So here’s a GP on GP services in Canberra:

#18 JumpingTurkey
11:51, 13 Aug 10

As an existing GP I have a few comments.

1. Building a huge builing to the tune of several million dollars is going to do absolutely nothing to address the GP shortage in Canberra. GPs are not going to be suddenly lured to Canberra to work in these new super clinics.

2. Issue of how to get GPs to work in Canberra is complex. I think it has to do with the fact that GPs generally don’t stick around in cities and places that they did not train in or grew up in. Until very recently, Canberra did not have their own medical school, except for students who rotated from Sydney Uni. Hopefully when ANU starts pumping out graduates, (and they are now) then this will address some of these issues.

3. You say that there are incentives for GPs to work in Canberra. I’ve never heard any details of these incentives. And I read through most medical newspapers / journals regularly. If it does exist then the government is not doing a good job of promoting this, are they?

4. You’ve got to stop blaming GPs for not bulk billing, but blame the government for not increasing medicare rebates. If you are an intern or a resident in the hospital contemplating your next career move – whether to specialise or enter GP training, and if you know that the government pays specialists double or more compared to GPs, and if you know that the training time for most specialties is only 2-3 years more compared to General Practice (and of course you earn an income as a trainee too, so its not as if you are paid nothing), then why would you enter general practice?

If you feel that your GP bills too much, then do you feel that your accountant who spent 3 years at Uni, followed by 2 years doing his CPA (compared to your GP who spends 10-12 years studying and training), charges you too much? What about your lawyer who charges you $50 for a couple of phone calls?
As a GP I’ve never dreamt of charging people for phone calls that I make to them, or bill them for the time it takes me to check their blood results or pathology results as they come through, or to call and talk to specialists or hospitals to discuss a patient’s case.

The money that you pay GPs need to pay for the surgery expenses, including rent, including electricity, phone bills, staff wages, and all sorts of expenses needed to keep the equipment sterilised, and also for medical indemnity insurance that protects you as a patient in case anything goes wrong (its not that we try to practice dodgily, but we are humans too and you’ve gotta be deluded to think that we never make mistakes).

The fact is that what medicare covers seems to rise in the order of 1% of less per year. Compare this to your electricity charges, or even the inflation that goes up at 3-4% per year. Or even your own salaries and wages that goes up by at least that amount per year.

5. Many GPs that I know will bulk bill patients who are in genuine financial difficulties. For instance, I bulk bill some of my patients – e.g. those with mental health issues, because I need to follow them up closely, and I don’t want money to be a barrier in them coming to see me frequently. Also we bulk bill those folks in nursing homes who are extremely fragile and often in the last few months to years of their lives.

6. I think having nurses working with GPs is a great idea. However you’ve gotta be kidding me if you think that nurses can replace GPs or do 80-90% of their work. What even makes you think / or what qualifies you to think that this is the case? As a GP, I can confidently tell you that 20-30% of my work is routine – i.e. coughs and colds, and issuing scripts and so forth. Around 40% are intermediate – they are things like people presenting for scripts but they actually need to be properly reviewed to make sure everything is okay – e.g. people who ‘thinks’ that they can come in asking for more scripts for diabetes tablets, without realising that they did not have a blood test for that in 12 months, or had their blood pressure checked, or does not realise that the sensation in their foot is slowly dying off due to diabetes, or their vision is silently going etc. That’s when I have to actually tell them that its not a simple matter of giving them scripts, but I have a responsibility to make sure that they are properly assessed again.

The other 30% of my work are diagnostic dilemmas. e.g. funny skin rash, or abdominal pains, headaches that persist, or dizziness etc etc. These are not ’simple’ things and they need extensive history taking, examination and investigations to get to the bottom of things.

Now, I think a well trained nurse would be able to do the routine things. They might be able to do parts of the intermediate things, but they will always need a doctor to check to ensure that nothing was missed. Often during the course of routine BP check, I often discover things like a mole, or funny irregular heart beats. And this kind of stuff only comes with years of medical training, not years of nursing training.
There is no way that nurses can deal with diagnostic dilemmas or the harder cases.

The fact of the matter is that nurses are NOT trained to be diagnosticians. Diagnosis is the most difficult part of health care. The rest – how to get you better – is easy – you just look up a book. For instance, if you KNOW that what you have is a skin cancer – treatment is easy – cut it out or burn it out (depending on the type). But getting to that point is difficult and requires specific training.

Nurses are good at ‘nursing’ people to health. Once they have a diagnosis, they are very good at taking good care of them, and monitoring their recovery to ensure that they are back to their health. With further training they become good at technical tasks – e.g. as scrub nurses who assist surgeons, or ICU nurses who are very good at looking after patients in critical conditions and become good at protocol-driven management of people’s airway, breathing and circulation issues.

However nurses are not trained to be diagnosticians and will never become good at this because they lack the broad medical training.

Remember 20 years experience as a nurse is not the same as even 2 years experience as a doctor, given that what you are doing is so different. this is same as thinking that a dental assistant working for 20 years will be able to do the job of a dentist – although they spend a lot of time looking after patients, they are simply not involved in making diagnosis or taking on the heavy responsibility of patient’s care – so how do you expect them to be the same???

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26 Responses to JumpingTurkey on GPs in Canberra
Drzaius Drzaius 2:22 pm 11 Sep 10

Just a quick comment with regard to nurses and diagnostics. A source at The Canberra Hospital tells me that just today some nurses received a test result for a patient whose nasal cavity is positive for commensal S.aureus. Firstly, they didn’t know what S.aureus was so proceeded to look it up on Wikipedia, next they didn’t know how to distinguish between commensal S.aureus and antibiotic resistant S.aureus and so assumed that the patient has Golden Staff despite the results stating otherwise, finally, they’ve put this poor patient in isolation and are treating them like an infectious disease patient. Through all of this they didn’t think to ask the registrar for any advice!!

I won’t be trusting nurses with my healthcare thank you very much! I completely agree with @JumpingTurkey.

MrNurseRatchet MrNurseRatchet 8:30 am 16 Aug 10

@JumpingTurkey: A very good question! I can only speak from my experiences receiving my training abroad but this is how it works: first and foremost you have to have several years of nursing under your belt before you are even allowed into most NP programs. I think here in Oz the minimum time before you’re allowed into a NP master’s curriculum program is after 5 years of practical nursing experience. A significant portion of those 5 years requires you to be working in an “advanced capacity” and you must have received some type of advanced degree in your specialty field during that time. (ie: graduate diploma in emergency nursing or rural and remote nursing). Once you are in your master’s degree program you receive plenty of didactic courses pertaining to advanced physiology, pharmacology/pharmacotherapeutics, physical assessment and pathology. At least in my program, many of these courses were shared with medical students. You also receive a host of other importance subjects such as qualitative/quantitative research and other professional development courses. Finally, we had several clinical placement courses that required us to spend 1000 hours working side-by-side with physicians and NPs in various clinical settings (unpaid, of course). Since my two Masters degrees were in Adult and Geriatric Health, the vast majority of my clinical hours were spent in rural and metropolitan primary healthcare centres. One entire semester was spent in a nursing home. During this time you are working to obtain those skills you’ve mentioned above. By the time I got out of my intensive 2-year curriculum I was working at a level of an NP. Then, when I entered into my professional life as a NP I was surrounded by NPs, physicians, surgeons, and PAs who worked collaboratively with me and the learning process continued. Interestingly enough my primary care experience was what was instrumental in making me such a successful cardioaortic surgery NP. The surgeon I was working with back then knew I was trained in primary care but wanted to see what mixing the two specialties would result in. So he essentially undertook me as my mentor to show me the acute surgery side of things. I guess you could call it my “residency.” The fact that patients were getting a holistic view of primary care during their surgical stay is probably what lent to the success of the model.

JumpingTurkey JumpingTurkey 10:33 pm 15 Aug 10

This is a genuine question: I am curious as to how the master’s program equips one with a full set of diagnostic and examination skills? Do you get attached with a doctor who demonstrates these skills to you? I found in medical school that I still struggled to perform a competent examination and get correct diagnosis even after spending 3 years in clinical years attached to various subspecialty teams and getting numerous clinical tutorials? I only truly acquire these skills after a couple of years as a junior doctor…?

JumpingTurkey JumpingTurkey 10:27 pm 15 Aug 10

So you think our teachers and firies and police officers ‘just get on with it’?
Then why do NSW teachers go on strike almost on a yearly basis? Why do police officers go on strikes? Why do ambulance officers go on strikes?
You’ve also got to realise that training time for teachers is 4 years. Training time for police officers (depending on what type) maybe 3-4 years. Ambulance paramedics are the same. Training times for nurses are 3 years.
For doctors to qualify to practice independently it takes a minimum of 10 years. The time that you spent earning money and time you spent on leisure time, doctors or would-be doctors were spending studying and seeing patients. Many trainee doctors would pull 70 hour weeks – and these are 70 hours not spent on a desk, but spent running around on your feet. Let me tell you that stories you hear about intern and residency work being tough is all true and more. Around 50-60% of interns will actually break down and cry on their first 14 hour overtime shift due to the overwhelming workload.

I hardly think that it is unfair that doctors are paid highly given this amount of self sacrifice and dedication. Please note that most doctors are well into their 30s by the time they finish their training. I don’t know of any other profession or occupation that has such a long training time.

I agree with many things that you say but I don’t agree with your view that GPs just deal with coughs and colds and refer on anything that is puzzling. Let me tell you – if you practiced in this way (i.e. referring everything that you are not sure), then you will quickly find that your patients will return very very annoyed. Imagine if you are sent by a GP to emergency department to only end up waiting 4 hours to be told by an intern that it is nothing to worry about, and sent home? And imagine if you refer someone with a puzzling rash to a dermatologist, and then the patient will return telling you that there is 4 months waiting list, and they would really like something done about it before then?

Leinna Leinna 10:23 am 15 Aug 10

I should also mention that is often a lack of respect by specialists for GPs. When you’re training in a hospital, the only senior doctors you deal with are specialists. Therefore you tend to get a one sided opinion of what it is like to be a GP.

Leinna Leinna 9:11 am 15 Aug 10

As a specialist in training… (whose father is a GP)

When I was deciding what I wanted to do with my life, I was considering specialist training versus GP training.

In summary:
1) GP training is just as long (if not longer) as specialist training
2) Specialists make AT LEAST twice as much as GPs, and if you work privately you can often earn 1 million/year
3) Most specialists have equivalent insurance premiums (with the exception of O+G)
4) Specialist work is often more interesting, as GPs have had a lot of their skills taken by specialists. GPs are left to sort out coughs and colds, and when they get something interesting (like a puzzling skin rash) their main decision is whether to refer on to the appropriate specialist (dermatologist)
5) GPs need to be a ‘jack of all trades’ and master of none. As a specialist, you focus exclusively on one area and become a master of that. Just don’t ask me about something unrelated to my speciality!
6) As a GP you don’t have to put up with the hospital politics, references, and so on. You can pretty much just say “I want to be a GP” and the GP college will accept you.

I think we need GPs as they can manage the multiple illnesses a person may be having. I also think we need to make working as a GP more attractive to medical students and junior doctors. The few colleagues of mine who have decided to GP often do so because they are sick of the hospital system / politics / crazy hours.

In my case, I had just about given up on getting a specialist position and was considering being a GP. Mainly because I wouldn’t have to worry about petty politics between and within the units, and so I could spend more time with my family. But it was definitely a ‘second choice’ given the benefits of specialist training.

Quokka Quokka 8:36 am 15 Aug 10

The nurses at the walk-in clinic at The Canberra Hospital will write a “sick certificate” if you need it. Whilst I think this is a good idea, I’m not too sure how useful it is. Apparently the hospital has refused to acknowledge it for it’s own employees, which does seem just a tad hypocritical! I mean if the place that issues the certificates doesn’t recognise them, then why should any other employer.

MrNurseRatchet MrNurseRatchet 10:18 pm 14 Aug 10

@Jethro: one, of many, alternatives to your question (if all you’re looking for is a medical certificate when you’re off sick for work for something minor) is to obtain a stat dec from a pharmacist. I believe that will accomplish the same result for you. (If there are any pharmacists out there could you please confirm?)

MrNurseRatchet MrNurseRatchet 10:12 pm 14 Aug 10

@GuruJ: The “traditional” difference lies in the fact that nurses are trained in a “nursing model” and physicians a “medical model.” Traditionally the nursing model of healthcare encompasses the patient’s perception of disease in a context of societal, socioeconomic, spiritual, and environmental (amongst other things) factors. Traditionally the medical model focuses on the disease and its interaction within the individual. At least, that’s my understanding of it when I was taught this stuff years and years and years ago. These traditional models are changing with the evolving landscape of healthcare. You are finding more and more physicians bringing in elements of the nursing model and vice versa (thus, the development of nurse practitioners and physician assistants.)

@JumpingTurkey: Just to clarify-I do not object to being classified in the same category as my nursing colleagues. I was trying to draw reference to the fact that NPs are able to do 80% of what a physician does (overseas, anyway) in their respective specialty areas and that registered nurses (also called APNs, CNCs, AINs, ENs, and a myriad of other appellations) are not able to do so-by law. It was only to point out that in a model where NPs are actually functioning at an optimal capacity that they function differently than their nursing colleagues.

You ask why I still call myself a nurse? Well I guess that’s who and what I am at my very core. Many moons ago I made a choice between nursing and medicine. At that time in my life the nursing model really resonated well with me… and it hasn’t left me since. Yes, I’ve picked up a few tricks along the way (learning how to build a differential, think critically about the impact of pharmacology and pathophysiology, etc) but I’m still a nurse…and I’m speaking only for myself here…but if you asked me to do something that was “below” me (ie: wipe someone’s bum) I would happily do so if that is what was needed to improve their recovery and comfort. Because that’s just the type of person I am. Still doesn’t diminish my ability to insert a large-bore chest drain or figure out the safest antiarrhythmic drug to place someone on. Besides, I can just turn the question around to you and ask “what exactly is a doctors role, anyway?” At a major metropolitan hospital located in Sydney I learned that placing cannulas, venipuncture, and inserting urinary catheters into males was a “physicians role.” Overseas those are very clearly nursing roles. So what is the difference between a doctor’s role and a nurses role? Seems largely contextual and cultural, if you ask me.

With respects to your suggestion to turn nurses into physicians: I think this is a creative solution to the GP shortage in Oz and merits a high-five for lateral thinking. The theory, however, is that NPs will be able to achieve the same result by going to their 2-year master’s programs.

vg vg 10:06 pm 14 Aug 10

JumpingTurkey said :

Vg, of course you could argue that GPs are already paid too much and don’t need more incentives than any other skilled shortage.
But what you don’t realise is that people think that health care is a right.
If you don’t have more programmers in Canberra, people aren’t going to die.
If you don’t have more public servants or lawyers in Canberra, then people aren’t going to die.

If you run out of dentists or GPs or nurses, then people will suffer.

The fact of the matter is that GPs aren’t coming to Canberra. And the fact is that this is causing a lot of problems for Canberrans.
The solution is to find ways of attracting more GPs.
In this capitalist society, you can’t “force” people to go anywhere, so you need to offer them incentives – in our society, it is money.

If you don’t have ambulance drivers, cops or firies the same happens. They just get on with it, rather than living with an inflated sense of self-worth

dtc dtc 8:58 pm 14 Aug 10

@Jethro – I suspect its your employers fault and that Drs probably agree with everything you say. Like many rules, medical certificates are there to catch the minority that abuse the system. Depending on where you work, the more senior people in your organisation probably only need medical certificates for, say, more than 5 days or even more than 10 days consecutive sick leave.

In ‘ideal world’, no one would automatically need a certificate, but HR would keep an eye on things and if someone was taking too much suspicious leave, they would get a warning and then would be singled out as someone who needed a sick leave certificate. Of course, that would involve HR or management having to actually manage, so a blanket rule that applies to all ‘potentially untrustworthy staff’ (ie in general not senior people) is made.

JumpingTurkey JumpingTurkey 8:26 pm 14 Aug 10

@jethro: you are absolutely right,I think that the requirement for the employers for their employees to have med certificates is in most cases a waste of time. And I think most GPs agree with this and most of the time it is a waste of everyone’s time.

The other problem is when someone comes to see me and says that they have a cold or a diarrhoea (and who knows whether or not they had diarrhoea – there is no objective test or anything that can prove or disprove whether someone has gastro except what they tell you) and says that they feel crook and cannot go to work, then how can I refuse their request for a med certificate?? Yep – if you’ve done this before and if you are reading this, then yes we know what happens – but we cannot accuse our patients of lying without having any proof so we go along with it.

So med certificate is mainly a way for employers to discourage their employees in taking a sickie. Only the most daring ones would chuck a sickie when healthy and go to their doctor and pretend that they have an illness to get a certificate. Most ‘honest’ people would probably be discouraged in doing so.

On the other hand, I am not so sure it is wise to let a pharmacist or a nurse (let’s stay away from the nurse practitioners, but just nurses) give out medical certificates. This is because even though 95% of the cases when a person thinks that they have a cold will have just a cold, 5% will not. And can you imagine a pharmacist actually examining you before issuing you with a medical certificate? Imagine in a busy pharmacy with other people watching you, your pharmacist pulling out his stethoscope and trying to listen to your chest… (not to mention that s/he has never been trained to examine people, or to make any form of diagnosis) Do pharmacists even have medical records where they can record down what happened in a consultation?

So I think it will be far better to scrap this requirement for medical certificates and make it compulsory only if one needs to take more than say 2 days in a row, or takes more than 10 days in a calendar year.

As for pharmacists and nurses issuing medical certificates – I really don’t see any point in it – they are not adding any value and I don’t see how they will be much better than you in picking whether or not you are sick enough to actually go to a doctor.

I suppose if they set up a consulting room and keep proper medical records and get trained in properly examining people for coughs and colds, then let them go ahead! I’ll train them myself (provided that my indemnity insurance covers it, and I get paid for it). But this seems to be far too complex a system when we can do away with this stupid system.

Jethro Jethro 6:40 pm 14 Aug 10

Since I seem to have the opportunity to quiz a GP on all things GP-ish, I have this lump on my knee….

No, really, I actually want to bring up the topic of doctor’s certificates and:

1. The fact that since its almost impossible to find a bulk-billing doctor these days, I need to fork out a bunch of money to be told I have a cold and to stay home and rest when I clearly already knew that.

2. The fact that by me going to the doctors, I’m taking up an appointment space for something that is very minor and not really in need of any medical attention, other than the need that I get a doctor’s certificate so that I can prove that, yes, I do have a cold

3. There seems to be a shortage of doctors in the ACT, so often I need to call 3 or 4 doctor’s surgeries before I can actually find one with an available space for today, and now someone who may actually need to see a doctor is missing out. (I have had a few occasions where a request for an appointment was met with a ‘We have a space open next week’). Also, this means I’m not visiting my personal GP, which I always feel a bit bad about because he’s such a good GP and knows my medical history, etc.

So… why do we have this requirement to get doctor’s certificates? Is this something that doctors agree with? Surely, this is a case where a nurse or a pharmacist should be able to certify that I am sick.

It really does seem to be a massive waste of 1. my money. 2. a doctor’s time 3. an appointment space for someone else who might actually need it.


JumpingTurkey JumpingTurkey 6:23 pm 14 Aug 10


Yes in the end, it doesn’t matter what field (nursing or medical) that one comes from, it is the ability to provide effective care that is important.

But in your situation, shouldn’t your title change to reflect your skills and status?
I am a bit intrigued: if you are capable, trained and experienced in diagnosis, then why are you still called a nurse? For instance, if you and I were working side by side, and if I asked you to do something that is traditionally nursing, then you’d object to it, wouldn’t you, given that you would feel that your skills would be better used. And also you already object to being classified in the same way as traditional nurses as is evident in your post?

To address any problems and misconceptions, why don’t Nurse Practitioners change their title? Physician assistants are an obvious example but this is a problem given that in US and also in Australia we have physician assistants coming out from 3 to 4 year university courses.

Or perhaps there should be a pathway that will allow someone like yourself to become a fully qualified doctor – in a shorter time given your experience and training already – maybe 18 months to 2 years to upskill on basic and clinical sciences – and fully funded (say at $50 to 60K per year).

GuruJ GuruJ 6:09 pm 14 Aug 10

Genuine question to either or both of MrNurseRatchet and Jumping Turkey:

What practical differences are there in the training that a nurse practitioner receives vs a GP?

Presumably you both get trained in basic medical science and diagnosis … is the main difference left that a GP will have trained in surgical techniques as part of their basic MD degree, whereas an NP gets trained in patient care?

MrNurseRatchet MrNurseRatchet 4:02 pm 14 Aug 10

Hi Jumping Turkey et. al:
With all due respect (and I really do mean that) I must heartily disagree with your take on nurses not being able to work autonomously, independently, nor have the ability to be “diagnosticians.” I’m not talking about “advanced practice nurses”, “general practice nurses” or other variants when saying that they can treat 80-90% of what a doctor can. I am speaking of “Nurse Practitioners” being able to safely, appropriately, efficiently, and effectively treat 80-90% of those diagnoses pertinent to their specialty field when compared to their physician colleagues. There is a WORLD of difference in this country between an “advanced practice nurse” and a “nurse practitioner” and I believe that you are blurring the distinction between the two.

I am a nurse practitioner from overseas that has been trained, through my extensive advanced education and experience, to BE a diagnostician. I agree with you that nurses are not traditionally trained to build differential diagnoses…but we’re not talking about traditional nurses anymore, now are we? Nurse Practitioners are able to very effectively work with those easy and intermediate cases…and many of the “diagnostic dilemma cases” as well. I was trained as a generalist NP, did heart failure for a brief stint, and then worked side by side with a cardioaortic surgeon for a while. He did the surgeries and as soon as they were extubated I did ALL of the medical and nursing management from that point on. The medical and surgical management of these cases was quite complex, and yet our NP-collaborative cardiothoracic surgery service had PROVEN decreased morbidity and mortality compared to traditional physician-directed models.

With respects to your epiglottitis example: Please. I have a lifetime’s worth of examples demonstrating the exact same thing but in the reverse: plenty of careless physicians making mistakes that, if it weren’t for my advanced clinical assessment, reasoning, and diagnostic skills, would have resulted in significant morbidity and mortality for patients. It goes both ways: there are bad nurses just like there are bad doctors.

Anywho: I definitely agree on your points on the GP Superclinics. I say devote more money to the existing infrastructures and find more creative means of providing services to the community. (Like hiring some NPs to work alongside with the GPs at the community centres!) It’s in my very strong opinion that the most beautiful, effective, and powerful healthcare occurs when nurses and GPs work side by side.

JumpingTurkey JumpingTurkey 2:24 pm 14 Aug 10

@ Sasquatch Sam

I see your point, but the reason why 20 doctors came down was only because the condition is so rare and serious so they needed a lot of people’s input on how to tackle the situation.
The point of this story is that nurses didn’t really know that such things could happen or that is a possibility.

Look nurses are fantastic at common things and things that are routine. For instance if you go into emergency with a gastro bug then they’ll be the ones looking after you really well, and you’ll be lucky to see an intern for 5 minutes who’ll just come in and ask you a few questions and then leave. They are lot more thorough than medicos, and often know their protocols really really well. So things like setting up IV lines and giving medications, and reassuring patients, they are really good at.

JumpingTurkey JumpingTurkey 2:18 pm 14 Aug 10



The solution is to find ways of attracting more GPs.

Sasquatch Sam Sasquatch Sam 1:40 pm 14 Aug 10

Astrojax, epiglottis appears to be something nurses will have learnt about as well (eg I think the nurse in this example didn’t do their job well (tonsils and epiglottis are completely different bits + drooling and tonsilitis just sounds painful, swallowing spit all the time, painful even for a Tongan). Thankfully JT was there to pick up this other induvudals slack. I don’t think this very old anecdotal evidence supports the idea that nurses working indepentely is a bad idea though.

In fact … maybe if his profession didn’t have this kind of objection people like JT would have time to time get up to date with the ACT health website and would be aware of things like the grant DTC mentions.

(I have nothing to do with nurses by the way, I’m in IT, I just think the DR lobby group are overly powerful)

justin heywood justin heywood 9:02 am 14 Aug 10

vg said :

Why do doctots need ‘incentives’ to work in Canberra any more than other skilled shortages.

When the AMA’s own data indicates the average GPs salary is around $300,000pa you can cry me an effing river

Doctors DO earn a lot of money – that isn’t the issue though. If we have to pay them more to get them to Canberra then I’m all for it.

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