Cover Story
Call the Doctor
by Linley Boniface
Continued from page 1...
National Party health spokesman Tony Ryall calls us “the world’s biggest importer and exporter of GPs”. He says New Zealand doesn’t have the money to win the bidding war for medical professionals, and should concentrate on training more doctors, lowering taxes and having a “bureaucratic bonfire”.
Health and disability commissioner Ron Paterson says foreign-trained doctors are over-represented in complaints, although the numbers aren’t yet significant. But he is concerned that many of the complaints come down to poor communication: doctors who don’t understand the position of Maori and women, and aren’t familiar with the concepts of informed consent and patients’ rights to information.
For patients generally, the GP shortage can mean a significant diminution in the quality of primary health care.
As Royal New Zealand College of General Practitioners president Jonathan Fox points out, patients who have built up a rapport and trust with their GP may say important things to him or her that they would not say to a locum. He says good general practice is built on a long-term relationship: “Records cannot reflect all the things you may talk about.
“Often, people come along with one thing, but they are burning up to talk about another, and if you have confidence in your doctor, you will say, ‘By the way, my wife just left me’, or ‘I think I have a drinking problem’. And that sort of thing is often more important.
“And locums, however good they are, are only there for a short time and are more likely to deal just with the immediate problem. It’s: ‘What’s the problem today? Right. Fix that. Out the door’, rather than suggesting a review and asking, ‘What’s going on here?’”
That can mean missed opportunities for diagnosis, “the case of the sore throat that turns out to be a lymphoma”.
Fox says that, traditionally, female doctors have been likelier to work part-time, but young male doctors now want that, too.
“When you are choosing your doctor, you need to think carefully about what service they offer. There may be very good GPs who may only work part-time, and that may not be appropriate for someone with a medical condition who needs to be able to see their doctor any day of the week. In our local area, I can think of some women GPs who might only work three days out of five, and if you are an elderly person who needs a lot of house calls, that doesn’t necessarily fit with the availability of the doctor.
When a GP is unavailble, “you may get someone trained in accident and medical care, but you are needing someone trained in general practice.”
The risks of seeing different doctors were highlighted in a Health and Disability Commission case in which a patient who went to a new doctor was prescribed a drug for migraines that should not be given to patients with asthma. The doctor was unaware there was a history of asthma, and the patient died within hours of taking it.
There have, of course, been other cases, where locums have picked up problems that regular GPs have missed.
Since 2001, the government has reformed the sector by encouraging GPs to join non-profit, community-based Primary Health Organisations (PHOs). These put more emphasis on health promotion, give nurse practitioners a larger role and encourage GPs to join forces with other medical professionals, such as physiotherapists, pharmacists and dietitians.
The previous subsidy system has been replaced by capitation, a form of bulk-funding that calculates how many times certain types of patients are likely to visit the doctor. The consensus among GPs seems to be that, although PHOs have brought patient fees down, the system lacks flexibility.
Some GPs have fiercely resented the government’s insistence on controlling fees in the face of rising expenses, seeing it as an unwelcome state intrusion into the freedom of small businesses to set their own charges. They have been particularly offended by the government’s readiness to portray them as greedy pilferers of the public purse whenever they complain that fees are set too low.
A membership survey by the College of GPs in 2005 found almost a third of family doctors were considering changing their work status in the next five years, with some planning to work less or quit.
“Some of them are burnt out and just can’t take it any longer,” says Fox. Only half of the college’s members are self-employed, and the number is falling rapidly.
Income levels for GPs remain relatively low. Hodgson uses research that suggests median net profit per GP practice owner was $153,886 in 2005, up from a low of $82,424 in 2000, and that a salaried GP earning $85,000 in 2001 would have been on about $127,500 last year. The college disputes those figures, pointing out that its membership survey found a mean gross income for all GPs (self-employed and salaried, full-time and part-time) of $93,000, which is $45,000 less than the median salary of specialists.
Almost as contentious as income levels is the issue of the administrative burden on GPs. Mark Peterson, chairman of the New Zealand Medical Association’s GP Council, says paperwork now makes up about 30 percent of a GP’s workload.
