Introducing GPs Can
One of our Human Books, Dr. Wendy Burton, has graciously allowed me to present her with a few questions about her project GPs Can. GPs Can presents a response to the hashtag #justaGP - it’s a way for everybody from patients to practice staff to healthcare practitioners to take a moment to appreciate the positive experiences they have had in their healthcare journeys. It’s such a powerful and fascinating project, so it’s a real pleasure to be able to dig into the background of the project and find out what’s driving it, and what’s driving Wendy.
L: In your section on the "Purpose” of GPs Can, you give a brief overview of what training is involved in becoming a GP. You mention that general practice is a medical specialisation, taking about 10 years all up by my count, and that this is how it’s been since 1988. Do you often find that people are unaware of this extra training? Can you tell me a little about the ongoing training that GPs do over the course of their careers?
W: Most people have no idea that GPs chose this career as a specialty. That we had to study extra, and sit extra exams. That not everyone passes. That it adds at least another 3 years onto your training. For the trainees moving into GP training from the hospital system, they have to also consider the implications that come from losing entitlements such as sick leave, holiday leave, parental leave, or carer’s leave. And after all that is over, it is just beginnning!
Along with other specialties, we are required to complete mandatory education, to update in CPR regularly and audit at least one aspect of our practice every 3 years. But since general practice is mostly a private contractor workforce, there is no funding for this. No personal development leave, no conference budget, no in-house training. Most of us are only paid if we are face-to-face with a patient, and we don’t usually have education events during work hours, unless we have taken time off to attend a conference. Contractors typically pay a percentage of their income to the practice, so if we attend during work hours, we lose income, and if we lose income the practice costs don’t get paid.
There are discussions underway about mandating at least 50 hours per year of education. I would personally do way more than that each year. Unpaid, after hours, in my “spare time”. Some of the leave I have every year is used to attend these conferences; it is not a holiday, but often patients view it as such.
L: In your “Inform” section, you mention that all doctors who have trained as GPs have also worked in the hospital system, which would of course give you rich experiences of the different pressures in different parts of the medical system. You also talk about how much you value the teams you work with, all the way from receptionists to non-GP specialists. Yet the medical system itself often changes, with different departments and services and regulations morphing over time. How are GPs kept up to date on the systems used by the services they have to coordinate with?
W: Keeping up with the changes in systems does my head in!
So many projects are commenced with a trial. We might engage in this, only to find there is no ongoing funding. Sometimes, by the time I need to use a specialty service, the “new” system I knew about has been changed and I have no idea what to do now. It consumes so much of our time, trying to figure it all out.
Sometimes it feels like they simply change for change’s sake. So often, their staff will rotate and they end up trying things that have already been done, and we GPs sit on the outside, shaking our heads and wondering how the heck they have funds to do this all over and over again. No corporate memory.
There is work underway on “health pathways” which may make it easier. Time will tell, and some of the early work has been complicated by being copied from New Zealand, who has a very different funding system to our complicated multi-tiered one. From my experiences, I believe there are 4 essential R’s to connecting the healthcare sectors:
Relationships
However these are often pre-existing, and not always positive.
Respect
It’s important to recognise that this cuts both ways.
Clinical Relevance
You won’t get my attention just because you want to save money in the public sector, I’ve got enough issues with limited funding in my own sector! Improving clinical outcomes, on the other hand, is something we can all buy into.
Realistic expectations
What gets funded gets done. I can no more do something with nothing than others can. They may want us to meet to discuss, but in (their) work hours - which means we lose money, which means our practice loses money, which limits our capacity to engage. Then we are told we are difficult to reach - but that’s because they don’t know how we work. I can’t meet you at 10am on a Monday morning, that’s the busiest day of my working week. Lunch time appointment? Good luck. Lunch time is always cut short by patients who present with 30 minute problems booked into 15 minute appointment slots. My time is finite and precious.
I have always found it best to treat people with respect even when (perhaps especially when) they have not earned it. Then they have something to lose. GPs are intelligent people who have demonstrated their resilience by surviving the system. We can work on better solutions, but it should be systematic, owned by the profession, and at some point it has to be funded rather than relying on individuals and their good will.
However, if it is only individuals that I can reach, then one at a time, we can do this better. Together.
L: The byline of GPs Can mentions its aims to elevate positivity in general practice. Can you speak to the ways that negative perceptions (or a lack of understanding) of general practice have influenced the culture of general practice?
W: I think that the more often you hear something negative about yourself or those in your group/tribe/profession, the more you start to believe it might be true. You dismiss aspirations of being better, you figure there is no point as everyone thinks poorly of you, so you have nothing to lose. They don’t respect you now, so why should it matter if you cut corners?
And when hospital colleagues believe GPs to be stupid or lazy, what hope is there for filling our training positions? Just this year (January 2020) a young registrar posted concerns online about moving from another specialty training into general practice: was she copping out? would people think less of her? She was only too aware of the discussions in the hospital…
I hear over and over again that most GPs are not like me - and fair enough, thank goodness there is only one of me! But I know so many amazing GPs who are doing good, even great work, both in my own practice and around me. But all the good we do is invisible. I just think it’s like housework - not noticed until it’s not done.
L: Here’s a bit of an uncomfortable question: in your site you make the caveat that “in saying that GPs can, I am not saying that only GPs can, nor that all GPs can, or even that GPs will.” I know from experience that anybody talking about a “Good GP” will usually be reminded of a “bad” one - so how can patients find the GP that can and will? Is it the patient’s responsibility to find the “can and will” in their GP, or is it up to fellow medical professionals to coax out the “can and will” in their colleagues? What’s the best way to go about it?
W: Nope, it’s not uncomfortable; I’m not a fool. I know that, like every profession, there are good, bad, and mediocre GPs.
I have dedicated a third of my working life over the past 12 years or so trying to identify and close gaps, principally in the maternity field. We need a multi-pronged approach but I think part of the problem is the system we are paying for.
We have valued convenience and cost over continuity and care. The general public, hospital colleagues, and politicians put so much pressure on us to bulk bill, but the standard Medicare rebate only buys about 7-8 minutes of a GP’s time. Everyone wants a fancy dinner, but Medicare only has the purchasing power of a Vegemite sandwich!
What gets funded gets done; but are people prepared to pay? They can pay higher out of pocket expenses, or pay higher taxes to fund the higher Medicare rebates. Hip pocket pain is a real issue which is compounded by the lack of understanding of our funding. People who will pay to see a chiropractor every week for months on end, or who take multiple expensive supplements from their naturopath, may ask - may demand - to be bulk billed, and that can create resentment.
Meanwhile, ask your GP. What is it that you are looking for? Perhaps they can and will do it, but need more time to provide the care you are looking for. And you may have to pay extra for that time.
L: And finally, one of the recurring themes in the project is the ability of GPs to untangle complex issues within patients, or even to help patients when there isn’t any more untangling that can be done, yet no answer to their problems can be found. I’d love to hear about your own experiences with learning to sit in that uncertainty, and how you built your own capacity to face it and guide the patient to a better place even without having all the answers.
W: Ah, uncertainty. Indeed, the very mild super power that GPs have is the ability to sit with uncertainty. It drives so many of our non-GP specialist colleagues to distraction - fancy not knowing! And yes for all that modern medicine does know, there is so much we are still working on, constantly revising. My own capacity has been built over time, but I also recall very early in my career - perhaps in the first few months of work as a GP trainee - meeting a woman with a complex interplay of symptoms that made no sense. The jigsaw puzzle would not assemble. The history was confusing, the examination unremarkable, and the investigations no help. I was completely stumped.
I suggested that it might be this, or that, but had to concede that I did not know.
“That’s okay,” she said, to my surprise. “You have helped. You listened.”
This is the power of the empathetic witness. It was an important lesson for me so early in my career. Peter A. Levine says: “Trauma is not what happens to us, but what we hold inside in the absence of an empathetic witness.” Our system is traumatising - or re-traumatising - too many.
I love my job. I get to see the difference that I make, and it doesn’t get much better than that! I know that I’m not perfect, that I will make mistakes. That the system sucks for some much, much more than others. That we have such a long way to go.
Liz, it is complicated. It is exhausting. It is draining. It is a cognitive challenge. It is misunderstood. Criticised. Undervalued, not recognised, frustrating.
But we are chipping away and I realise that I may fail, but if I fail it won’t be for lack of trying. I’m in the arena, giving it my best shot, and I have terrific support.
Because it is also rewarding. Exhilarating. Life changing. A gob-smackingly incredible privilege.
Wonderful.