‘I’m totally, utterly done’: The insider take on our growing GP crisis

This story is part of Good Weekend’s best cover stories of 2022.See all 13 stories.

Tarryn Beatty is a registered nurse. Her husband, Martin Carlson, is a GP with almost 30 years’ experience. Together, they are the very definition of devoted primary health workers. In November 2019, they opened a clinic in Moruya, a small town 2.5 hours from Canberra. Their dream was to focus on best-practice continuity of care. They wanted every one of their patients to really know their GP, and every GP to be “looking after families and their kids, and their kids’ kids”, as Beatty puts it.

It has been a battle from the start. They planned the practice around the idea of getting another two doctors on board, plus a second nurse, but after two-and-a-half years of continuous advertising they’ve been unable to recruit a single GP from anywhere. This has left them both carrying enormous patient loads. Sixty-year-old Carlson sees between 30 and 40 patients a day (that’s up to a patient every 20 minutes for 12 hours) and Beatty sees between 15 and 20. “I’d like to be winding down,” Carlson admits. “Since I graduated, the shortest week I’ve ever worked is 60 hours.”

Even without the workload, things have been almost unimaginably hard. The Black Summer bushfires were already burning just 20 kilometres away when they opened the practice, “and by Christmas they were in Mogo, which is five minutes away”, says Beatty, who is 40. “Moruya was threatened by fires for the best part of three months – we were evacuated from our own house on five occasions.”

Registered nurse Tarryn Beatty and her GP husband Dr Martin Carlson at their NSW South Coast practice. Despite advertising for more than two years, they haven’t been able to recruit another GP.Credit: Dean Dampney

Determined to keep the practice open, the pair lived in the clinic, sleeping in the tea room on blow-up mattresses. “And we kept working and we kept things going, because that kept us going,” says Beatty. “But you look back now and it was really awful. Not knowing if your house was still there at the end of the day, but having to deal with everybody else’s emotions. People would come in just to chat. One evening, one of our friends fell off a ladder, so we’re in here, in the tea room, in the middle of the night, stitching his scalp back together, not knowing if the town was going to be overcome, not knowing if our house was gone.”

This kind of devotion is, oddly, what we expect of doctors. Even more oddly, they almost always deliver it. And perhaps this has played into the way the rest of us have viewed the cataclysm facing the Australian healthcare system in general, and general practice in particular. Well, they’re doctors, we think: they’re used to crisis. They’ll keep on keeping on.

Except when they don’t.

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How long has general practice in this country been in trouble? Well, Australia’s two years of COVID border issues severely restricted the flow of extra GPs from overseas and between states, leading to drastic deficits. The system of remuneration and funding has been building towards disaster since 2013, when Medicare GP consultation rebates were frozen until 2018 (they rose by 1.6 per cent in July). And the number of GPs actually working in Australia has been falling for more than a decade: by 2032, according to research, there’ll be a projected shortfall of more than 11,000 GPs, which is almost 30 per cent of the workforce.

In the 1980s, about 40 per cent of all medical graduates went on to be GPs. Today, according to the Royal Australian College of General Practitioners (RACGP), it’s just 15 per cent. In 2019, the RACGP reported that for every new GP, there are nearly 10 new non-GP specialists.

Why is this so? Well, as is so often the case in life, money in every form – from basic Medicare rebates to complex funding models; from a simple payment for services to an esoteric signal of moral value – lies at the heart of the problem. GPs earn less than any other specialty: in a survey by University of Melbourne researchers, using figures from 2018, GPs’ median hourly income rated dead last out of a list of 30 specialties, and their median annual income was little more than half that of the other specialties: $188,000, compared with $329,000.

Of course, $188,000 is hardly peanuts. “I think,” says one senior doctor who (unsurprisingly) does not wish to be named, “GPs are just a bit of a frustrated bunch, at the end of the day. I’ve worked in other medical professions and, I don’t know, the GPs – they’re just never happy. All this moaning about not earning what other doctors earn – well, they do three or four years of specialty training; other specialties do many more. Earning a couple of hundred grand a year is hardly terrible.”

Interestingly, however, when you actually sit down with GPs themselves, few of them are actually moaning about the money. They do talk about Medicare and bulk-billing rates – in tones of universal rage – but rarely do they say: “The problem is, I want to earn a lot more money for what I do.” (As one GP says to me: “There are plenty of specialties that are basically licences to print money – if that’s what I wanted, I’d be doing one of them.” )

What they’re angry about is the ever-increasing hell of paperwork, and the pressures of a funding model that inexorably links pay to speed, rather than quality of patient care. The net result is a job that’s lost a lot of its joy and meaning, not in one fell swoop but by a thousand tiny cuts.

“There are plenty of specialties that are basically licences to print money – if that’s what I wanted, I’d be doing one of them.”

Dr Annie Marshall, 45, owns a practice in Sydney’s inner west with her husband, who is also a GP. She has 16 years’ experience, and is extraordinarily organised and competent. But, she says, she almost never sees a patient for less than 20 minutes. “I see two or three patients an hour,” she says. “I don’t really pay for my own space.”

She and the 14 doctors at her practice (filling eight full-time equivalent roles) are mostly “still in the office two hours after the last patient leaves, just dealing with the admin from that day, never mind all the results coming in, the people you need to call, the follow-up appointments you need to make”. Marshall has three children, but she’s often still at the surgery at 8.30pm. (Martin Carlson, in Moruya, is at the surgery until midnight one or two nights a week.)

Carlson sees between 30 and 40 patients a day. “Since I graduated, the shortest week I’ve ever worked is 60 hours.”Credit: Dean Dampney

COVID-19 has not helped matters. Telehealth consults, remote prescription processing and the desperate push to vaccinate – GPs have administered half our pandemic vaccines – all added to the administrative load. The past two years have also vastly increased patient numbers in areas such as mental health, domestic violence, obesity and addiction. “No one’s got our back,” says Marshall. “Every time ScoMo opened his big mouth during the pandemic, he was saying, ‘Just call your GP.’ But there was no help, no support, nothing.”

Labor promised almost $1 billion to fix primary healthcare at the May federal election: $220 million for GP grants of up to $50,000 to allow practices to improve skills, equipment and infection controls; and $750 million for a “Strengthening Medicare” task force. There are few details about this task force, which met for the first time on July 29, 2022.

“For the remainder of the year, we’re going to be working to figure out the priorities,” Health Minister Mark Butler tells me. “General practice is in a parlous state, but I’m very confident that our investment of funds, and also our energy – I’ll be chairing the task force directly – will start to turn things around.”

Unless and until this turnaround occurs, however, being a GP “is a shit job”, to use the words of Annie Marshall. “It’s a shit job, and I love it. But there’s just so much stuff that gets in the way of enjoying it, and doing it well.”

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Paying people more to do “a shit job” is certainly one way of making them keep on doing it. What are the chances of seeing an increase in Medicare rebates – which, in a sense, form the basic wage of GPs – under Labor? “Well, I don’t want to pre-empt recommendations of the task force,” Butler says, “but we’ve committed substantial funds to the process, and those recommendations will feed into the budget process for next year, so funding can begin to flow from July 1, 2023.”

Even if this process does miraculously lead to increased rebates, it seems unlikely to be the total solution. Historically, one of the great advantages of general practice as a career has been its variety, and its status. GPs delivered babies, managed trauma and took care of people through every phase of their lives. They were, in return, greatly valued by their patients: crucial pillars in the fabric that held towns, suburbs, entire communities together.

But today, this is not always the job GPs perform – or the reputation they hold. Annie Marshall started her career in rural practice. On her first week back in Sydney, she saw a patient with a “massive thrombosed haemorrhoid” (an eye-watering condition occurring when a vein protruding from the anus develops a blood clot). “She couldn’t sit down,” Marshall recalls. “I was like, ‘You poor thing, get on the bed.’ So I anaesthetised it, got a scalpel, removed the clot. But it took me 15 minutes to find the equipment – the scalpels and everything – in the practice. And later, when I mentioned that to the other doctors, and told them what I’d done, they were like, ‘You did what?’ And they all said they’d have referred the patient to hospital. I said, ‘Well, how quickly would a surgeon have been able to see her?’ They were like, ‘Oh, a couple of weeks.’ And the woman couldn’t sit down!”

“She couldn’t believe that she could come to one person and have it all dealt with. But that’s my job. And it cost her less than a single specialist visit.”

Marshall points out she was lucky to have the training that allows her to perform such procedures. “It’s not that [other GPs] don’t care,” she says. “They may just not have had the exposure; or they don’t have the time.”
Many GPs, certainly, are hamstrung by a system which doesn’t allow – or reward – this kind of care. A month or two ago, Marshall saw a new patient right at the end of the day, a European woman freshly arrived in Australia.

“She wanted an ophthalmologist to screen for glaucoma; she wanted to see a gynaecologist for her pap smear; she thought she needed an endocrinologist for slight hypothyroid; and she thought she’d need to go to the hospital to get an IUD.” Marshall organised for her to see a local optometrist to check her eye pressure, “but I could manage everything else. She couldn’t believe it; couldn’t believe that she could come to one person and have it all dealt with. But that’s my job; that’s what I do. And it cost her less than a single specialist visit.”

“Churn-and-burn medicine exists,” says Dr Annie Marshall. “But you cannot make a patient feel reassured that you’ve had a proper look, that they’ve been heard, in six minutes.”Credit: James Brickwood

Marshall spent more than an hour with this patient, for which Medicare rebated $113.30, the highest payment possible for a timed GP consult. Many GPs would have written the referrals for the patient and gone home. And many others, even if they’d wanted to treat her, would have worried that they couldn’t, because they wouldn’t be paid enough to make it worth their while; or because their practice owner wouldn’t approve.

In 2008, 35 per cent of GP practices were owned by GPs themselves. By 2020, that figure had fallen to 25 per cent, due to the growth of large, corporate-owned clinics. Some of these clinics are excellent, with doctors relieved of the administrative burdens of practice, and supported to practise high-quality medicine. But there have also been suggestions – including in a controversial 2021 article in the Medical Journal of Australia – that corporate GP care might be harder to access and of lower quality than in traditional clinics. In particular, GPs themselves report stories of colleagues being pressured to see ever-larger numbers of patients in ever-shorter consults: so-called “six-minute medicine”.

“Churn-and-burn medicine exists,” says Marshall. “The only way to get a patient out of your room within six minutes is to give them a piece of paper – for a scan, a blood test, or a referral. You cannot make a patient feel reassured that you’ve had a proper look, that they’ve been heard, in six minutes.”

Gerard Foley, the CEO of Sonic Clinical Services Australia, the largest corporate GP business in Australia, with more than 2000 GPs working in more than 240 practices, rejects this characterisation. “We do not dictate how [the doctors in our centres] conduct their practice or how they bill their patients,” he says. “[There are no] quotas imposed by us, or, to the best of my knowledge, by other GP operators.” The average time spent by a Sonic GP with a patient, according to Foley, is 15 minutes.

A good GP saves lives, notes RACGP president Karen Price, based in Victoria: “We just do it very slowly.”

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For most of human history, the greatest cause of death among humans was infectious disease, followed by catastrophic injury, and in either case there was very little anyone, including any doctor, could do. But in the wake of World War II, with its stunning advances in professional surgery and the advent of penicillin, medicine actually began to save lives. Antibiotics cured previously fatal infections like TB; immunisation protected against sweeping contagions like polio and measles and smallpox; surgery and drugs began to overcome tumours and allow for the repair, even the replacement, of organs.

It was here that the heroic ideal of modern medicine was born – the doctor who strides in where the rest of us fear to tread, a real-world Marvel superhero. I put this thought to Karen Price, president of the RACGP, and she sighs. “And that’s why I hate Marvel movies,” she says.

Like it or not, modern medicine was built around this ideal of heroic intervention. Money was, and is, poured into the hospital system, which houses the technology, tools and specialist skills that acute health crises require. Federal spending on general practice, in contrast, is tiny: between just 4.2 and 6.8 per cent of total health expenditure, depending on how you classify it.

Hospitals are also major centres of research – in 2019, the RACGP reported that just 1 per cent of Australia’s Medical Research Future Fund was allocated to primary care. Money flows according to our perception of value; and acute, hospital-based care is the part of medicine that society still holds in awe.

The problem with this model is that it forgets another, equally important one: the model of incremental care. Not all life-saving medicine is heroic. Especially as deaths from infection and trauma have dropped, what ails people, and what now kills us in far larger numbers than any acute illness, are chronic health issues – heart disease, diabetes, cerebrovascular disease (which causes stroke), lower respiratory disease, and all the many problems of increasingly wealthy, long-living societies: the dismal effects of smoking, inactivity, obesity.

Surgeons and specialists of all kinds treat these people, of course. But it’s GPs who see them day in, day out, year after year. The problem is, this kind of care isn’t sexy, so it’s not valued as highly by society, and not funded in the same way.

For every 10 extra primary physicians per 100,000 people, 49 fewer people died on average per year.

And yet, there’s no doubt good GP care saves lives. “Look at smoking cessation,” says Price. “Yes, people can go to hospital to have a specialist put stents in their arteries to save their lives. But everybody knows, in fact, that the best way to cure smoking-related health problems is to stop smoking! And who does that? The GP. That nagging voice of the GP is actually much better – infinitely less expensive for the taxpayer, less risky for the patient, and with far better long-term overall health outcomes if successful – than putting a stent in.”

Again and again, research has shown that incremental care matters. In 2019, a US study found that adding 10 primary care physicians (the US equivalent of GPs) per 100,000 people was more than twice as useful as adding any other kind of doctor when it came to life expectancy. A 2007 study found that the same increase in GPs improved all health outcomes, including all-cause cancer, heart disease, stroke and infant mortality. For every 10 extra primary physicians per 100,000 people, 49 fewer people died on average per year.

This is because GPs are really the only doctors most people actually get to know. They’re the only doctors who might also know our family members; who understand we hate our job or don’t like taking our antidepressants or can’t make the rent. They monitor our health – and our lives – longitudinally, over years, and if this relationship is consistent and successful, it can make an enormous difference to individual health. “That’s our superpower,” says Price. “Our therapeutic relationship.”

In future, GPs will only become more important. Our ability to capture individual health data is increasing all the time. We can already track sleep, heart rate, breathing and activity via our devices. As American doctor and author Atul Gawande writes: “The more capacity we develop to monitor the body and the brain for signs of future breakdown and to correct course along the way – to deliver ‘precision medicine’, as the lingo goes – the greater the difference healthcare can make in people’s lives.”

And this “course correction”, he points out, is not via heroic intervention, but incremental adjustment: helping you lose a bit of weight, slightly altering your blood-pressure medication, figuring out a plan for you to drink less. All these things are done by your GP. As Price puts it: “We do save lives. We just do it very slowly.”

The question is, will GPs be valued – and thus funded – to keep on doing it?

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Australia has a weird health system. We have funding from both the Commonwealth and the states; we have public hospitals and private hospitals and private patients in public hospitals. Professor Stephen Leeder is an emeritus professor of public health and community medicine at the University of Sydney. “An alien arriving from an exoplanet and looking at the health system in Australia would go crazy,” he says. “It’s just an incredible shambles.”

“An alien arriving from an exoplanet and looking at the health system in Australia would go crazy. It’s just an incredible shambles.”

A shambles with two crucial details for general practice. One: apart from some one-off measures during COVID, states and territories generally pay nothing towards GP care. And two: if patients end up in a hospital emergency department as opposed to a GP clinic, then the Commonwealth avoids paying GP costs (though it does, also, part-fund hospitals). This is a simplistic rendering of the problem, but the fact remains: both levels of government have incentives to maintain the status quo.

This, say the experts, has to change. Federal and state funding must be brought together. “Having one health system is a critical part of reform,” says the RACGP’s Karen Price.

Perhaps surprisingly, Health Minister Butler himself says he can see advantages to this model. “There is a history of multipurpose services in rural communities,” he points out, “where the Commonwealth and states recognise that alone, neither of us can really deliver a full service, so we co-operate. And I agree – the Tasmanian premier, for instance, who is also the health minister, has already reached out to me to explore ways in which general practice and the state government health system can better integrate to deliver care. I’m very open to that.”

Indeed, it appears to be already happening, at least at one GP clinic in Tasmania.

In March last year, Dr Toby Gardner, an affable 44-year-old GP, and his four practice partners at the Newstead Medical clinic in Launceston, opened a new wing, which offers an unusual medical service.

It’s called urgent care. “It’s basically when you can’t wait for a GP appointment but you don’t quite need the emergency room,” says Gardner. Instead, patients with acute but not hospital-level problems (cuts and abrasions, sprains and fractures, hives and rashes, food poisoning) can go to the urgent-care clinic, and be seen more quickly and cheaply than they can in an emergency department (ED).

Dr Toby Gardner and his practice partners opened an urgent care wing at the Newstead Medical clinic in Launceston.

These kinds of clinics have been trialled in Australia before without success – former Labor prime minister Kevin Rudd’s failed super clinics spring to mind – and other versions do exist (there are some in Western Australia and Victoria, and pilot “priority service” centres in South Australia). But the Newstead practice is based on the national model of New Zealand, where urgent-care clinics all over the country have significantly lowered ED visits.
Mind you, there was no government funding for Gardner or his partners. “We just did it ourselves,” he laughs. “We spent $1.2 million of our own money building it.”

The clinic resembles a small hospital emergency department, with a central admin hub, surrounded by nine curtained beds and an infusion bay. It’s staffed by one doctor, a radiographer, two nurses and an administrative assistant, with an extra doctor during rush hours. The partners decided to charge a flagfall co-payment fee of $150 on arrival, with standard Medicare consult and procedure fees billed on discharge and fully rebated.

But a few months after it opened, the state government began funding the flagfall fee for concession-card holders who visit outside normal GP hours. “They also provided a grant to help fund the cost of penalty rates for nursing staff and administration staff working on the weekends,” explains Gardner.

At $150 a pop rather than the $480-odd it costs the Tasmanian government every time a person walks into an ED (and about $600 for the emergency component if they’re admitted), this represents a massive saving: almost three patients for the price of one. The clinic has also helped relieve ambulance ramping rates and ED waiting times at Launceston General Hospital, which were among the worst in the state. “We’ve got busier and busier,” says Gardner. “We’re seeing up to 30 or 40 people a day on our busiest days; Launceston ED might see 120 a day. So we’re seeing a third of their patient numbers.”

For GPs like Gardner, the thrill is not the revolutionary funding model, but the work itself. “I just wanted to use my skills,” he says. “I started out practising in the country, and did extra bits of accreditation, and I love the variety. It’s about wanting to have other aspects to your professional life. In urgent care, as in emergency medicine, patients don’t really know how sick they are. We have heart attacks, strokes, fractures, sepsis, arrhythmia, anaphylaxis, acute severe asthma. People are, literally, dying on us. I like the adrenalin, the procedural stuff. It’s massively improved my job satisfaction.”

“I’ve got friends who are cardiologists, gastroenterologists. And they’re sooo much wealthier than I am. But let’s face it, their work is kind of boring.”

It’s not all perfect. “The big issue is manpower – getting GPs to work weekends!” Gardner grins. “It’s really perceived to be a part-time, or a Monday-to-Friday, nine-to-five area of medicine. I think there’s a generational thing there, too. Young doctors are just not prepared to work weekends!”

But Gardner believes showing students the variety and excitement of GP work – and reminding trained doctors about it – is what’s required. “I’ve got friends from med school who are cardiologists, gastroenterologists,” says Gardner. “And they’re sooo much wealthier than I am. But let’s face it, their work is kind of boring. I like being a generalist. It’s a hard job, and it’s interesting.”

This message has to be hammered home, to medical students especially. “You’ve got to have good, inspirational teachers showing that general practice is not just coughs, colds and scripts.” (Gardner is also a clinical lecturer in general practice and community care at the University of Tasmania.) “And we know that if we can get procedural stuff into general practice, and more opportunities for research, that will really draw people to the specialty.”

Meanwhile, urgent-care clinics are about to go Australia-wide. Labor has pledged $135 million for at least 50 such clinics around the country, with the first expected to open mid-2023.

Australian Medical Association president Omar Khorshid has criticised the plan, saying it will not prevent hospital emergency queues and will disadvantage other clinics, and Gardner himself is non-committal. “We’ve worked out that the money they’re proposing wouldn’t quite cover the cost of the doctors’ salaries – let alone the infrastructure and everything. So who knows where the costing’s coming from.”

Could Labor be hoping the states will come to the party with funding, as Tasmania has done? “Well, at the first meeting I had with state and territory health ministers, there was a real enthusiasm by all jurisdictions to partner with us,” says Health Minister Butler. “That partnership might be at different levels in different places, and we’re at an early stage in our discussions, but I’m open to any constructive suggestions.”

Back in Moruya, Martin Carlson and Tarryn Beatty didn’t lose their house in the bushfires, though it burnt to the fence line on three sides. But they had no time to process this miraculous escape, because no sooner were the fires over than the COVID lockdowns began. “So we had this big cohort of patients who were already traumatised,” explains Carlson. “And then, suddenly, they were in lockdown. And what’s happened now is that, whereas before COVID I’d say 10 per cent of my practice was mental health, now it’s 70 per cent.

There’s not a day goes by when I don’t have three or four people whose lives are falling apart. But all the psychs are booked out months and months ahead, so you become the psychologist, too. And inevitably, you get someone who’s booked for 15 minutes and you spend 45 with them. Because I know if I stop them talking, I can’t see them again for weeks.”

Beatty has made the decision to leave nursing. “I always wanted to do it, I absolutely loved it. But now I’m totally, utterly done. I still love our patients, but the passion has gone.”Credit: Dean Dampney

At some point in discussions like these, one begins to wonder not only about the mental health of patients, but also of GPs. Earlier this year, GP Annie Marshall lost an old friend from her intern days. Dr Jonathan Morling was a beloved Western Australian GP obstetrician in the small country town of Bridgetown, where he coached a local soccer team, was a volunteer firefighter, starred in local theatre and played his guitar online to cheer people up during the pandemic. Battling depression, he committed suicide on February 26, at age 41.

“Before COVID I’d say 10 per cent of my practice was mental health, now it’s 70 per cent.”

Both Beatty and Carlson take active steps to look after themselves. “But there are days when I’m tired, I’m frustrated, I’m drained by all the people feeling so bad,” admits Carlson. This echoes Marshall, who pauses at one point, saying: “Every 20 minutes, someone is giving you their biggest problem. That’s the job. It can be really hard.”

For Beatty, meanwhile, the battle has led to permanent changes in her life. “Last year I was really unwell; and finally I’ve gotten on top of that,” she says. “I never thought I’d burn out. I didn’t become a nurse till I was 27; I always wanted to do it, I absolutely loved it. But now I’m totally, utterly done. I still love our patients, but the passion has gone.”

She has, in fact, decided to leave nursing. For her, this will be more than the loss of a career – it’s the loss of a vocation, a way of life, a shared pillar of her
marriage. “I had to be really brave to tell Martin!”

She smiles, and Carlson shakes his head. “I know what she’s feeling,” he says. “I still love it, but I’m tired. We all remember the old-style GP, who looked after multiple generations of families for years, and knew them all. That’s an incredible privilege; that’s what I love about being a GP. It’s a fantastic job. But the whole thing has changed enormously in the past decade.”

He pauses. “If I could just get rid of the paperwork, and stop saying to people, ‘No, I can’t fit you in,’ and have some new, enthusiastic doctors around to share the load with, and share my experience with. Then it would still be a fantastic job.”

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