Time Share

Time traveller
Time is the basis of human experience, it is the foundation of narrative, the vehicle of observation and the thread of trust. Its linear and physical path draws our attention away from the cyclical daily routine we inevitably follow at times. Understanding the importance of the future is health itself. Building and discovering a past that nourishes us is what provides our peace, contentment and a framework for generosity. As a healing profession, we must work with time, give our time and help people regain or maintain their desire for health and well-being.
Many people we see as general practitioners need our time more than our tests or our treatments. Just spending time with someone on a few occasions can have a significant impact on their lives. This is not well understood but does depend on our care and reputation. We do know that science has not been able to determine which components of many effective ‘talking therapies’ (such as cognitive behavioural therapy) actually make a difference over and above the engagement of a significant person with shared goals for a period of time. Spending time in conversation with someone in difficulty is inherently worthwhile. It must involve listening, should involve challenging the key determinants of the person’s situation and may involve sharing some insights gained elsewhere. Doing so builds two narratives; the narrative of the person’s life and their difficulties as well as the narrative of the time shared with us. Insights inevitably arise and as a consequence a changed view of the past and future. These narratives, now shared, allow trust to grow with a mutual understanding, and can be drawn on in the future when further difficulties intervene.

This approach also has a role in acute care. If we think of ‘monitoring’ a person’s condition as limited to taking measurements and making observations, it reduces our impact to the singular (and sometimes very important) biological dimension. However, we can also use time when someone is acutely ill in much the same way as when the person is distressed, building trust and a shared narrative. That way we can work with the ill person not only to make sure they are safe, but also to learn how we should work together effectively in the future. Such an approach allows a mother to take her sick child home for a short period (perhaps 4 hours or overnight) and return to discuss any changes, what social support they have been able to muster and how they are both coping. What we learn together can be used to ensure a good outcome and also to determine appropriate care when similar situations arise in the future. This provides a much greater gain than a prolonged trip to the emergency department to be tested and scanned unless, of course, there are signs of major illness.  The shared narrative is valuable to all concerned regardless of the next decision.

And what of protracted physical symptoms such as back pain or headaches. Although tests seem most likely to provide benefit, it is rare that they do. We know, for instance, that most changes seen on CT or MRI scans of backs do not correlate with symptoms. But doctors tend to make these spurious correlations, leading to ongoing concern and even an unwarranted deterioration in perceived health. Using time, as part of a naturalistic approach, is far more helpful, leading to observation, trust and a shared narrative. If the person will not take time to get stronger and more active or take time out to relax and nourish themselves or other simple measures to address the problem, then this can be challenged, but only from a position of trust. Arthroscopies may damage knees (especially in the elderly) while time often heals them. It takes a practitioner’s time to gain the trust of a person that allows them to give their bodies time to recover.

No one is time poor, for we all have the same day-to-day allocation. Horizons shrink with age and illness but time marches constantly. Even when our patients die, the once shared narrative remains as illustration or, in its public form, to share with relatives and friends and provide a new basis for trust. Time has one demand. We must be realistic. As Camus said, “Live life resolutely without hope for there is no consolation.” This is not a call to hopelessness but a call to being realistic and it is a very helpful stake in the ground for people who have a grave diagnosis and much uncertainty.

A growing personal narrative, more valuable if shared, is at the heart of our humanity. When thin or missing it is a mortal wound. People create this story with parents and kin, often regigging and changing the colour of bits and pieces. It becomes who we are, the gaps , the inconsistencies.  It is far harder to fill gaps retrospectively when they emerge later in life. The stolen generation and secretly adopted children testify to this. The value of memory with anchoring narratives is probably paramount to a happy life, no matter the distress that may have been part of the experiences that generated it. Working with our patients to put together the narrative of their lives, despite their focus on the woes of the present, is a wonderful experience and can make a difference for generations.

Why bother?

Hong Kong Hang OutIt is easy to get the feeling that we could all do a good job in general practice if it wasn’t for the crazies, the difficult ones, the slower types and the worried well. It is a bit like John Cleese in Fawlty Towers – who made the same mistake.

Today I saw a woman that I met a decade ago. She looked dreadful, much as she had done then. At that time she had been banned from our local emergency department. Now she is unable to get care from the psychiatrists. A decade ago she was complaining of pain and was relentless in trying to get medication and something done. In fact she had an abscess in her neck, no doubt due in some part to her lifestyle. She was sent away to a tertiary center and put through the mill. Spinal surgery, intensive care, rehabilitation.

She recovered in terms of her abscess but remains as out of control now as she was when all this started. Today, 10 years later, she is again begging me not to see her as a drug seeker, a doctor shopper, a write off. It was difficult not to do so all that time ago despite her neurological signs, just as it is now.

I have never prescribed her painkillers or benzodiazepines despite massive protestation: the sort that makes you bleed. It is heart felt, theatrical and even a little endearing before it becomes somewhat intimidating, quickly tedious for those measuring their own responses in terms of best practice or guidelines. There is absolutely no vaguely visible road to success. It is so compelling only because she genuinely suffers so much; wailing, pleading as tissues amass in or near the bin.

She sees her future only in terms of medications provided by doctors; me and my colleagues only in terms of degrees of rejection. She is “The Hulk” of medication users – she even looks a little green. There is no end of medical and social labels that apply, made all the more compelling due to her lack of insight. She is stark naked in her intoxicated disguises.

How to help? Her life is always on a thread. Efforts to help from a myriad of agencies lead nowhere noticeable. The pain is felt by all.

I shook her hand today and we parted peacefully enough. She might take me up on my offer to help her be a little healthier without feeding her hunger for intoxication. Some I have known like her have died younger, some have stumbled into middle age where they sparkle like drunk adolescents in a bowls club. I really wonder at her will to live and be fed. I feel for her family.

Do I have room for hope?

Je suis feminist

Southern Beach Gender is a big topic in medicine at the moment. Since Elizabeth Blackwell (US) graduated in 1849 and Elizabeth Garret Anderson (UK) gained recognition as a Medical Practitioner in 1865, women have been making headway in taking their rightful place in our ‘honourable’ profession. Constance Stone, Australia’s first woman in medicine, graduated in the US in 1888 as the University of Melbourne did not admit women. With hindsight, it appears immensely unfair that women could not study medicine and at what cost to humanity? It has been tough on those leading from the front in what is indisputable social progress. This progress does carry with it implications for our profession and for interactions with our patients and peers.

As our profession becomes more gender-balanced, the status of medicine becomes more dependent on the general status of women in society. Some will know of what happened to the standard and resourcing of the medical profession in eastern block countries when a majority of female practitioners were trained and employed without the status of women changing in those societies. Thus, if we are to be a gender-balanced profession and maintain the status of the profession then we all have an interest in the status of women. Self interest for all!

The majority of patients presenting to general practitioners are female and having access to a greater number of female doctors is positive for those who seek this. Research shows this correlates with the more ‘patient-centered’ approach of female doctors; but as men and women have the same medical training I suspect this is a social skill of women rather than a professional attribute. At the start of my career approximately 40% of women preferred female doctors for PAP tests, 15% preferred men and the rest had no preference. I could find very little data in Pubmed on current preferences but in a recent paper on gender preferences of men with erectile dysfunction it was approximately the inverse. Clearly this varies with cultural influences; importantly the lack of access to a doctor of the preferred gender may lead to reduced uptake of a required service, particularly in non-acute care. This may extend to colonoscopy.

I am aware that modern society is more sexualised and this almost certainly has an impact on gender preference in the consultation. At a Taylor Mac performance I recently attended he described his gender as ‘none’ and his sexual preference as ‘audience member’! Should we ask patients not only their preferred provider gender but also their preferred sexual preference? Would this change things for patients? A heterosexual male patient, whom I have counselled through a distressing period in his life, told me that he would prefer to see another doctor for his check up as he liked me! Presumably this was due to the possibility of an intimate examination. Very young girls with asthma are quite often reluctant to show me their chest when I am examining them. Sexualisation of life further promotes gender alignment in the consultation out of a feeling of safety.

An unintended result of increasing gender alignment is the deskilling of general practitioners in gender-specific medicine. I would propose that this is already a significant problem, added to by an increasing number of doctors working in primary care who are uncomfortable with cross-gender medicine for cultural reasons. Some avoid this aspect of practice altogether. In large cities this is not such an issue but in rural practice it can be catastrophic. The wonderful female doctor visiting program is a patch for this but is not a long term solution as it is very expensive and does not address men’s needs. All doctors need to understand gender and be in touch with those aspects of gendered behaviour that make others feel either comfortable or uncomfortable. General practitioners must take care of humanity, leaving gender preference to their patients.

What are the consequences within the profession itself of becoming gender-balanced? Clearly there are more opportunities for cross-gender interactions with peers; some of these will become sexual. One visible result is the larger number of dual-doctor families rather than the common doctor-nurse couplings of previous generations.  Let’s not get too hung up on people making sexual approaches within the profession even if these are a little foolish or fumbled. When the approach is sexual harassment then there are well established legal pathways. But any association of such liaison with job progression is completely unacceptable – whether through negative threats (“you won’t progress if you don’t”) or positive inducements (“I could do a lot for your career”). Calling this out for what it is should bring the spotlight on the unwanted attention rather than the individual in receipt. Managers must address this, and if the person providing the unwanted attention is the manager, then there must be a third party involved.

Our professional colleges could be a means for this to be dealt with when there is no other mechanism or the system is failing.

We must also consider the possible inappropriate calling of harassment. I am a non-gendered shoulder-touching and kissing sort of person and not everyone finds that acceptable (male and female); but it is my culture and I have got better at recognising when it is not accepted by others. I have never made any sexual advance to anyone at work in my career but I have had one doctor feel uncomfortable with my approach to physical contact. How far can we be expected to change for individuals? It is a general question worth asking. Recognising others’ cultures is important but being genuine and relaxed is also a positive attribute. How far does a widely acceptable non-sexist culture have to take into account another’s culture in these matters? The answer is probably “to reasonable lengths”.

So let’s all be reasonable in most matters but intolerant of any indications that women are being treated in a way that is unfair. This is all about fairness and humanity.

The doctor’s concern is the patient’s fear

River Bed
Katherine River
How often have you listened to a patient’s story and thought, “OMG! This person has a brain tumour.” After a few more minutes listening (if you are into that sort of thing) your concern might have developed into a mere brain abscess or perhaps a cerebral vascular abnormality. Reacting directly to such gut responses is one reason that doctors now do so many CT Scans of peoples’ brains. I am ashamed to admit that we now cause more brain tumours than we detect. That is clearly not good for our patients and the public purse. In fact, it is a disgrace.

So what should we do with this concern that patients so easily generate in our viscera? We ignore it at our peril for we do not know if it is based on reality, searching google and incorporating the symptoms, a grief reaction to the death of a loved one or even just chance. Whatever turns out to be the case, if the patient was not fearful before telling us their story, they will be after they witness our response. 

What I am saying is – the doctor’s concern and the patient’s fear is the same thing. Singular. One. 

 There is a solution. To respond as a professional rather than as a social being. The neighbour, friend or chat room acquaintance will stay with the patient’s fear – “You need a CT Scan my friend”. As a doctor you can feel and acknowledge the concern, either internally or openly with the patient, and recognising that it is probable that the patient is afraid of whatever you have become concerned about. Now park that concern and go about your professional business.  You can continue gently with the history gathering information that might confirm or refute the possible calamity and examine the person carefully. I cannot stress enough the need to examine people carefully if you are going to refute their fear and explain the symptoms another way. The laying on of hands shows care and attention to detail and justifies our professional opinion.

There is still work to do but investigation is not usually helpful if you do not think it will change the management. Investigation may mean an easy life for you and the patient might attend less in the short term. But the patient has proven that they were right to be afraid and shown that the doctor needed to do a test in order to discover that the feared condition was not present. What is that patient to do when the symptom recurs? How long is a reasonable gap before the test is required again as the doctor is unable to allay the fear without the result? It is a bit like the acceptable period before a widow or widower takes a new partner: there is a wide variety of opinion and a lot of gossip.

 Once in a while, the fear may be so out of touch with reality that it is best to refute this in theory and avoid getting dragged into a clinical black hole. I met a patient who was repeatedly terrified that she had melanoma and would only trust a biopsy result; the doctors were concerned. When I refused to do this on the grounds that she had no added risk and normal skin, she became a very frequent attender for a skin check. It was only when we began to focus on the rest of her life that this fear resolved. 

So use your fear barometer, your concern dial, but be aware who is pushing it.

I want to see a general practitioner

Cheeky Docs

Cheeky Docs

I am a general practitioner, are you? When a patient says they need or want to see a general practitioner I put my hand up. But so do a lot of other people. Some of those people are better general practitioners than me and some are not so good, but what if the people who are putting their hand up are not general practitioners? Are PGPPP doctors general practitioners? I think not. Do patients know when they are seeing a PGPPP doctor? Almost always. Are GP registrars general practitioners? Not yet. Do patient’s know when they are seeing a GP registrar? Sometimes. What about the other doctors working in general practice?

The situation in general practice is now much like that in hospital. There are many types of doctors at varying levels of experience and qualifications working in general practice. The following types come to mind in order of qualification:

  • International medical graduates that have not passed the clinical AMC (Intern level exam) and working on the basis of exemption from Medicare restrictions
  • Australian graduates doing prevocational experience in general practice who are interns (PGPPP – will cease from Jan 2015)
  • International medical graduates who have the full AMC and working on the basis of exemption from Medicare restrictions
  • Australian graduates doing prevocational experience in general practice who have full registration (PGPPP – will cease from Jan 2015)
  • International medical graduates with full AHPRA registration working on the basis of exemption from Medicare restrictions
  • Doctors training to be a specialist general practitioner or a specialist rural generalist
  • Doctors who have VR based on experience in general practice including grandfathered Australian College of Rural and Remote Medicine Fellows (FACRRM)
  • Doctors who have completed their Fellowship assessment by the RACGP or their Fellowship assessment by ACRRM

The only clearly discernible group of doctors, from the public’s perspective, who have completed and passed an objective assessment by their peers (and so demonstrating that they meet a standard of care necessary to provide a quality general practice service) is doctors with the Fellowship of the Royal Australian College of General Practitioners (FRACGP). There is another small group who have completed formal assessment, the graduates of  ACRRM, but these are not distinguishable from those given the qualification based on experience.

I believe the public has the right to know if they are seeing a specialist general practitioner or rural generalist who has completed formal assessment. I understand that there are many reasons why this is not transparent to the general public, but this needs to change. I suggest that we reserve the name ‘general practitioner’ for those doctors working in primary care who have their FRACGP and ‘rural generalist’ for those who have an assessment based FACRRM (FARGPs could use rural general practitioner?). The reserved name may be “specialist general practitioner” and “specialist rural generalist” if that suits but it needs to be meaningful to the public. Other doctors need to be presented in a way that the public can discern the role and qualifications attained. We can set a deadline for this in 5 or 10 years to give people a chance to be formally assessed, but after that, doctors who have not been formally assessed should not use the reserved name. After all, you cannot call yourself a dermatologist because you work in a dermatology unit; in fact you might well be taken to court.

This may all appear to be in my own self interest; I have the FRACGP and I want to see change. But how on earth do we argue for the value of training in general practice and rural generalism unless the outcome and benefit is available and visible to the people of Australia. Statements like “I will never see a doctor from overseas ever again” or “I just saw a rubbish GP” are increasingly common where I work and unpleasant to respond to. To be fair to all doctors I need to explain to this patient that there is a huge variety of doctors working in general practice and that a blanket statement like this is not appropriate. When the patient asks me how to tell if the doctor is OK, I say, “The only doctor you can be sure of based on their qualification is one with the FRACGP”. Do you have a better idea?

 

Change Pace Change Price

liftum foot

Lift um foot to change direction?

The Australian health care environment suffers from change fatigue and we are about to see the most massive dose yet experienced in primary care in Australia. I love change, opportunity and innovation. But I have learned that change has to be at a pace that is manageable and where the motivation is understood and embraced. The real problem on the ground is that change occurs at lots of levels – within the organisation, locally and at State and Commonwealth level. If you want to sink, guarantee failure, it is best to ensure that change takes place at all levels at once – oh and add multiple dimensions to really twist the knife.

This is my situation – from where I read the Federal Budget. I work in a GP Super Clinic, a non-profit, that is owned jointly by two universities and supplies 24/7 services to a rapidly growing local community with huge industrial development 30 Kms south of Darwin.  The service is evolving into a training and primary centre provider throughout the Top End of the NT. We have a few specialist general practitioners, 5 registrars, 9 medical students coming and going, our PGPPP doctors are no more, and our solid group of IMGs are now under the pump. We have contracts with the somewhat fluid NT Department of Health, who after the Federal budget changes will no doubt be reviewing our arrangements. We now have a relationship with a Hospital Network faced with delivering on budget (never happened before) and our Medicare Local. Both are just finding their feet, the NT Medicare Local recently emerging like a phoenix from a merge of Divisions which itself only lasted a couple of years. NT Medicare local is already a formidable alliance of interests that is aiming to support general practice better and working hard on closing the gap. They are working closely with NTGPE – our soon to be dissolved local training provider which has been a pillar of stability lasting over 10 years! NT Medicare Local is now being dissolved to form a new PHN whatever that means. OMG – does anyone in Canberra know what it is like out here?

I cannot imagine the cost in capital, social and human terms of this change. Add to that a $7 copayment which will cause problems with our local community, many of whom will not pay – no way. Is anybody happy? What is this for?

I know that this sort of upheaval is happening around the country in one form or another.  WentWest Medicare Local in Western Sydney has been a trail blazer in provision of integrated Medical Local services and GP Training – the result of considerable planning and negotiation. But when there is only political impulse and convulsion, how can we plan? Should we say enough is enough? Should we plea to the tax payers of Australia that these changes amount to massive waste?

The price of change at this pace is staggering. What should we do?

Copayment Shmopayment

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I must confess that I cannot see any benefit from the proposed Medicare copayment either as a price signal or a revenue saver. And I stress that I am loath to write off any approach to improving health care in Australia. It is difficult to think of a blunter, more chaos inducing instrument to apply to Medicare. How will it save money? Largely from committed general practices located in deprived areas – the more committed the higher the saving.

The most lucrative savings will arise from pressure on practices to accept the lower bulk billing rebate – this will save $7 per visit. Let’s face facts, GPs already do this for the majority of patients; in poorer areas GPs will have to continue to do so at a very high rate because many people will be unable to or will refuse to pay. What will we do for a 29 year old who has no income and new onset diabetes? How will we manage an infection in someone who drinks their weekly income on pay day, or a refugee who has no income. In many Aboriginal Health Clinics it will be devastating. Please imaging living in poor over crowed housing on the edge of a town or in a remote area without public transport or any other facilities, with high prices for all consumables and getting the same income as a person living in a well resourced urban area. In the NT discretionary spending may be little more than a single visit to the clinic. The $7 (plus test on costs) will be a care killer. The primary care ‘Closing the Gap’ initiative has provide free health care and has had a big impact where I work. The copayment will reverse these gains immediately. Government Ck-Ching, primary care Ck-Chang.

The safety net is a massive administrative issue – $70 a year limit for an individual ($490 for a family of 7). How on earth will this be managed? Such approaches may have worked while the money was reimbursed but this is a payment at the time of service, prior to service for many I suspect. Who will keep tabs on who has reached $70? What a nightmare. We have had Medicare fraud with sharing of Medicare cards for some time. This will certainly add to incentives to share cards, only presenting with cards that have reached the limit.

The Corporate Practices who are profit focused will be working on ways to generate the same income without adding disincentives to patients. Such practices appear to be the primary target of this copayment but I am equally sure they will be best placed to minimise the loss of income. We are likely to see a major escalation of SIP payments and payments for non-attendance items in response to this. Government will get their dollars back, but new leakage is likely to occur. Successful approaches will put pressure on surrounding practices to match them.

I am the first to admit that there is wastage in primary care and that we do more harm that we intend. I am very interested in spending Medicare dollars where it is likely to return greater benefit. I have already raised one such approach in a previous blog Saving Medicare. But I do not think that the proposed copayment will do anything but harm in many areas of this country. I would like to work with Government to come up with focused responses to the use of Medicare funds that are wasteful. Our College is the vehicle to do this and has developed the slogan #CoPayNoWay  using social media – the top tweets can be found here.

Watch out – Medicare Shmedicare.

Engaging with Australia

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Grand Beauty

One challenge we have as specialist general practitioners is that our work is never done. There are thousands of special interest groups who vie for the attention of both general practitioners and our patients. Often the agendas are not transparent: a favourite concern of mine is the push for PSA testing by the Urological Society of Australia despite the lack of evidence of benefit. Faced with patients that seek an intervention they have seen or read about, we are overcome with the need to help and do good. Our education on topics is largely sourced and funded by those with financial interest in our behaviour. We often do not have the tools and information to unravel the evidence and be in a position to provide sound advice to our patients. Very few of our colleagues are equipped or brave enough to challenge these sources: a notable exception has been Prof. Chris del Mar getting the evidence together and going public on PSA testing. Do urologists get lead time bias?

I would like the RACGP to engage in a direct dialogue with the Australian community and investigate the needs felt in primary care and seek innovative and practical solutions that are commercially sustainable. It will be important to include peak bodies in this discourse, while seeking to understand their funding models and motivations. We need to learn how to deal with issues with more trust in our clinical know-how, less medications and fewer tests. Patients prefer such approaches when accompanied with understanding.

Enduring issues that arise in such discussion are the expressed need to have timely access to care when a person is sick and to maximise continuity. These pose difficulties for all of us; hence their appearance in surveys around the world. Meeting these needs can bring more satisfaction than many might think. I work in the large Palmerston GP Super Clinic providing 24/7 general practice and urgent care, covering a population out of hours of 25,000 or so. It amazes me that patients understand the pressures we are under and genuinely value the fact that we deal with emergencies – although it is only 30 minutes to the hospital. Working some shifts is necessary to provide comprehensive primary care just as it is in retail. Continuity means that we need to stay engaged, not referring at the drop of a hat. Generalists need to take responsibility for a broad range of presenting problems and work with patients to come up with solutions. Patient satisfaction is not the sole aim – it does not lead to better health. Getting these things right is a real challenge and requires resources and genuine investigation.

At the heart of our work is care; primary care, health care – what ever you call it. It works better if we care and we can only care together. That’s what our College is for.

Wherefore Good Fellows

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I am pleased with the attention our President of the RACGP is giving to the issue of prescribing Roaccutane.(isotretinoin). It is a serious drug that is used to treat a common condition. Liz Marles is advocating that the prescription should be made in general practice.

There are good reasons for this. First, at least in my experience, if I refer for this purpose to a dermatologist they invariably prescribe. Second, contraception and adherence is something we know about and is the main argument for specialist review. Third, NZ GPs have been doing well since being able to prescribe the drug in 2009.

I would argue that, where such regulator concerns exist, at least in the first instance, Fellows of the RACGP should be able to prescribe the medication as specialist general practitioners. This provides evidence to regulators and patients that the GP has reached a suitable standard to take such action and monitor progress. I understand there are good doctors working in general practice without Fellowship, some no doubt far better than I. However, when actions demand high standards of care it seems reasonable to initially back doctors who have put themselves through assessment by their peers to ensure they are suitable for independent practice.

I would go further and promote those specialist general practitioners, their training and commitment to standards. Does the general public understand what Fellowship means? Do politicians? Do they understand that no one has been grandfathered by the RACGP?

Does your practice draw attention to Fellowship and what this means to your patients? Do they have a right to know?

Saving Medicare

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Consider carefully

I personally worry at the waste in healthcare and how we can save on Medicare. Unless we do something we will have to start thinking about how to save Medicare itself. To give an example: prior to the arrival of bulk billing practices in Darwin a few years ago we had one radiology provider and a couple of pathology companies. We now have 4 radiology providers and a few extra pathology providers. These also bulk bill. So I can now order unlimited blood tests and radiology without cost to myself, the practice or the consumer (a more appropriate name in this setting). I can get an MRI in 15 minutes and almost any test apart from an ultrasound within the hour.

I can’t imagine the actual increase in costs – is anyone imagining? I do see the result of confused patients with multiple positive obscure serological tests and a cascade of radiology – each new test suggested by the radiologist to rule out the sinister nature of some incidental finding on the previous view. Further tests require further brief visits while time heals almost all things. Dollars all round – nobody’s money.

This is not ideal and the opportunity cost of unnecessary attendances, laboratory tests and radiology investigations is probably massive in terms of non-health fields such as housing and other basic services. So why don’t we come up with some alternatives for consideration. A $7 co-payment  doesn’t seem to do the job at all and seems to have few advocates. Here is an idea of my own which has had as little thought as the co-payment but might help funds go where they do more good.

Any attendance resulting in issuing of a private medical certificate for a period off work of less than 7 days will not be billable to Medicare. This would apply at the time of the visit or at any point in the future (to avoid being able to issue the medical certificate at a later date in order to claim the fee) but would not apply to parent or carer certificates for children.

Would this reduce medicare claims? Would it reduce the time off work for minor illness? Could it work? Would it be open to gaming? Let me know what you think.