Young GPs overlook family practices

Retiring family doctors are not being replaced and few medical students are interested in general practice. CATHRIN SCHAER reports on the changing face of your most regular encounters with medicine.


Conjure up your stereotype of the family doctor. Male, middle-aged, trustworthy, perhaps wearing a cardigan and glasses and carrying a battered leather bag. Most likely he is ministering to the needs of sick old ladies and adorable, red-cheeked children with runny noses.

Now imagine a meeting room full of these worthies, and their equally worthy female counterparts. The question is asked: "How many of you would leave your jobs tomorrow if you could?" Rather shockingly for us, more than half of those pillars of the medical community raise their hands.

Almost exactly that scenario took place a couple of weeks ago in central Auckland at a meeting of GPs to discuss the new PHO (Primary Health Organisations) system. About 58 people attended and when the question of getting out of general practice was asked, roughly two-thirds of the doctors signalled that they were.

At another larger meeting held about the same time on the North Shore to discuss similar issues, about a third of the GPs signalled they were looking at getting out.

"Frankly, I was surprised," says Peter Foley, chairman of the General Practitioners' Council of the New Zealand Medical Association (NZMA), who was at both meetings. "It was a fairly representative group and I would have expected maybe three or four hands to go up. But not that many."

He confesses that one of those hands was his. "I love my job and I love my patients, but if I could find something else, I would leave, if not tomorrow, then within a year."

Foley has been a GP for 20 years and runs a practice in Hawkes Bay. He is one of New Zealand's experienced GPs, but is dissatisfied.

"I come from a family of doctors - my grandfather, my father, my uncle, my brother and sister were all GPs. I have four kids now and if one of them asked whether they should be a GP, I wouldn't discourage them, but I would definitely be telling them to approach the idea with caution."

IN NELSON, a young doctor is contemplating his future. As a medical student, Richard Pole worked for a service hired to drive doctors around Christchurch. He wrote about this experience in a weekly medical newsletter.

"About 50 per cent of the countless GPs I met during my training seemed to think it was their duty to convince me not to do general practice," Pole writes. "For most, the frustration was written all over their faces. Even the positive ones were realistic about the problems in general practice.

"Here at the beginning of my career, instead of being full of positivity and courage, I feel at best confused and slightly suspicious about what exactly it is that the bureaucracy has in store for me."

Pole is chairperson of the Doctors-In-Training council of the NZMA. During a break from his work as a house surgeon at Nelson Hospital, he says: "As a young person, it just seemed to me that being a GP wasn't the best of roles to aspire to for a number of reasons. It's still a great job - there are just other things that get in the way."

As a final disincentive, his brother-in-law, Keith Brockway, sold his general practice in Christchurch and left to work in the Middle East. In an email from Saudi Arabia, where he works in what he feels is a better environment, Brockway says he left because it was a job with "no sense of career structure, recognition, thanks or rewards.

"It's always denied by political spin but I had the perception that GPs were neither wanted nor valued [in New Zealand]. That was despite being a GP with a good practice and being respected by colleagues in the university department of general practice, where I used to teach.

"We were struggling financially, with no prospect of seeing our way clear to retirement. Our income after practice expenses and tax had dropped by 5 per cent a year over the past three years."

Brockway couldn't find a younger GP, someone like his younger brother-in-law, for instance, to buy into his practice. He was lucky to be able to sell to a nearby solo practitioner who wanted the advantages of working in a group practice.

He has been joined in Saudi by a New Zealand GP who was working in Tauranga, considered one of the best places in the country for doctors to live and work. "Out of 70 GPs practising there," Brockway writes, "he tells me there are only two or three under 40."

As a final salvo, Brockway says: "There is nothing that would have made me stay in New Zealand. In fact, I have vowed never to practise there again."

For those who rely on a generally happy, long-term relationship with family doctors, it raises the question whether the good, old-fashioned family doctor is an endangered species.

Jim Vause, president of the Royal New Zealand College of General Practitioners, says it is "not quite as bad as an endangered species but there are certainly some significant workforce problems coming up for a lot of reasons. Probably the biggest ones are to do with business and with graduates."

"Since I went into general practice 21 years ago, there have been huge increases in workload, with bureaucracy, information technology and changes in government philosophy," Vause says.

No more is your local doctor the admired, trusted member of a tight-knit community he or she once was. Add to that other financial pressures and continuing instability in the health system and the result is that at one end of the workforce, many long-time GPs are feeling unappreciated, overworked and potentially underpaid."

In the not-so-distant past, at the end of a doctor's career they could reasonably expect to sell the practice they had spent years building up to generate enough capital to retire on. Now, those investments are being sold for the price of their buildings and chattels.

As early as 2001, the then-president of the Royal College of GPs commented that for the first time GPs in Wellington were finding it hard to sell their practices. The situation does not appear to have improved.

In August last year it was reported that Panmure GP Eileen Brosnan had "virtually walked away" from a practice catering to 1700 patients that she had built up over 18 years.

The former Auckland Medical School teacher says she had to accept $20,000 for a business she would have sold for around $100,000 five years earlier and in which she had invested much more. In her early-50s at the time, she could not retire on this amount.

A few months later a local newspaper reported on the plight of a doctor in Herne Bay, who had repeatedly tried to sell his practice but was not able to. That doctor has only recently found a buyer.

In June, it was reported that a Wairoa GP was quitting his practice after failing to find a buyer, a move that could leave more than 3000 patients without a doctor. And last month, it was reported that Kaikohe could end up with two GPs serving as many as 9000 patients because out of the four doctors working in the area, one had resigned and another was "considering his future".

Doctors will tell you anecdotes about the GP in Rotorua who sold his practice and bought a supermarket, or about the GP from Wairarapa who went to Australia to drive trucks.

So as doctors try to quit at the end of their careers, medical students are seeing general practice as not a viable option.

The average age of GPs is now 44 and rising. As one disillusioned trainee put it: "Servicing major student debt while working like a dog with none of the guarantees of job security my medical forebears had doesn't seem like a very good prospect to me."

Foley believes there is another difference between his generation and the younger workforce. "They are more interested in quality of life and in family life. These days, people are encouraged to plan for leisure and to consider the balance between work and lifestyle. They're not really prepared to put up with what we did.

"As a child, I saw my father on Friday night for fish and chips and on Sunday at church. My kids have seen slightly more of me, but I don't think younger doctors would put up with any of that."

Pole agrees. "Running your own business is not really something that appeals to me. Here [at Nelson Hospital] I have an employer, I get holiday pay and various benefits.

"As a recent student you also need to worry about paying back your student debt - which is obviously going to be more difficult if you're running your own business at the same time. Actually, I think a lot of doctors in my generation are probably more interested in working on a contract basis, so maybe we'll see more of that in the future."

You have to wonder if everybody is just complaining a little too much. Doctors earn good money, don't they? Maybe this is just a natural progression and they should all just learn to deal with it?

That ancient model of the old fellow with the cardie and the battered case has, in fact, long gone and most family doctors happily acknowledge that.

"Life as a solo GP is almost impossible now," says Foley. "The demands on a GP are so broad. You simply cannot work in isolation." Many doctors now work together, sharing a practice manager and the demands of being on call.

In future, it seems if the family doctor hasn't moved into a more lucrative specialty, they are most likely to be female (more than half of all medical graduates are women), to have been trained overseas and to be working inside a modern medical team. While the doctor performs the diagnosis and makes out the prescription, the clinic's nurses are expected to take over more practical duties.

"There has been some natural evolution," Foley agrees. "Involving nurses and other health professionals in primary care has been a good thing. But to evolve to the point where the GP workforce has extremely low morale and feels undervalued, that's obviously not so good.

"I don't think GPs should become a distant memory, a sort of medical dinosaur. It's important to have continuity in primary healthcare.

"The patient may go to the emergency clinic for some things but they come to us when they have a real problem - a family crisis, a mental problem or life-threatening illness. That's when they want to go back to that point of confidence, which is the doctor their family has always gone to."