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THE recent death by suicide of one of our GP colleagues, Dr Ezha Lau, in Sydney felt like a tragedy for her community but hit another level for me as a fellow female GP with a young family. It felt eerie.
Dr Lau was one of us in a system that has seen reductions in funding, resources and workforce, each contributing to increasing workplace stress and definitely one that does not value the type of medicine most female GPs practise.
Reflecting on my own practice as a female GP, I was recently pregnant and gave birth during the COVID-19 pandemic. Like most female GPs, I am a contractor and do not get maternity leave. Along with the joy of being pregnant, I found myself trying to balance that with the stress and unknowns of being pregnant during the COVID-19 pandemic while still trying to maintain clinical work for as long as possible. To address the changing requirements for COVID-safe practice and my own concerns, I found myself moving to telehealth consults only. Inevitably, my earnings decreased as I offered fewer care plans and health assessments, which remunerate higher than standard consults. My bookings dipped as some patients needed face-to-face consults and I was unable to provide these.
My challenges were specific to being female and pregnant at the time, but even without the pandemic, female GPs bear an additional burden in the workforce simply because of the nature and scope of our practice. We see more complex patients, see them for longer, and do more non-billable administrative work. Anecdotally, most of us find it harder to privately bill our patients compared with our male counterparts.
A joint report by the World Health Organization and the International Labour Organisation shows that women working in health care earn, on average, 24% less than men. Previously in Australia, this has been estimated to be between 22% and 25% less for female GPs (here and here).
One may argue that female GPs are doing the same amount of work for less compared with male GPs, but the answer often lies within our scope of practice. Female GPs are much more likely to see patient presentations for psychological symptoms and women’s health than their male counterparts, who are more likely to see presentations of the musculoskeletal system, respiratory system, and skin.
There is an incredible amount of complexity that goes into managing mental health as any GP will tell you, and often female GPs are more likely to address social issues such as housing or domestic violence as well, which adds to the complexity of a consult. Most female GPs anecdotally, and as reported in the media, struggle to privately bill consults for these reasons. Formal statistics on this are lacking but, in my experience, women are expected to be empathetic and altruistic. Combined with the complexity of our patients with regards to their socio-economic situation, my colleagues and I have often found it difficult to privately bill our patients.
On the day I started charging a private fee rather than bulk-billing, half of my patients asked to be bulk billed. In my opinion, this is not an experience some of my male colleagues have had in practice when shifting to private billing.
Female GPs also tend to see patients for longer, possibly due to the complexity of the consult but also to manage more issues per consult. In the long term, this appears to lead to better health outcomes in terms of needing to see their patients less often, prescribing less, and our patients being admitted to hospital less.
For those who offer bulk-billing, performing longer consults does not translate into a higher income, as the Medicare rebate per unit of time is less for a longer consult than for a standard consult. We also tend to perform a higher proportion of non-billable administrative work, again likely linked to the complexity of our consults. I can remember working late for several evenings filling out paperwork for community housing, the National Disability Insurance Scheme (NDIS), and psychological therapy referrals as well as on the phone trying to get my patient seen by the community mental health outreach team.
Having children seems to also explain some of the pay gap, as female GPs with children earn $30 000 per year less than comparable female GPs without children. But male GPs with children were found to earn $45 000 more than comparable male GPs without children in a 2016 report. Females often tend to take on the unpaid task of domestic labour and raising children and this is likely the case in general practice as well.
The recent announcement of the changes in continuing professional development (CPD) measurement will likely impact female GPs with young children more as it reduces the flexibility of options for completing the educational requirements. As proposed, GPs will be required to perform 50 hours of CPD each year and there is no reduction in the annual total hours if the GP works part-time. I’ve already had to cut my hours down in my clinical work while raising our baby. I struggle to think about how I can fit the unpaid task of new CPD requirements into my schedule.
GPs all over Australia are struggling with burnout and, anecdotally, quite a few are looking to retire early, cut down their hours or find other sources of income. This has never been more pronounced in my group of female GP colleagues.
Our patients seem more complex, and our work and hours are renumerated less, and we often must balance this with the demands motherhood and family place upon us. There does not appear to be any financial reward in managing complex conditions, beyond the altruistic.
We have been doing this for years, but there has been no tangible change to make general practice funding more equitable for females, despite there being several years of evidence pointing the problem out.
This is not a conversation about male versus female GPs, but this is a case for a more nuanced look at the way primary care is funded. GPs in general seem to be struggling to get more crumbs added to our already woeful level of funding, but female GPs especially seem to get an even lower portion of the slice.
It affects the care we can provide, but more importantly, impacts our own mental health.
Dr Aajuli Shukla is a Sydney-based GP, and a Deputy Medical Editor with the Medical Journal of Australia.
If this article has raised issues for you please reach out to any of the following resources:
DRS4DRS: 1300 374 377
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- Victoria … 03 9280 8712
- Tasmania … 1800 991 997
- Queensland … 07 3833 4352
- WA … 08 9321 3098
- SA and NT … 08 8366 0250
Medical benevolence funds
- NSW … https://www.mbansw.org.au/
- Queensland … https://mbaq.org.au/
- Victoria … https://www.vmba.org.au/
- South Australia … http://doctorshealthsa.com.au/resources/medical-benevolent-association-of-sa
AMA Peer Support Line … 1300 853 338 or 1800 991 997
Hand-n-Hand Peer Support … www.handnhand.org.au
If you or someone you know is having suicidal thoughts, there are people here to help. Please seek out help from one of the below contacts:
- Lifeline| 13 11 14 | 24-hour Australian crisis counselling service
- Suicide Call Back Service| 1300 659 467 | 24-hour Australian counselling service
- beyondblue| 1300 22 4636 | 24-hour phone support and online chat service and links to resources and apps
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I’m surprised by the venom in some of these comments. I don’t think the divide is necessarily gender-based (myself and my husband flip the stereotype on its head in our practice), but slow vs fast description is very apt, with the latter being perversely rewarded to patients’ detriment. The person who wrote about MBS rebates for initial psychiatric consult is wrong, the rebate is around $230 for 45 min plus ( but some spend 90 min or more). The suggestion that doctors should pick and choose their patients runs counter to the ethical principles which we should practice by, I would think. Overall, my impression is that doctors increasingly are in it for themselves, not the greater good, which is a shame.
Wonderful article. But there is more than F vs M GPs. As a transgender GP I had 3 wonderful kids in my lady phase and a solid salary in my gentleman phase. Couldn’t be happier. There are always options. Best wishes to all.
I suggest that it is not productive to make this a gender issue.
The main issue here is the ridiculously low GP rebates for complex consultations. It’s about time the AMA started seriously putting a business case forward for increasing GP rebates.
The only other option is for salaried general practice, but hearing the stories from relatives about waiting 3 months for an MRI scan or 2 weeks for an urgent doctor appointment, not to mention the horror stories from young GPs in the UK who have an even worse time than Australian GPs, I really don’t think that is a great idea.
Australia once had a world class primary care system that was allowed to run down for short term budgetary reasons and now needs adequate funding to bring it up to speed again. What is not needed is lobby groups and government bureaucrats trying to empire build and reinvent the wheel.
I sympathise with the author of this article but don’t accept some of the arguments. As a GP , or in any specialty you should be in control of your own case mix and workload. You can assess, triage and ( unless you are in a solo practice) influence the types of cases you want to see. Many female GPs work part time, and there is consequently immense pressure on appointments, but that is their choice. I recently recommended a young female GP to a friend, who was then told the GP was working only 2 days a week and no longer taking new patients ( she had only been in practice for 2 years ! ) Bringing GP suicides into this is unhelpful in my view. In any suicide there are complex factors at play, often clinical depression, other mental illnesses or drug / alcohol problems.
I still do not understand why doctors complain about the issues in their speciality of choice.
I worked in GP land for several years in the 1990s and for the effort I put in the rewards, both financial and non financial were not to my liking.
So I moved on….
I put my life on hold for several years to get into and complete a very competitive speciality training program. The work enjoyment and financial rewards were much more to my liking. I work in a female dominated speciality and they are a very happy bunch.
If you don’t like what is going on in your workplace then change it.
Whining without action is a waste of your time.
The cognitive load of caring weighs heavily on women and it is the invisible and intangible work that is hard to measure.
As a female GP, parent and practice owner, my brain is constantly juggling multiple tasks of work and home.
No wonder our brains are tired!
Until we have parity in roles, remuneration and expectations at home and work then women will continue to be overloaded and burnout.
On top of the inequity in our workplaces my challenge to my male colleagues is to do an audit of who does these roles in your household? How much time does your partner spend each day thinking/doing or reminding about these tasks.
– answers the phone calls from daycare/school
– meal planning
– school notes
– time management of drop offs and pick ups
– after school activities
– money for tuck shop
– makes sure there is milk fridge
– who gets up at night to baby/child
– folds the washing/changes the sheets etc etc
Just like good general practice – what we do isn’t noticed or appreciated until it breaks down.
I think its interesting the gender split here. Truth is it’s not about gender its about fast and slow medicine. For the patients the difference can be deadly.
For example a patient comes into see me, he’s seen 3 other GPs in the past 2 years, has talked about PR bleeding which was written off as haemorrhoids. He comes to see me with low iron and mildly deranged liver functions, which his previous GP had seen on the last day at the practice and hadn’t arranged for followed up. I arrange for an ultrasound which shows metastatic liver deposits. 2 years ago when the patient complained about PR bleeding and constipation he might have survived. If he had seen me two years earlier he would have had a colonoscopy and a fighting chance.
Lady comes in with PV bleeding, on HRT for 5 years. Bleeding has reached the point of being constant and she wants to try a different product with a different estrogen content. She had been bleeding constantly for 12 months and seen by a college 6 months ago who had upped the HRT dose in response to the bleeding. Cerviacle cytology shows uterine adenocarcinoma. I wouldn’t have continued the HRT 12 months ago, I would have investigated when the bleeding started back then.
For these patients a slow GP 12-24 months earlier would have been lifesaving, but medicare encourages fast medicine and they both had GPs doing just that.
People talk about female GPs not having good boundaries. Good boundaries in this setting means missing that bowel cancer or that uterine cancer, good boundaries means just prescribing the antibiotics because its easier to write the script that spend 1/4 of an hour arguing why antibiotics aren’t necessary.
There are a lot more fast male GPs out there than female GPs, they make more money but ultimately cost the health care system and their patients so much more. So no its not actually an article about male verses female GPs its an article about fast vs slow GPs.
The range of comments here would be wonderful in a seminar for undergraduate medical students, and go a long way to dissolve the many myths young women are subjected to, and sadly deeply held by many. (E.g. all striving strong ambition in men is ‘toxic’, the hierarchical structure of medicine is a patriarchal power play, tough questioning in tutorials that makes you ‘uncomfortable’ is teaching by humiliation, and stern demands by busy consultants simply telling you to do your job plus rearrange your priorities is ‘bullying’). All this tends to fall away as reality hits in their twenties, as they realise it is just damned hard work, and they are surrounded by colleagues also under stress. It is pleasing to note how hard Aajuli tries to avoid victim positioning – that at least represents progress in this debate. I made myself read “The Wife Drought” – all it meant to me was her unsuccessful attempt to superimpose some ‘us’ versus ‘them’ irrational sexist lens to what clearly is a couple-based enterprise. If a couple plans to have children in a way that one partner does most of the work of raising, that’s their business, and if one’s a hard working male doctor that’s surely ok if it’s a mutual decision. Aajuli I bet you’re a really good empathetic GP, and a great mother! I hope you and their father reached agreement on the details, and those kids are straight and true.
Spoken as a retired rural paediatrician with memories of studying for the Membership between the 10pm and 2am breast feeds of twins, with the screamer in a baby sling between me and the books. Well done! But maybe charge more, split your consults, have one day off a fortnight, slot one day as fortnight for extra complex cases, and check out someone like the psyche trained guy above – you might need better ‘closing off’ skills!!
Thank you to all the hard working specialist GPs out there, (female and male) from a grateful hospital specialist. You are the backbone of our medical system and deserve much better. You are very much appreciated and valued by your colleagues.
I am proud to say that RACGP has been actively advocating against the changes to CPD for at least the 3 years when it was first suggested.
Our program was well researched & the better than any of the non GP specialists
However “for the sake of uniformity “ I suppose we were railroaded.
Yes this is in the college publications
Thank you for you article and your thoughtful conclusion, which is not reflected by this ironic comment.
“My experience is that female colleagues are more prone to poor time management and boundary setting. This affects income. We do not focus enough on this in training.”
I’ve felt compelled to post as I’ve recently seen a flurry of these types of posts on social media and other forums.
If you are ‘stuck’ with prolonged consults that remunerate poorly by Medicare, then you charge for your time instead of crying about it online.
There is a huge need in the market for a GPwSI in mental health. The wait lists for psychiatrists are insane, many have closed their books. If that is your forte as a female GP, then use it. Last I checked, my local psychiatrist initial consult is about $450 out of pocket (Medicare rebate is only $75) and a psychologist is $75out of pocket (Medicare $75). So then why do you bulk bill? The fault lies not with the patient, not your male colleagues, not the government. If you are competent, if you are skilled, then you should be confident in your abilities and you charge what you’re worth. It’s that simple.
I understand the concerns and respect the opinion of the author, but I really don’t think this should be made a male versus female issue. Many male GP’s myself included see plenty of complex patients.
The best advice as others have pointed out is to talk to your practice owner and express your concerns and stress factors. If they cannot address these, there are a plethora of good practices out there you can choose from who will move heaven and earth to make the work of their contractor GP’s sustainable.
I completely agree BB must be restricted to a very limited number of patients, perhaps those with severe disabilities, palliative care, and 90% of patients need to start paying. That will be literally the only thing that drives change at government level. Let’s all just get out of our own way on that. The very last thing we would want is an NHS model. Primary care in the UK has fallen apart. I know that from my families recent experiences there.
GP funding in Australia is not fit for purpose. It discriminates against female GPs which is unconscionable in these enlightened times. Complex patient management is not considered in the Australian context. A better model is the British model of general practice (the best thing about the NHS).
The male GPs who claimed sexism- You have no idea. Walk a day in your female colleagues’ shoes and you might begin to understand what they are complaining about.
I’d like to ask a few gentle questions of the male GP’s ( especially those with kids) who have taken offence here:
Who remembers birthdays and buys presents in your home?
If the kids require a costume or a cake for school, who does that?
If one of the children is sick, is it a 50/50
split between who stays home with them?
Who organises bed linen changes in your home?
Who does the clothes washing?
Who does vomit, blood, pee and urine clean ups?
When the kids need clothes, who do they ask and who takes them shopping?
Who attends parent/teacher interviews?
Who does the pet care ( regular exercise, vaccinations, food and vet visits)
Who runs the family menu?
Who does the grocery shopping?
Who keeps a tally on how much milk is left in the fridge?
Who initiates and organises children’s parties, friends visiting and family get togethers?
And just finally: who was pregnant and who breast fed the babies- and were your earnings affected? Were hers?
Now – for most apart from the last 2 questions- the answer may be a 50/50 in your house. And if it is : well done!
But if it’s not, just think on this for a while.
The MBS is the same for male and female practitioners. Those who do less billable work will get paid less. The highest earning medics are those who run understand the economics and maximise their time spent doing high income generating work. No one ever got rich from being a bulk billed shoulder to cry on. Like it or not, having children is a choice which will have financial ramifications. It is not the tax payer’s responsibility to subsidise our middle class lifestyle choices. The division of caring and bread winning responsibilities between partners or spouses is a decision for each household. I work 70+ hours a week by choice as a specialist in training, and thus will earn more and acquire skills and experience faster than someone working 40 hours a week, let alone someone in the same role who takes 12 months of leave. Likewise, a clinician operating a business continuously will likely develop a larger patient and referral base than one who takes multiple periods of prolonged leave, all else equal. These are some of the often ignored factors that contribute to the gender pay gap. To portray it as endemic sexism is over simplification of a far more complex issue.
This is a specific example of a broader issue – general practice (outside of high SES areas) is in a death spiral. As a specialist working across a number of metro and regional areas I’m an interested external observer.
Once the principals of the practice retire, they are virtually never replaced by someone with the same time commitment. Bulk billing is entrenched and has seen a gradual erosion of income. Bulk billed GP practice is now financially unviable unless you offer 5 minute consults. GPs have tried to push on for 10+ years despite the above, largely because of their own goodwill to patients, as well as the “squeamishness” doctors feel when talking business. The government has capitalised on this via the Medicare freeze and used GP’s good nature against them. Patients expect to be bulk billed and request that despite not expecting no out of pockets at the hairdresser. Reluctance to appear mercenary means doctors acquiesce to the request and the cycle continues.
Ultimately, the economists will tell you the market always wins, and that’s what we are now seeing. As a young GP looking for practices, you are in demand, would you choose the private billing practice in a high SES area, the corporate “McMedicine” one in a poorer or regional area, or the struggling and overworked GP owned one where you know you’ll get hammered with work for lower remuneration? Hence the latter can’t get doctors and the whole thing is falling apart.
Thank you, Dr Aajuli for pulling together this information. It helps us articulate what’s going on so that we can begin to address it.
I agree with Dr Aajuli Shukla. “Female GPs also tend to see patients for longer, possibly due to the complexity of the consult but also to manage more issues per consult. In the long term, this appears to lead to better health outcomes in terms of needing to see their patients less often, prescribing less, and our patients being admitted to hospital less.”
I worked approximately half time in General Practice from 1967 to 2016, and did some full – time country locums during 2011-2018. I supplemented my income from General practice with working in Family Planning Clinics for a number of years, once my children did not need constant care.
Generally I think that women are better at allowing time for patients to talk about what is really worrying them – not always a medical problem – but a cause of some distress. Sharing the problems can provide some relief.
Completing CPD requirements often seemed a waste of time, and not relevant for much of the work I was doing.
Of course, you are all woefully remunerated for your time, training, efforts on behalf of your patients, and your dedication. The only thing that will correct this is to get yourselves onto a decent, properly negotiated salary – whatever that takes. It is going to become a necessity soon anyway, if the future funding trends favoured by the powers that be have their way.
Some of the comments from the male GPs on here are amusing. No one is suggesting that male GPs don’t work hard for their remuneration. The fact is that they are ABLE to do so due to societal structures (e.g. wife at home looking after their kids) – take a look at Annabel Crabb’s book – “The Wife Drought”. If only we all had wifes to do that for us! Unfortunately many of the population have husbands who are usually caught up in their own careers and seem unable, or more to the point unwilling, to take time off to contribute to the mental and physical load of running the household. I also love the comment about women having substandard time management skills. ? As the author here has clearly outlined, the societal expectation that women will give everything of themselves for little or no remuneration is the barrier here – not that women seem to be lacking in their training or personal skills.
The suggestion that female GPs see more complex patients than male GPs is an offensive sexist generalisation
I am a female GP who decided I needed a break during my 3 children’s teenage years. Initially planning to take 6-12/12 off, I was offered some surgical assisting work and have not returned working as a GP.
The psychological relief was great.
The new CPD requirements particularly irk me. “Reviewing performance” and “measuring outcomes”….not a good use of a dedicated, conscientious GP’s time (I believe the vast majority of GPs are in this category).
Aimed to flush out substandard practice (the minority) whilst we all have to waste 25 hours to this charade each year. Disappointed the RACGP has not lobbied against this onerous obligation GPs now have to fit into their busy professional lives….other forms of education much more useful to us given we have such a broad scope of practice.
I do more mental health than my colleagues in our practice. I did a couple of years on the psychiatry training program so my colleagues tend to offload patients on me. I am male. I run on time, rarely late. I time manage well and set boundaries, and yes I private bill. I also train registrars. My experience is that female colleagues are more prone to poor time management and boundary setting. This affects income. We do not focus enough on this in training.
The greater complexity is another reason I earn less, as I can’t sustain that level of personal involvement needed and work full-time hours.
As a female GP, who was a practice owner for 30 years, worked very long hours, had 3 children, a husband often away, and who was on call after hours until recently, I know how hard it can all be. However, the bigger issue is the disgraceful funding of general practice as a whole. Why does the NDIS, or My Aged Care pay those with many less years of training than a GP, many times the pay? Compare an OT doing a home visit, and a GP doing a home visit. The therapist fee starts at $200, and often more, and the government happily pays these amounts. Compare the hourly fee of a psychologist. GPs, male or female, who do a good job, managing complex patients, are punished.
I completely agree that women take more time over consultations, charge less out of sympathy for the patient and therefore earn less than their male counterparts despite working harder.
I retired early after working as partner in provincial GP. I was married with no children but despite working longer hours earned less than my male partners as I saw all the “D and Ms” ( deep and meaningfuls). I was booked out 2 weeks ahead and kept 6 appointments each day for acute cases and they were the first 6 calls on the phone each day. Rarely did I see sick kids or coughs and colds despite 9 months training as a paediatric registrar ( and diagnosing a child with prada willi syndrome that the specialist had missed!). I feel very sorry for GPS in general and female GPS in particular. Time based consultation has to go.
When I was a young male GP with young children. I worked very hard with long hours and after hours work included. My time with family certainly did suffer and yes having children impacted my personal, business and family life but that is what happens when you choose to have children. My wife cared for our children and also worked from home often after the children went to bed. It was very much a team effort which continues today. The idea that male GP’s some how are given lots of money because they are male is offensive and sexist. I worked long hard hours that most people were not prepared to do and hence earned a higher income.