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Professional courtesy (providing free or discounted health care to doctor-patients and their families) is a long-held medical tradition. While it may lower barriers to health care, there can also be drawbacks. Open discussion about professional courtesy between the treating doctor and their doctor-patient is important.
The term “professional courtesy” has been used to describe a range of behaviours between colleagues, but most commonly refers to the provision of free or discounted health care services to a doctor and their immediate family members.
Tradition is a powerful driver in medical culture. While the Hippocratic Oath does not directly mention professional courtesy, Percival’s Code (1803), often considered the first code to define medical ethics, stated that physicians should provide care to other physicians and their families “gratuitously”. The American Medical Association’s code (1947) supported this stance. This approach was seen as an opportunity to encourage the seeking of independent care noting that a physician might have difficulty providing objective care to themselves or to their family. More recently, American and British codes have not included this “ethical obligation”, nor do the Australian Medical Association’s position statement on doctors’ health and wellbeing or Medical Board of Australia’s Good Medical Practice address this issue.
Professional courtesy as an expectation was still widely practised in the USA as demonstrated in a 1993 survey. More recently, it has been discouraged with some insurance restrictions creating potential legal concerns around billing.
Australia’s health care system, with its universal health insurance framework, involves independent medical practitioners setting their patient fees. Anecdotally, professional courtesy is commonly extended to doctors and sometimes their families, often by bulk-billing.
In 2021, Dr Michael Steiner, an AMA (NSW) former president, stated that waiving fees is a part of a medical practitioner’s “responsibility to look after the health of their peers and to lower barriers to their wellbeing”. However, this topic is rarely discussed among doctors. Most doctors learn about professional courtesy through the hidden curriculum, by seeing how others extend professional courtesy to their peers.
What motivates doctors to extend professional courtesy to their doctor-patients?
In 2024, we interviewed 26 general practitioners about their experiences and challenges when treating doctor-patients. When asked what they do differently when their patient is also a doctor, 73% said they bulk-billed all doctor-patients, 8% bulk-billed most doctor-patients, and 19% said they billed all patients in the same way. Reasons for bulk-billing doctor-patients included:
Collegiality: upholding a cultural tradition that recognises they are members of the same profession:
“It’s still that old-school mentality of ‘we’re all part of the same tribe here, we know how hard it is’ and it’s just a small part of my way of acknowledging that…”
To promote/encourage good health care: the hope that professional courtesy reduces barriers that doctors experience accessing appropriate health care for themselves. Any barrier to doctors’ health access can increase the risk of self-treatment and delay help-seeking:
“I would rather a doctor come to see me to discuss their concerns than self-prescribe or have a colleague prescribe …. And I know that is the reality of what happens.”
Professional expectation: “I would say there’s almost a pressure among health professionals, almost an unwritten rule to provide health care for them at a bulk-billed rate.”
Expectation of reciprocity: “If I do something for you, you might one day do something for me.”
What are the potential drawbacks, for both the treating doctor and the doctor-patient?
While the majority of GPs in our study chose to bulk-bill doctor-patients, they also expressed a range of concerns.
Financial impact: Low medical rebates reducing their income was a potential deterrent to being willing to see doctor-patients.
“If there are days where I have back-to-back medical clients, my billings can actually be a third of what it would be if I see someone else. And it’s not a deal breaker by any means but that does cross my mind a few times.”
Equity and fairness: Some felt that most doctors could afford to pay, so it seemed unfair for doctors to be bulk-billed, if other patients in more precarious financial circumstances were not.
“I actually get embarrassed when my GP bulk-bills me, I stand there at the desk, and the receptionist says, ‘Oh no, that’s fine, it’s bulk-billed’. And I think, there’s the whole waiting room sitting there, and I’ve been bulk-billed. I don’t like that feeling. It’s kind of not fair.”
Impact on the care provided:
“I think there are really good arguments for paying as the doctor-patient. Like you want to get treated the same. You don’t want to financially inconvenience the person who is seeing you. You don’t want to feel like you are burdening them, and therefore I think if you didn’t pay, it might put you off seeking medical attention if you need it.”
Doctor-patients do not want to financially inconvenience their treating doctor, nor to take up too much time. This possible impact was recognised in the 2019 American College of Physicians Ethics Manual: “When physicians offer professional courtesy to a colleague, physician and patient should function without feelings of constraints on time or resources and care should be consistent with care provided to others”. Some doctors feel that paying the full fee can normalise the therapeutic relationship.
Moving forward
The role of professional courtesy is debated within the medical literature and among doctors themselves. Being a “doctor’s doctor” can be a very rewarding role, although potentially challenging. Treating doctor-patients involves complex dynamics, with issues of collegiality potentially impacting the care of doctor-patients. While some doctors expect that professional courtesy will be extended, others are quite comfortable paying standard fees. Open discussion can prevent discomfort resulting from assumptions —either way — and enables transparency with the financial arrangements.
Supervisors training junior doctors should recognise that professional courtesy is a part of the hidden curriculum that impacts our learning about doctors’ health. There are benefits to initiating a conversation about these pros and cons.
Extending professional courtesy in itself is not the concern, although its impact on the doctor–doctor therapeutic relationship needs to be recognised. The doctor-patient may wish to clarify the issue early in the consultation, even prior to the appointment. Whether or not the issue is raised, the treating doctor should ensure clarity regarding the billing arrangements. All doctors, as patient or provider, need to proactively consider their assumptions and expectations and decide how they will manage these issues within their own therapeutic relationships.
Claire Hutton is a psychologist and doctoral student at Monash University. Her research area is doctors’ health, looking at challenges for doctors when their patient is also a doctor.
Dr Margaret Kay AM is a general practitioner and researcher. She is currently Chair of the Doctors’ Health Alliance and continues to advocate for doctors’ health and wellbeing.
Dr Monika Coha is a newly fellowed general practitioner working clinically in Melbourne, and working in medical education and education research at Monash University.
Chris Barton is an Associate Professor in the Department of General Practice, Monash University.
Doctors’ Health Alliance:
Call the Doctors’ Health Line 24/7: 1800 006 888 to be directed to your local doctors’ health service. Doctors’ Health Services are free and available across Australia for doctors and medical students.
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The statements or opinions expressed in this article reflect the views of the authors and do not necessarily represent the official policy of the AMA, the MJA or InSight+ unless so stated.
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Reminds me of the old joke, “Why don’t sharks bite Lawyers? Professional Courtesy.”
There is no doubt that PC is special privilege and should be recognised as such, definitely not a right.
I’m of the age where sadly medical visits are common. I ask not to be bulk-billed saying that i am well able to pay full whack and consider it paying forward to the next indigent patient for whom full charge might be crippling. It’s true, for me bulk-billing would be a disincentive to attend.
I wonder if you have data regarding the Suicide Rates of Female Doctors in Australia and NZ, which appears to be increasing, possibly relate to the Feminisation of Medicine and the destabilisation of Work / HEX Debt / Life.( HEX = Student Loan in NZ where the is no Medicare )
GPs remain the lowest paid, so Bulk-Billing is the tip of the iceberg, of mismatch, and those teaching should openly “own’ outcomes from Medical Schools to Post Grad Colleges.
Health Departments rely on Denial when it suits their propaganda regarding Public Health targets, and the “Social Contract” with Hippocratic Oath should be revised “First Do No Harm, to Yourself !”.
I embrace Stoic Philosophy “Memento Mori” but one’s vocation should not create a cause / effect relationship.
Oh I love this. I stopped bulk billing colleagues ~ 2013 as a specialist GP because it didn’t pay my bills.
As a colleague myself it made me very uncomfortable to be BB by my GP so much so that I went less than I should have because I knew she was essentially working for free.
A couple of years ago I told her to pls bill me else I’d have to look for someone else, when she’d insisted on BB me despite my protests till then.
Drs have a right to be paid for our services unless we choose freely to BB, unbound by unspoken expectations.