Tom Skotnicki *
David and Trina Gregory first met in 1987 as young ED registrars. David took the lead in setting up their first practice in Port Macquarie the following year while Trina had six children over the next few years. Both are still working as GPs, albeit in Canberra. But when Practice Matters asked them if they would do it again if they were starting out today there was a cautious reaction. They both agreed that the 1980s was a far simpler time for General Practice.
David said when he first met Trina he was working 12 hour shifts of seven days on-seven days off. On his off days he would often work at General Practices in the area to get a feel for what was involved. It was the pre-fellowship days where you could choose to join a practice or simply hang up a shingle.
He was on the verge of taking a job with the Flying Doctors service in Broken Hill when he became involved with Trina who was also working at the Port Macquarie Hospital while on a working holiday from her psychiatry training in England. Having decided to stay in the town he opened a practice in close proximity to the hospital with another doctor who had trained with Trina in England and who had been working at the Coffs Harbour hospital.
“It was a very busy ED which I was basically organising and running sometimes with the help of a resident. We would see 70-80-90 patients a day. Many of them were General Practice presentations and I realised that there was a business potential if I was treating them in General Practice as I think I was on about $25 an hour in those days,” he told Practice Matters.
The new practice called “8 to 8 Medical Centre” operated 12 hours a day, seven days a week and was located about 500 metres from the Port Macquarie Hospital. His wife Trina was slated to be the third partner in the practice but fell pregnant with their first child. David and his partner each worked six hours a day for five days and 12 hours once a week so each could have one day a week off. Trina worked part time for a few years “There was no nurse or reception and on my first day I saw one patient, a girl with tonsillitis.” The doctors did their own cleaning and it was two months before they employed a receptionist. The practice began with a $50,000 loan to fit out the building and in the early days David and Trina kept doing shifts at the local hospital to make ends meet.
Despite complaints from other local GPs that they were “squatting”, within six months the practice was seeing 300-400 patients a week and was able to employ a practice nurse as well as a receptionist. It started off leasing half a building and within two years purchased the building and took it over in its entirety with the numbers having grown to 600-700 and up to 800 patients a week. “We didn’t know what we were doing, we couldn’t cope with the numbers and we were desperate to get other doctors to come,” David said. Trina often worked afternoon and evening shift to relieve the pressure and there would be up to ten patients waiting to be seen. Another doctor joined the practice within 12 months but “it was in the days when there weren’t that many doctors being trained and they were hard to get,” David said. The solution was the practice in 1991 started taking on registrars, initially just one but eventually two registrars. “It was chaotic but after a few years we found ourselves with up to 10 doctors and up to a 1000 patients a week,” David said. Trina said the focus at that time was on acute reactive medicine and the practice was employing several practice nurses before there were even item numbers for them as it was being run more like a rural ED.
David said although it would be hard for a young inexperienced doctor to take on the responsibility of running a practice on their own it is also difficult when the partners ‘practice objectives are not aligned. He said his partner was far more focussed on the business side. “I guess it’s part of the tension in General Practice between being a viable small business and a quality general practice.” Trina added that the balance between having a viable lifestyle, a viable business and doing the right thing by patients is one of the great dilemmas facing all practice owners. David agreed it was a difficult balance as “no one cares if you go out of business, there is no one underwriting the practice so if you don’t make it work, it’s too bad.”
Trina said as the practice grew through the 1990s it became almost like two practices as many of the acute patients returned for ongoing care and the acute reactive model made way for more of the planned preventative approach. One of the key changes came with the emergence of computerisation which was followed in the late 1990s by the funding of health assessments which increased the focus on continuing patient care and preventative medicine.
The practice was an early adapter of computerisation with David leading the charge. “ I had a friend Frank Pyefinch, (they were in the same year at medical school) who established Medical Director in the early 1990s and I met up with him and he told me he was writing software to be able to write prescriptions and I told him that would be brilliant. So he sent me the software so I was one of the beta testers for it. I was very keen on it because I saw the potential in the long term but no one else in the practice was really interested because it slowed things up to enter information. So I then became involved with promoting computerisation within the Division of General Practice.”
David said his practice started using software for prescriptions in 1993-94 but in 1996 I told Frank that it would be great if it could be used for notes but he was not sure about the need because everyone had their written notes. He agreed to try it and I guess it was about 1997 that I approached the other doctors in the practice and told them that we would be using the computer for notes and eventually intended to go paperless. We were definitely one of the early adapters in the country.”
At its peak the practice had about 8 full time equivalent doctors, eight consulting rooms and was seeing over 1200 patients a week. It was in 2004 that David and Trina decided to sell their interest in the first clinic to their partner who only months later sold it to Primary Care. The couple decided to establish a new practice with a greater emphasis on preventative medicine and treatment of chronic and complex patients. “Almost like a medical home!!!!,” Trina said.
“We basically left and had nowhere to go and six young children to support,” Trina added. The couple found a building and got it renovated within a month. “One of the receptionists from the previous practice followed us and we started taking telephone calls before the opening and by the time we opened we had more than 300 appointments lined up and were fully booked,” David recalls.
The practice called CPC (Complete Primary Care) initially had five consulting rooms and although it was just Trina and David they were soon joined by a registrar and then other doctors asked to join, with several being their former registrars. The practice had three buildings with one being for allied health including, psychology, dietetics and physiotherapy as well as a separate building for pathology and a skin clinic. The practice had a strong emphasis on case management of patients, the use of health assessments and care navigation directed by the GP. “Bulk billing was standard because of the patient demographic, they couldn’t afford to pay and we didn’t want to turn anyone away because of financial limitation,” Trina said.
The practice not only enabled the couple to practice what they regarded as quality medicine but was even more financially successful than their previous practice. “Patients followed us and we had a single receptionist that was run off her feet and just one practice nurse so it was comparatively low cost. So we were really efficient but the reality is we became less efficient as we went along as it’s just too much strain to be so lean and mean,” David said.
David said the downside of practice ownership and the type of medicine they wanted to practice was that it depended on their always being available. “It also became more difficult to employ and rely on contract doctors on being able to pay them enough so they could earn enough to make it worthwhile so they could support us in the sort of practice we wanted to run.” Trina agreed, “somewhere along the way, the bubble burst and it stopped being as sustainable.”
The couple finally decided in 2014 to sell their practice. The government decided that it would provide $7 million in funding for a Superclinic in Port Macquarie leading to an arms race with major expansions of existing corporate centres as well as a new facility. “It meant for someone like us we could not really attract doctors without paying more than the the practice could afford. It was also the patients who if they needed something after hours or had a simple problem could head for one of the mega centres while still seeing us for the complex problems. We could see the writing on the wall and the alternative was to borrow $10 million and go into competition or not, and it was not.”
The consortium that won the Superclinic funding turned a former nursing home into a clinic with 28 consulting rooms, a gym and other hospital type facilities. All they needed was patients and staff so Trina and David effectively sold them their list of 8000 patients, their staff and doctors. “It was an all or nothing deal, no cherry picking no one got left behind,” Trina said. She also admitted that after 26 years the couple were ready for a change. “It was a strain never being able to take holidays or travel together because if we were both away for any length of time the practice would start to suffer. It was fine when the kids were little because there are lifestyle limitations with young kids but with them leaving home we were questioning priorities,” Trina said. Other factors were also at play with the Medicare rebate freeze also starting to impact on practice income helping to create a perfect storm in favour of selling, David said.
David said since the early 1980s general practice has also undergone a huge transformation from a cottage industry to an increasingly corporate model. “When I first started there was a class of specialists called General Physicians to which you could refer complex patients. The role of the General Physician no longer exists, it became the GP who is expected to manage complex patients and is not really being rewarded appropriately. The reality was that in Port Macquarie it had been a decade since we had seen a new patient or treated a patient with a cough or a cold, we were totally busy caring for our existing ageing patients who on average were aged 75 with multiple chronic illnesses.”
Asked what they would do today if they were once again starting their careers and had just completed their fellowships, they were uncertain. Both said for a variety of reasons such as workforce issues, higher start-up costs and narrow margins it was a difficult call. “One of the great things about running a practice is being able to do things your way. So the levels of personal satisfaction compared with working for someone else can be far greater,” David said.” “My gut feeling is that if we were that age and here in Canberra, we would do it again,” he said.
Trina was less convinced as she expressed concern over the extreme deterioration in recent years in the comparative value of the rebate and its impact on the practice of “good” medicine. She said it is awful when economic viability impinges on the provision of quality medicine. “It leaves me really conflicted,” she said. “Perhaps if there was a group of GPs with similar standards, similar quality outcomes and documentation (it could work) it is deflating seeing patients with incomplete, missing or inaccurate data where the notes are not filled-in, basic observations like blood pressure and BMI not recorded, cardio vascular risk assessment … but you can’t really expect GPs to do that for 65% of the standard rebate,” Trina said. “So what do you do, do you marginalise and disadvantage those who are already marginalised (by charging) or do you revert to 10 minute medicine?” She is not sure of what the pathway is for young GPs committed to quality care.
*Tom Skotnicki is Practice Matters editor and can be contacted at firstname.lastname@example.org