The builder chatted while I checked his blood pressure, waist circumference, cholesterol, fasting glucose and urine protein. We discussed bowel and prostate cancer screening in detail and I gave him written information as we were out of time. As I signed his script for blood pressure medication he winked.
"That was easy money for you, wasn't it?"Â
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$37.05. That is the value the government places on up to 20 minutes of my time. This figure, the amount a practice receives from Medicare for a standard consultation, hasn't changed in four years. Under the rebate freeze, it won't change for another three. But are the pennies well spent? Let's see.
Tuesday morning.
0830: Young homeless girl slouches while I explain why she needs the daily medication that keeps her out of hospital. After nine minutes her body language changes.
"Oh. If someone had just told me that I would've taken it. Can I get a chlamydia check while I'm here?"
0846: Eleven minutes assessing a feverish toddler. Are you dying of meningococcal septicaemia, or do you have a cold? Repeat this consultation six times today.
0901: Stoic man vaguely requests a "check-up". After 10 minutes, he mutters that he has a funny feeling in his shoulder, "probably nothing". Ask nurse to do an ECG.
0914: Fifteen minutes with a young man who just lost his leg. We make a list of the things he will think about when he can't take his mind off the gun in his uncle's garage.
(0932: Check stoic man's ECG and send him to hospital. Three hours later he is having heart surgery. He survives.)
0940: Three minutes silence with a woman with finger marks on her neck. Does she want to talk today? Nope. Talk about migraines instead. Maybe next week.
0953: Insert contraceptive implant into giggling 18-year-old.
1004: Attend to 18-year-old who has fainted. Call from nursing home – three new urinary tract infections, someone is delirious and Bert's family are here from Perth and want to talk. Can I come by?
1010: Determine whether 89-year-old is fit to drive.
1027: Explain to young man that men as well as women can carry sexually-transmitted infections, and he should be treated for that discharge. Screen him for depression. Not depressed, yet, but he is injecting testosterone and has a secret abscess he'll let me see.
1045: Explain to woman with nine years of symptoms unresponsive to dry needling, crystal healing and zinc replacement that she probably has coeliac disease.
1056: Reassure first-time mum with post-natal depression that she is not evil. Organise support.
1115: Shout at 92-year-old that she's gained four kilograms of fluid. Receive beatific smile in return. Jiggle medications. Stop the four least useful of her 15Â medications and arrange to review tomorrow.
1132: Repeat child with fever consultation.
1148: Repeat child with fever consultation. Notice child has stopped growing. Re-book to investigate.
1203: Advise local butcher she should invest in Hepatitis A vaccine prior to Thailand trip, for all our sakes.
1212: Phone call from lab – blood count from yesterday's patient with the night sweats is weird. It looks like cancer. Call haematologist. He's busy.
1218: Repeat child with fever consultation.
1230: Notice suspicious mark on bricklayer's arm while taking blood pressure. A notorious no-show, I won't see him for six months. Biopsy today.
1254: Lunch! Call the haematologist again. Call the patient with the weird blood to request he come in today. Quick reading to brush up on weird blood. Paperwork. Visit nursing home.
General practice costs 7 per cent of Medicare's budget. The frontline is starved, and the idea that we can build a tower to Mars with the money we'll save by starving it further is madness.
GPs save Medicare money by keeping people out of that economic sinkhole, the hospital. If we keep one patient a week out of intensive care, five a week out of hospital, we are worth it.
 I assess three to four infants a day who don't need a bed in emergency, and I send the declining asthmatic who does. I jiggle medications to keep people stable.
Last month I saw a socially-isolated man who wanted to quit the cannabis making him psychotic. I saw him every two days for a fortnight, encouraging him through withdrawal. I can only imagine the cost of an admission to the mental health unit for drug-induced psychosis, but it's probably more than $185.25.
Often an expensive test isn't going to change what we know or do. Having invested 11Â years and more than $100,000Â in my eyes, ears and mind, utilising these before a multinational pharmaceutical or pathology company seems wise and cost-effective.
But the more I get squeezed, the less time I'll spend. The government doesn't want to pay me and neither do the people.  While my expenses go up, my income doesn't. Can we all stop looking surprised when we have to pay a GP?
People in Saba jackets complain to me about "crap bulk-billing doctors". It's like whinging that McDonald's gave you reflux. For GPs, it's becoming one or the other – a gap payment, or eight patients an hour. I haven't burnt out yet, but soon I'll have to start either charging a gap or doing Botox parties of an evening. If you want better care, pay a gap or write to your MP. Preferably both. You get what you pay for, because your government won't.
If I had charged the building contractor the private fee of $70, he would have been refunded $37.05 from Medicare. Of that $70, 35 per cent goes to the practice for rent, electricity, equipment, and to pay the receptionist and nurse. After tax, my Medicare levy and student debt, I receive $24.56.
But I bulk-billed him, which means I made $13.01. That dizzying sum covers sick, holiday and maternity leave, superannuation and about $8000 a year in fees, insurance and continuing training.
So no, it wasn't easy money.
Elizabeth Oliver is a Sydney GP. A version of this piece first appeared on her blog, That Lady Doctor.
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