Note: This is the second installment in a seven-part series Brian Doyle prepared to help colleagues make the most of an emergency medicine rotation Down Under.
Part II: Free Emergency Department Care In general, the government provides free health care to all of its citizens… i.e., nationalized health care. There are some private hospitals in Australia and people can purchase private “health cover,” but most people go through the “public” system. It is my belief that the overall delivery of health care in Australia is actually better than the USA. However there are individual features of the US system that are probably better (i.e., invasive cardiology). All citizens have Medicare (regardless of age). Emergency Department care is free. Some GPs (general practioners… this is the preferred term for what is called family practioners) in the community may charge a fee over and above what Medicare will reimburse. Patients have to “pay the gap.” A minority of GPs will “bulk-bill” and only charge what Medicare will reimburse. It is getting more difficult to find GPs in Australia who will bulk bill. As one might imagine, this does create some conflict because, “Why would I want to pay to see my GP when I can go to the ED for free?” Therefore some GP type patients do present to the Emergency Department, but this is what triage is for... There is no EMTALA in Australia, but it is uncommon to see a patient denied admission to the ED.But, I have heard some triage nurses suggest to patients that it would be best if they saw their GP for minor complaints. The advantage of free Emergency Department care is that the patients seem to be less demanding and they don’t seem to mind waiting as much as their American counterparts… perhaps this is more of a cultural phenomenon. It is easier to get patients in and out quicker. Since they are not paying $200 to walk through the door, I don’t feel as obligated to put on a big show… (I hope you know what I mean.) The other advantage of free ED care is that you can ask people to come back to the Emergency Department the following day for a quick check. I do this often for burns, cellulitis, and abdominal pain that I send home. I also tell patients to come back and “see me tomorrow” for a quick recheck if I am a little worried about something. Obviously this is a bit foreign to the American system, but I like it! There are no major expectations on the part of the patients, and they seem to be very grateful for the follow-up. If they are OK, I send them away usually within two minutes and my notes are VERY brief (see about documentation below). Obviously, I select which patients I want to come back... as you can imagine there are some patients (fibromyalgia anyone??) which are best to get back to their GP urgently.
Free Care and Incentive for Service Unlike the USA, you will not see EDs advertising on billboards to “come to our state of the art Emergency Department.” The ED is NOT run on a business model. There is no economic incentive to be quick or efficient. You do not get paid more for seeing more patients. To the contrary, more patients imply utilization of more resources. As you might imagine, this creates a less efficient system. Don’t get me wrong… the system is no where near as bad as the typical Veterans’ hospital in the USA, but you will notice some inefficiency.
Examples would include: No ED secretary to answer phones (this one can drive me nuts at times…). I generally don’t answer any phone primarily unless I am not doing something else (which is rare) and eventually one of the nursing or other staff answers the phone. It is really not efficient to have the nurses answer the phones either, but this level of efficiency has not quite entered into the EDs where I have worked. At times you will need to fill out forms and slips (i.e. x-ray slips) and walk them around to the x-ray department. Rather than get extremely annoyed by this, you should think of this as “mental break time…” Trust me; you will not change the system overnight. There are many Australian ED’s that expect the doctors to draw all of the blood and put in all of their own IVs! Fortunately, the hospital where I currently work is an exception. I rarely have to put in an IV, although the nurses are usually quite reluctant to place one in a child. Since I have “deskilled” at putting in IVs, I usually ask one of the junior doctors to put one in for me as a courtesy… they usually look at me funny and then oblige- this doesn’t come up often. You may find the nurses ask you to put in urinary catheters in male patients (the term “foley” is not used in Australia) although I seem to always get out of this one…
