ZARA has been waiting a while for her turn, but she’s grinning as she hobbles through the door. “I’m the problem child,” she says. She is not complaining or apologising, just matter-of-fact. Smiling from behind her desk, Sue Harnett agrees. She explains to me, the observer in the corner, that Zara “freaks Neale out.” Her colleague Neale Gunning has a squeamish stomach and had to tend Zara’s dressings last week when Sue was on holiday in the Kimberley.
Neale’s dislike of gore is a frequent subject of banter between these two GPs. After years of sharing this rundown surgery in south-western Sydney, they have the routine down pat. In between patients, they snatch the chance to joke, and not only about each other’s foibles. Patients, medical specialists, anyone else who crosses their radar – these are all potential subjects of a pithy aside. The two doctors also have a habit of finishing each other’s sentences. “Neale is like another husband,” says Sue. “We’ve worked together for the nineteen years I have been here. We get on very well. That’s important – you need to have a working relationship to keep it going.”
Now, on the Tuesday morning after the Easter break, she is crouching before Zara, explaining to me that the practice, being in a poor area with mostly bulk-billed patients, is among the general practices (around 40 per cent of them) that don’t currently employ at least one practice nurse.
“So I have to do the dressings,” says Sue. She watches as Zara, who is somewhere in her late fifties, unwinds the bandages around her left foot, revealing a horribly ulcerated heel, the result of peripheral neuropathy. No one knows what damaged the nerves in her foot, and over the past four years Zara and Sue have been on the specialist merry-go-round, trying various specialists and podiatry clinics. The best advice came from an orthopaedic foot surgeon in Oxford after Sue emailed him a photograph of Zara’s foot. “See how much better it is now,” says Sue, holding up her mobile phone to show what the foot looked like before a skin graft.
But the gaping wound still looks ghastly, and my stomach churns as Sue’s gloved hands slice away dead skin. Droplets of blood and flakes of skin fall to the floor. “She shouldn’t have to do this,” says Zara, “but where am I going to get it done?”
“Usually I try to do it twice a week,” says Sue, “and her husband dresses it in between.” Zara nods. “We just plod on, don’t we doc?” As Sue wraps up the foot, she explains that they use female sanitary pads for dressings, to save money. And Zara washes her bandages for reuse. Specialist clinics, says Sue, often recommend products that her patients can’t afford. “It costs me thirty bucks a month just in pads,” adds Zara. “I thought when I stopped having periods I’d never see these pads again, but no such luck.”
Returning to a well-worn thread of conversation, Sue says: “They say they improvise in the bush but we improvise here as well.” She thinks the needs of patients in the corridors of metropolitan disadvantage are woefully neglected compared to the extra help that’s given to rural doctors and rural health.
Zara pulls down her trouser leg and stands. “You want to see me Friday?”
Zara shuffles out, throwing a parting comment over her shoulder: “I’m not dead yet.” She is trying to make us laugh but instead leaves a poignant moment in her wake. It’s not only her courage that impresses, but the intimacy between these two women, and the jokes and unpleasantness that they share.
Zara is barely out the door when Neale drops in, wanting to know what Zara had said about their encounter last week. “Sue was away, and I freaked out,” he says. “I’m not a great fan of blood.”
“But he’s got more personality than Doc Martin,” says Sue drily.
IT WAS 1989 when Neale first came to this practice, in a dirty white-brick house on the main street at Condell Park, one of the oldest parts of Bankstown. He bought it from a GP who’d been practising in the area for thirty years or so. On one side of the surgery lies a modest strip of suburban shops; on the other, a produce store. The bags of manure and animal food that teeter precariously against the adjoining fence are a reminder that it has taken less than a lifetime to transform a semi-rural area into bricks-and-concrete suburbia. During that time, the population mix has been transformed, with more than a third of Bankstown residents now coming from non-English-speaking backgrounds.
The doctors are identified by tarnished brass plaques on the front of the Simmat Avenue Family Medical Practice. Patients compete for parking space in the unkempt backyard and then enter the building by a concrete ramp to the back door. The waiting room is spotless but distinctly no-frills, with grey lino on the floor; the paint on the bathroom walls is peeling, under the light of a bare bulb. A sign on the reception desk advises of a $40 fee for non-pensioners.
Over the past twenty years, Neale, who is fifty-one, has watched a cohort of patients move from their middle years to old age. “Some patients you really get to love,” he says. “My favourite was a seventy-five-year-old lady who weighed about twenty-eight stone. The first time I met her she said, ‘Hello, I’m fat.’ I said, ‘So am I, so we will get on very well.’ She went for another fifteen years, and we became friends. I got to know the family, which I really love.”
But generally he prefers working with children. Yet he gave away paediatrics training after three years. “I think it was a lack of self-belief,” he says. “I didn’t think I could do it. Looking back it seems ridiculous, but the thing that pushed me over the edge was when my wife was pregnant with the oldest, and thought she was miscarrying, and I was on night shift in ICU” – the hospital’s intensive care unit – “and couldn’t go home. That is David, who is now in his twenties.”
And the enthusiasm for working with kids? “Funnily enough, I am not really a good people person,” Neale says. “At parties I sit in the corner and think: what is the shortest amount of time I can stick around before I go…? I think I am an introvert who acts like an extrovert. With kids, the child in me comes out. You can goof off and just talk to them.”
His first few years in general practice were an anxious time, knowing that anything from a cold to a stroke could come through the door. “But after ten years or so, you have seen everything that could walk through the door. I have seen cancers, strokes, brain tumours, I have had ruptured aneurisms and a cardiac arrest in the waiting room. I don’t find it scary any more.”
A third doctor, who left the practice in 2001, has not been replaced, though both admit they could do with another doctor. Sue would like a four-day week, but feels this would put too much pressure on Neale, who has closed his books to new patients.
Neale sees mainly children and families, whereas Sue’s patients tend to be older, with chronic diseases.
“He can get through more people than me,” says Sue.
“Anyone who takes on the elderly…” says Neale, all but rolling his eyes.
“We do get disadvantaged…” continues Sue.
“All the forms that you fill out do take more time. It’s not worth it…”
“But it is more interesting,” says Sue.
Conversation then turns to another familiar subject, the problems with specialists. There are not enough rheumatologists, eye surgeons or orthopaedic surgeons for the ageing locals, but, says Neale, “plenty of cardiologists and too many gastroenterologists.”
Cardiologists, he adds, are often hard to deal with, “because they think the heart is the only organ in the body.” Later, he clarifies what he meant: “They will put people on medications that are good for the heart but may cause problems for other organs,” he says. “There is a tendency for some specialists to want the problem to be in someone else’s organ.”
Psychiatrists, meanwhile, are impossible to find. Neale says the only one in the area “is absolutely swamped and you can’t get in to see him.”
Community mental health services are not much help, adds Sue. “They are mainly only providing us with mental health nurses, but the nurse can never be a doctor. We need specialists to help when we are having difficulty. The division [of general practice] is looking to provide rooms so the psychiatrists can come in on a sessional basis.”
Sue says the area desperately needs more specialists with expertise in chronic diseases like diabetes. “They tend not to want to come here because they don’t earn a lot because of the bulk billing,” she says. “It’s very good medicine in this area, it’s interesting; we get a lot of disease… but the patients can’t pay.”
Nearly half of the people in the local government area are on some sort of pension. Sue is familiar with all the stats because of her role as chair of the local division of general practice.
Neither doctor is convinced that the federal government’s GP super clinics will solve the problems of under-served areas. “If the clinics are placed in areas not served by GPs, I suspect that they will have trouble getting GPs to work in them, for the same reason that the area was poorly served in the first place,” says Neale. Sue thinks smaller, traditional practices are best suited to building the relationships with patients that are important in providing long-term care for chronic diseases. “I can’t envisage myself working in a super clinic,” she says.
Today, Neale saw his first patient at 8am, stopping for a home visit on his way to work. He says it’s very difficult to get this man, a ventilator-dependent quadriplegic, into hospital, although he’s had a positive result in a bowel-cancer screening test. “No one wants to give him a colonoscopy. He is complex, one of the ones the system doesn’t work for.”
On the other hand, another of his patients this morning, a young girl with recurring tonsillitis, is “interesting enough that you can ring a paediatrician.”
In addition to patients who present because of media scares, Neale is annoyed by people arriving with nothing more than a bad case of worried wellness. He points to the appointments schedule on his screen. “Those two are coming in with nothing,” he says.
“Some people come in, and if I’d gone to the doctor like that when I was a kid I’d have been embarrassed,” he says. “One lady came in six weeks after her baby was born. I said, what did you come in for? She stood up and hiked up her dress and said, ‘Do you think my knees look fat?’
“I said, ‘Of course they look fat, you just had a baby six weeks ago.’”
SUE is fifty-three, tall and trim, and her high heels are in continuous motion. When she’s not at her desk, clicking into her computer or labouring over forms from Centrelink and elsewhere, she is moving between her patients and an impressive selection of instruments.
After dashing down lunch over paperwork, Sue greets Rosalie, an attractive young woman with long dark hair, who complains that she feels “strange” and had to stop a gym class this morning because of feeling dizzy.
No, she admits, she didn’t have anything to eat or drink before the gym.
“I will shoot you on that one,” reprimands Sue.
Rosalie also admits that she enjoyed plenty of Easter chocolate and didn’t eat as well as usual over the break. Sue, meanwhile, is having difficulty getting a reading from the device to measure Rosalie’s blood oxygen levels because it won’t work through acrylic nails, which are her “pet hate.” “Look at that, it’s a completely straight line,” says Sue drily, but “you aren’t dead.”
She tells Rosalie that her blood pressure is a little low because she hasn’t been having enough fluids. “Not having something to drink before you go to the gym is a very bad idea. You should have 250 to 500 mls before exercising. You’re already dehydrated after fasting overnight, and may be worse than usual because Easter chocolate contains caffeine. So you have to push up fluid and salt intake. It’s the only time I like sports drinks, because they have salt and sugar in them.”
Sue wraps up the consultation: “So do you need a certificate for today? Otherwise you are normal – except for your fingernails…” I ask, not entirely in jest, if Sue has ever considered a sideline in comedy. She has injected humour into just about every consultation today. One man seems quite chuffed to reveal that she called him a “boofhead” last time they met.
ON OUR WAY to the nursing homes at which Sue is to be found most afternoons, we drop into the local division of general practice. There, the executive officer, Andrey Zheluk, explains that the area has some of the country’s highest bulk-billing rates, reflecting its high levels of social disadvantage. General practices in poor areas generally have less revenue than those in wealthier areas to pay for practice nurses, chronic-disease management programs, and other “extras” for patients. It also means that they generally spend less time with patients.
This is one way that our health system’s fee-for-service model ensures that poorer people with the highest needs are least likely to be well-served. But many of the problems confronting GPs are not medical. “The basic problem is society – not a medical problem with medical solutions,” says Sue.
As we drive past houses that seem surprisingly flash for an area known for its disadvantage, Sue mentions that she spent three years training to be a physician and planned to be a cardiologist. “But you are still a woman,” she says. “I had a family and a sick father. And it’s much more fun in general practice. I can play in any field; I don’t regret it one bit.”
She points to where a large mushroom farm once stood. “This was very rural before World War Two. Many ageing Europeans settled here after the war. Some of the patients in the nursing home have been living here since the 1920s. And now we’ve been having another wave of immigrants over the last twenty years.” After the war, the arrivals came from Lithuania, Latvia, Italy, Greece, Malta, Poland, Holland, England and Yugoslavia. These days, Lebanon and Vietnam are the most common countries of origin.
At a charity nursing home she has been visiting for more than a decade, Sue does a whirlwind round, jabbing a succession of elderly residents with flu vaccine. She reels off their names easily – Olive, Thelma, Nellie, Gloria and more – and I wonder how on earth she keeps track of them all.
For someone unused to such places, the visit is sobering. Sue herself doesn’t want to end up like one of the frail creatures propped up in wheelchairs before blaring commercial television. Most are on multiple medications – antidepressants, sleeping pills, antipsychotics, as well as various supplements. “I hope I drop dead, I really do,” she says. Uncharacteristically serious for a moment, she adds, “Society needs to have a discussion about euthanasia.” She nods to the rooms we have just visited: “Some of them ask me for it.”
WHEN I return several weeks later, the surgery that looked shabby on first impression seems familiar, even homely. Sue is pleased it is raining and Sydney’s traffic is even more tangled than usual. “It won’t be as busy,” she smiles. “I don’t mind the rain.”
Over the next few hours she treats an ingrown toenail and a succession of elderly patients, and negotiates a screaming toddler who really doesn’t appreciate the doctor’s attempts to look down her infected throat. Yesterday she saw a woman who had stuck a cotton wool bud through her eardrum. “The medical centre said she had a cold and didn’t even examine her,” she says. “I had to send her to an ENT surgeon. That is what gives general practice a bad name.”
Frieda and Ray, who have both seen better days, have come in for general check-ups and a referral, and are also concerned that Ray might lose his driver’s licence, which is already conditional. He insists that he drives only to the local shops, but it’s a safe bet that he is probably also a regular at his local club.
“I won’t swear today,” promises Frieda in a gravelly voice.
Sue: “Just as well, you know it bothers me.”
Frieda laughs: “Bugger, then!”
Sue says Frieda is doing pretty well, considering her severe asthma. Ray thinks he knows why. “I do the housework,” he offers.
Frieda protests: “I always cook tea and breakfast… I’m going to buy him a new vacuum cleaner.”
There is not much levity when the next couple arrives. Hunched and shrunken into their cardigans (his neatly patched at the elbow), they move slowly and expressionlessly into their chairs. He says he’s had indigestion and “my mouth is not too good.”
Knowing their back-story, Sue is on to the significance of this in a flash. She looks for, and finds, a thriving yeast infection in his mouth which is probably also affecting his digestive tract. It is a side effect of malnutrition. The couple, in their nineties, have form – at one stage, they were sharing a single plate from Meals on Wheels, but are now cooking for themselves. The wife is down to forty-nine kilograms and has lost weight since her last visit.
Sue questions them closely about what they have been eating. Her frustration shows when the husband says a doctor at the hospital gave them a list of salty foods they shouldn’t eat. “You’re not eating enough food,” she says. “There’s nothing wrong with your cheese and tomato sandwich.”
The pair, who care for a disabled adult son, hold hands as they slowly exit. “They are only just managing at home,” explains Sue. “For someone to belt them up about salt… You don’t give them the same food-restriction diets that you would to a sixty-year-old because the longevity is different.”
Later, she explains part of the reason why the two aren’t able to care for themselves. “These people went through the Depression of the 1930s, where wasting money or food was deeply frowned upon,” she says. “Those years became ingrained into their minds that to survive, everything had to count and be used wisely. They never threw food away – it was usually reused in another dish the next day. The modern generations today talk about climate change but are so wasteful. Those dishes such as bubble and squeak, toad in the hole, Queens pudding have now disappeared, haven’t they?”
Many of Sue’s other patients are in a similar predicament to this couple – frail, elderly and no longer safe at home because of inadequate support. Again, medicine is being asked to pick up the pieces after a process of social change. “What has happened is that the family structure has fragmented,” Sue says. “In the past, they would go and live with the family. We are getting more selfish and don’t want to look after them.”
ON OUR WAY to the nursing homes in the afternoon, we detour to see Larry, seventy-five, who is dying of lung cancer. “He came out of a medical centre, the bane of my life,” explains Sue as we approach the modern brick home. “They don’t want to do house calls, and weren’t treating him properly; I have had him for about eight months.”
We find Larry on the sofa, attached to oxygen, with his wife of forty-five years hovering in attendance. Their home is immaculate, with large photos of grandchildren on the walls. Larry complains that he gets breathless just walking to the nearby toilet, that he is frightened when taking a shower, and that he’s been agitated and crying. Sue says the steroids might be affecting his mood and that she can juggle his medications, though this may make him more drowsy.
“I can’t even go out shopping in the wheelchair because I get stressed so much,” says Larry. “I don’t know why. I have so many things swirling in my head… Please don’t let me down.”
Sue says it will take a few weeks for his new drug regime to settle down.
“I wish I could walk,” he says.
“I tell you a hundred times a day, you can’t,” says his wife. “You have got to be grateful you are not in pain.” Sue backs her up: “You’re eating well, you aren’t in pain. Considering what is wrong with you, you’re not too bad. We have got to be grateful for what we have got at the moment.”
After we leave, Sue says Larry doesn’t appreciate his relative good fortune. “Usually lung cancer patients have a lot more pain at this stage.” She laughs: “And he wants to go out shopping!”
Do we expect too much from doctors? “I think we do,” says Sue. “All these medical shows giving people the impression we create miracles, but we are still extremely mortal.”
And what will happen in Larry’s final stages? “That’s up to them. They can stay at home. Palliative care will bring in a bed. We can keep them at home. There will be increased nursing but the wife still has to do a lot. If they don’t like that scenario, they are offered a palliative care bed in a hospice, but they are so full we can only use them if they have two weeks to live.”
DENISE CRATE has been the practice manager at Simmat Avenue for twenty-one years and, like Sue and Neale, has developed long-term relationships with many patients. When I ring, several weeks after my second visit to the surgery, to ask about her impressions of how general practice has changed over the years, she tells me the surgery has had a makeover since my visit.
“We’ve had it painted,” she says. “The doors are a beautiful French blue and there’s a lovely carpet, lovely new pictures. They’ve updated everything. It looks much smarter. The lino has gone, thank heavens. The patients are loving it. They appreciate it.”
Over the years, Denise has watched generations of patients pass through the surgery’s doors. “I’ve seen families grow up and children of patients are now having their own families. I’ve seen them make their debut and weddings. It’s one of the nice things about a family practice like this, that you do get to know people and you become quite fond of them.”
It can also be sad, especially when the elderly start to dement. “To see people change, it’s really hard,” she says. On the other hand, she adds, “I could probably tell you a million funny stories.”
It’s the stories that are so often missing from our public discussions about health reform, which tend to focus on concepts like “governance,” “evidence” and “systems.” Yet, as I heard one senior health-service manager tell a recent meeting, health reform is more about “people, relationships and culture” than about funding and governance models. Just as healthcare itself, at its heart, is about people – those in need of care, as well as those who provide it.
Hearing and respecting the diversity of these people’s stories may be as important to the journey of health reform as is understanding the technicalities of casemix funding and governance arrangements. But in a health system that is so often structured around meeting the needs of the better-off, the stories of the most under-served in our communities often go untold and unheard. •
Melissa Sweet is a health journalist and editor of the health policy blog, Croakey. She has honorary appointments in the School of Public Health at the University of Sydney and the School of Medicine at Notre Dame University (Sydney campus). Patients’ names have been changed to protect their privacy. Declaration: Melissa Sweet helps produce a newsletter for the Sydney West Cancer Network, which is run by Sue Harnett’s husband.