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The emerging medical specialties

NB - Article below written seven years ago.

Sport Health March 2001

Extra items were added to the Medicare Benefits Schedule on May 1 that may change the face of primary care medicine in Australia. This change was reported a month earlier in Australian Doctor, but has otherwise passed without notice, the reason being that, at the time, it affected very few doctors. On this date, sports physicians who had up to date qualifications with the Australian College of Sports Physicians (ACSP) were granted access to new Medicare item numbers, effectively the equivalent of VR general practice item numbers. Although these new item numbers are only relevant to approximately 100 doctors Australia-wide, they may have greater relevance for the many thousands of GPs in Australia, in that the government has given a stamp of approval for patients to see a different type of medical practitioner without needing a GP referral.

Doctors who are Fellows of the ACSP are hardly dancing in the streets over this change. There has been a great deal of relief that the FACSP qualification has finally been officially recognised, eight years after Part I and Part II exams and a full-time four year advanced training program had been instituted as the method for obtaining the FACSP. It is a pity that it was officially recognised by the government before it was by our peers in the AMA, who may also now consider including sports physician consultations in their list of recommended fees. Even with the recent MBS recognition, the patients of sports physicians are still the worst-rebated of any doctors with MBS-recognised qualifications. Whilst the consultation levels now have parity with VR GPs, there are no associated ‘extra’ payments available to sports physicians like ‘PIP’ grants, or opportunity for our patients to access rebates extra services such as childhood immunisations or case management reviews. Procedures that sports physicians perform, such as the measurement of compartment pressures in the work-up of chronic shin pain, are still ignored by the MBS, so that the patient must pay the entire amount out of their own pocket. There are no payments built in to our MBS rebates to cover the costs of typing and sending letters back to referring practitioners, and no payments to principals for having sports medicine registrars in their practices. Patients of sports physician registrars working alongside Fellows are only entitled to non-VR payments, compared to VR-payments when they see a general practice registrar.

Having recently been in a worse predicament with no recognition at all, sports physicians realise that there are doctors out there in our footsteps, who work in areas such as venereology, travel medicine and women’s health. Some of these doctors have expertise and training in these fields that are not recognised at all by the MBS. One of the major benefits of being neglected by the MBS for such a long period is that sports physicians are universally under no illusion that the government is solely responsible for providing us with our income. Like most specialists, we set our fees at what we think is a fair level, and let the patients worry about what rebate they get back from the government. Nevertheless, we don’t think it is fair that our patients get lesser rebates than patients of other types of doctors with similar qualifications and training.

Given the current status of sports physicians (in being recognised by the MBS as primary care practitioners but not as specialists) we are in a dilemma as to how to develop our practices with respect to GP-referrals. Most of us believe that we are no different to other specialist physicians, and that we should therefore be trying to ensure that all patients have a referral from their GP before we see them. GP-referred patients already make up a significant percentage of the consultations of many sports physicians, but it is difficult to recommend to prospective patients to go out of their way to get a GP-referral when it will make no difference to the rebate that they receive from Medicare.

The fate of sports physicians will set a precedent for the future landscape of community medicine. If we stay for long enough in a position of being primary-care specialists, then others, such as venereology and travel medicine specialists, will join us and in time it will become a new category of practice. GPs will have an effect on whether the emerging medical specialties are added to the ranks (and status) of existing specialists by their referral patterns. For example, if GPs referred most of their complicated (but non-surgical) sports medicine cases to sports physicians, then it presents a good case for making sports physicians fully-fledged specialists. If GPs see sports physicians as some form of opposition group and refrain from making appropriate referrals, then we will probably stay as a permanent fixture on the primary-care landscape, perhaps competing with GPs for patients.

Whatever status sports physicians and other emerging specialty groups are given in the future, at some stage the government must give consideration to financially supporting training programs for specialty areas that are non-hospital based. At the moment the funding for sports physician training is generated out of the goodwill of existing sports physicians, so it would be very difficult to expand the ACSP training program without some external support. The supply-demand differential for sports physician training posts will only get worse with the number of junior doctors graduating exceeding the number of medical postgraduate training positions available. The further development of training programs in genuine areas of patient demand, such as sports medicine, sexual health and travel medicine, should be seen as an essential step to narrowing the gap between training post numbers and medical graduate numbers.