Trying to understand Medicare #1

Referrals to Specialists

In Australia you don’t need a Referral to see a Specialist. So, say you wanted to see a Plastic Surgeon about a skin lesion, you can just find a Plastic Surgeon on the internet or ask a friend and make an appointment and off you go. But be prepared for a bill – sometimes a really big bill. This is because, you won’t be able to access a Medicare rebate for the Plastic Surgeon’s fees. To do so you need to first have a valid referral from your GP. But it is not as simple as just calling your GP and asking for a referral.

What is a Referral letter?

It is a legal requirement to have a valid referral to access Medicare for the care provided by the Specialist. In Medicare speak, the referrer must first “consider the need for the referral.”

A referral is a written, signed and dated request to a Specialist to assist with care of your medical problem. Often the Referral is to a specific Specialist, but this is not necessary. From DHS

“Referring practitioners don’t need to address a referral to a specific specialist or consultant physician. Patients should also be given the choice of where to present the referral, including where the referral is submitted electronically.”

This however can be an issue for referrals to public hospitals (that is a story for another time).

In the Referral letter, I usually would explain the problem, what I would like the specialist to do and provide a list of your medications, allergies, previous medical problems along with a copy of relevant investigations that may have been done. I find that this is best done face to face in a consultation to avoid miscommunication.

A specialist may run a triage system; a way of sifting through referrals to pick those that need more urgent care.

There is an expectation that a letter of reply will be forthcoming following your consultation with the Specialist.

How long does a Referral last?

A standard Referral is for 12 months of care. This starts when you first see the Specialist, not form the date the Referral was made. This makes sense as you are unlikely to see a Specialist on the same day as seeing the GP.

Referrals can be made for an indefinite period. but this is generally used for conditions that are unlikely to go away. For example, you could be referred to an Endocrinologist for help with managing diabetes indefinitely.

What is a Referral for?

A referral is for a single course of treatment of the specified problem. If a new problem arises then a new referral is needed. Therefore, if you see an Orthopedic Surgeon to manage your broken arm you will need a new referral to deal with your hip replacement.

The Specialist can bill more for a for a first visit, then less for subsequent. Unless a new problem arises, which requires a new referral, you shouldn’t be billed for a new visit after that.

Who does Referrals?

GP can refer to all Specialists.

Opticians can refer to Ophthalmologists. Midwives and Nurse Practitioners are also able to make Referrals under Medicare rules. Dentists can refer to Dental or Orofacial Maxillary Surgeons.

A Specialists can refer to another Specialist but these referrals only last 3 months. An example here could be a Paediatrician may refer to a Paediatric Neurologist to help with management of problematic epilepsy. For ongoing care by the second Specialist a GP’s referral may be needed.

Backdating Referrals

As a Referral is a legal document, Medicare does not permit backdating a Referral.

A Specialist can see a patient without a valid referral only in an emergency. Apparently, if your dog ate your referral, or another good excuse, there is a exemption available for you to claim your rebate if the Specialist notes that the “Referral is lost”. I am sure that Medicare would get suspicious if this happened a lot. Medicare do audit what GP’s and Specialists get up to make sure the rules are being followed. There are fines for not following the rules!

If you need a Referral make sure you see your GP before seeing the Specialist if you wish to get a Medicare rebate for the service. Asking your GP for a backdated Referral is like asking the Specialist to forward date your consultation so you can get a Referral. Both are not permitted under Medicare.

One final thought

Surprisingly, your may find that your GP may actually be able to fix the problem you want a Referral for and save the inconvenience of seeing a Specialist.

Medicare rule can be found here

Here is a summary from the AMA

For more details you may wish to read the Health Insurance Act 1973 and Health Insurance Registration 1975 but it isn’t easy reading with its subsections and subregulations, respects and accordances. Lots of Legal speak.




Medical Podcasts

Where to find Medical Podcasts?

I’ll avoid the Podcosts which I don’t do because the “F” in FOAMed is free.

Well  you could go to iTune for your medical podcasts, which include some “podcosts” here

Or if you prefer Android or PC and if you don’t want to contaminate your PC with Apple stuff then click on the Podcaster’s website to link to the podcast.

Be warned iTunes catalogues a lot, an awful lot of podcasts, more than enough to turn your brain off and makes you walk into a passing bus.

So here is a much shorter list of stuff that I have listened to from time to time.

Australian Prescriber podcasts

Bit’s and Bumps for women’s health from Penny Wilson and Marlene Pearce

Broome Docs by Casey Parker. Currently there are almost 100 podcasts to enjoy. I haven’t listened to them all.

Dr Daniel Aranov’s EBM Podcasts These are easy listening and good humoured. I like these Daniel, keep up the hard work.

Don’t forget the Bubble for paediatric stuff

EmCrit by Dr Scott Weingart an ED Intensivist from New York.

ETM as in emergency trauma medicine

GP Skeptic by Dr Justin Coleman being educational and well skeptical

IM Reasoning Drs. Art Nahill and Dr. Nic Szecket, have a passion for teaching clinical reasoning.

Life in the Fast Lane with a lot of other stuff

Reach MD really sounds like a radio for medical stuff from the US

St Emlyn’s podcasts on academic emergency medicine

The Health Report by Dr Norman Swan

Therapeutics Education Collaboration Canadian’s promoting healthy skepticism and critical thinking

The Good GP from Drs Tim Koh and Sean Stevens, in collaboration with RACGP WA.

The GP Show by Dr Sam Manger

This one will have stuff interesting for GP’s too

The Purple Pen Podcast is a fortnightly discussion about clinical pharmacy in Australia.


If you think any should be added please let me know at

Most of the major medical journal offer a podcast on recent articles with author interviews.

Australian Family Physician

America Acedmy of Family Physician



Medical journal of Australia


The Lancet


There are a lot, what is your favourite?


Would you take seal oil?

In a recent Diabetes Management Journal that ended up my desk. “Could seal oil reverse diabetic neuropathy?

This article refers to a study done in Toronto, Canada on just 40 type I diabetic patients whose peripheral nerves have been damaged by their illness. This was an open label-study, proof of concept study. So not randomised nor blinded. The authors used corneal confocal microscopy to look at the changes in the corneal nerve fibre length as a surrogate for more peripheral nerve damage, thus avoiding the need for a nerve biopsy.

The study has been taken up by a number of web and print medical news journals,

I wonder if the editors of these news journal, or indeed the authors of the research paper considered the ethical dilemma of harvesting oil from species protected in many countries around the world, including Australia.
The oil used in this study was sourced from Auum who according to their website are at the forefront of omega-3 supplements. Further, it claims to be “dedicated to developing and manufacturing superior nutritional products to support the health of all.” That is of course unless you happen to be a Canadian seal.

The Harp Seal (Pagophilus groenlandicus) appears on the IUCN Red List as an creature (some would say resource) of “least concern”. Canada’s seal hunt remains mighty controversial even within Canada. National Geographic asks why Canada still allows a seal hunt. And there is more emotive posts about Canada’s seal hunt, for example The Dodo website. Obviously there are proponents of seal hunting, and you can buy seal products, such as Canadian Sealers Association. Another proponent of seal oils suggests that the cute cuddly white coated variety are no longer hunted. It is okay to harvest these older seals as they are able to swim on their own and have left or been abandoned by their mothers. So that makes it okay if they are “abandoned”. Kerthunk…..

A problems with seal oil is the potential for contamination. One product blurb for seal oil appears to suggest that their product is safe as it is bio-filtered fish oil. As seals are much higher in the food chain than fish, “seals use their digestive system to filter out the many natural impurities found in fish.” Conversely biological dogma suggests the further up the food chain you travel, the more likely you end up with more contaminants, such as mercury, PCBs etc, not less. Dr Ho, who can sell you seal oil overcomes this problem through a process molecular distillation. His process removes all the impurities, such as mercury, metals and PCB’s from the oil and makes it a purer product that is safer for human consumption.

Interestingly, I found on DPAGold another Canadian seal oil distributor’s website this paper written by researchers at RMIT, Melbourne and supported by Meat and Livestock Australia. The authors suggested that taking 10 seal oil capsules a day “may be more efficient than fish oil at promoting healthy plasma lipid profiles and lowering thrombotic risk”.  Thankfully, Meat and Livestock Australia will have to keep their hands (or clubs and harpoons) off Australian seals through federal legislation.

Personally, if I need more omega-3 in my diet I would be using the Australian Heart Foundation list of natural dietary sources and thankfully omits seals, which are protected in Australian waters.


Emergency at 30,000 feet.

Three hours into an intercontinental flight, the dark blue waters of the Pacific ocean pass below. A cloudless azure sky offers contrast. The remains of another airline lunch has been collected. Postprandial heads began nodding. A few fellow passengers have already succumbed to slumber assisted by duty free spirits.

 “Can a medical practitioner please make themselves known to a member of the cabin crew, please”

A few people steal quick looks around. Maybe hoping someone else may volunteer, maybe just curious.

Finally, a hand reaches for the call button, a red light came on with a ding. Dave stands, sweeping the remains of crumbs from lunch from his shirt front. He adjusts his glasses and steps into the aisle. A flight attendant strides up with a serious professional look on her face. “Come this way please” and he follows her to the rear of the aircraft. There, a young lad lays curled up looking like he was in some distress. A plaintiff cry intermittently escapes his lips. Next to him a woman, obviously his mother, is worriedly mopping his brow, saying “shhh”. The Father similarly worried, is in the next seat to the the pair.

“Are you a doctor?” the Purser inquires “Do you have some identification?” she continues, demanding polite but firm.

Taken a little aback Dave mutters “Yes, just a minute” he fumbles his wallet from his jeans. Chuckling as he looks through his wallet for some form of identity, “Maybe I should have worn my stethoscope around my neck?” Finally he pulled out his RACGP ID card and offered it. “Hmmm, okay that will do”, the Purser accepted. “Can you help with this young man. He has pain”.

Dave takes the empty seat next to the lad and asks a few questions of the lad’s parents. He lays a confident palm onto the lad’s belly, skilfully feeling, discerning the pain and its possible causes. He nods, knowingly distilling the information. He stands to talk to the Purser, “Where’s the nearest place we land to get the lad to a hospital?” In the blue emptiness of the Pacific there was no where closer than from whence they came. Dave rubs the quickly developing stubble on his chin. He knows there is but one thing he can do.

He turns back to the parents to explain what he must do. Colour drains from the Mother’s face, the Father just nods, silently shocked. Dave looks into the offered medical kit then turns to the Purser, whispering a few requests. The pair heads to the first class galley.

Dave returns, having marshaled his resources and equipment from what he could find. He gives the lad a large tot of first-class OP rum, splashing more onto his own hands and the remainder onto the now naked groin of this stoic young lad. He directed the two burliest cabin crew to hold onto the lad’s arms. To the parents he whispered “its going to be okay, just breath”.

The father solemnly nods to Dave then looks into his son’s eyes, which are now tightly shut unaware of what is about to happen.

Dave pulls on the latex gloves, flicking the cuffs. There is a hush only broken by the noise of the jet engines outside. Armed with sharpest steak knife Dave could find, still warm from its dunk in boiling water, he skilfully cuts into the lad’s tense scrotum. Linen serviettes soak up the blood. He picks up a pair of nail scissors and eye brow tweezers and continues his artful surgery.

The lad gives a rum tainted groan and gratefully lapses into unconsciousness. A young lady in seat 25E quietly vomits into a sick bag. Her partner grimaces and crosses his legs.

Adroitly, Dave untwists the dusky organ on its stalk. A flush of fresh blood fills the testicle. Those watching burst into spontaneous applause.

Finally Dave uses the Purser’s stapler to close the wound and wraps the scrotum in a clean silken scarf.

The young lad’s Father gives a weak smile knowing his son’s future progeny has been saved. Dave wipes his hands on a fresh first class serviette.

The Purser directs Dave to his first class upgrade, hands over a card for lifetime membership of the airlines Gold club and cracks a bottle of Moet. “Well done Doc, I’d fly with you any day”

Behind, the final smart phone camera video light flicker off awaiting an active wifi link.

The pilot announces that the planned emergency diversion to Kiribati is no required to the grateful passengers.

– A work of fiction


And if you thought this impossible and not too sqeamish…

Slow Medicine

I recently began working in a new Mackay medical practice started by Dr Nicole Higgins called Health on Central.  And when I say new I mean new. Last time I visited the building it was to buy some screws as it had previously been a hardware shop. Sadly, competition from the mega hardware supermarkets down the road meant the the business became unsustainable and it closed down. Turning a gutted hardware store into a multioffice medical clinic was an adventure I’m sure she will tell you.

The clinic still has an industrial look about it, big windows bring in natural light, a living plant wall, a bench from an old train station and dining table in the middle of the waiting room.

Because the clinic is new, I get to spend 30 minutes with patients and this really has opened my eyes to a different way of practicing medicine. I felt I had time to listen to patients story. Studies have shown that a patient is interrupted at between 12 and 23 seconds after starting their story. Obviously this interruption may mean vital information may be lost and it can make the consultation longer. The silence of the doctor is a neglected tool in building rapport. They are many papers which focus on improving doctor -patient communication. Dr David Dugdale wrote Time and the Patient–Physician Relationship in 1999 which is a good starting point for those seeking to improve the efficiency of time spent in consultation. Dr Simon Morgan, who tried to teach me General Practice up in the NT, wrote this a paper on consultation skill tips for new GP registrars.

Dr Nicole recently exclaimed “Slow Medicine” in a GPDU post, and I thought that sounds like a really good idea. I have a slow cooker at home and I can use it to make wonderfully richly flavoured food. As I discovered Slow Medicine is not a new concept. Dr Alberto Dolaro an Italian cardiologist, wrote about in 2002. It is said he was inspired by the rising Slow Food movement, a reaction to Macdonalds in the culinary heart of Italy. His paper’s abstract describes his ideas,

In clinical practice, hyperactivity is often unnecessary. Adopting a strategy of “slow medicine” may be more rewarding in many situations. Such an approach would allow health professionals and particularly doctors and nurses, to have a sufficiently long time to evaluate the personal, familial and social problems of patients extensively, to reduce anxiety whilst waiting for non urgent diagnostic and therapeutic procedures, to evaluate new methods and technologies carefully, to prevent premature dismissals from hospital and finally to offer an adequate emotional support to the terminal patients and their families.

This goes beyond the drive to improve efficiency in the consultation. The movement focusing less on the time but more on the relationship between doctor and patient, the connections made and our shared humanity. The Slow Medicine has been aligned with the Choosing Wisely movement which aims to educate both doctors and patients that quality of healthcare can be achieved by eliminating unnecessary and sometimes harmful tests, treatments, and procedures. Yes less tests can be better for you.

If you are interested in reading more opinions and thoughts on Slow Medicine here are a few links.

Direct to the source but you will have to rely on google translator if you don’t speak Italian. Slow Medicine Society.

I love the snail logo and their Manifesto which is available in English.

Sobria, Rispettossa, Giusta

Measured, Respectful, Equitable

And if you speak Portuguese have a look at the Brazilian version of Slow Medicine.

If Slow Is Good For Food, Why Not Medicine?

I’m so glad I don’t work in an eight minute medicine world!

For the Very Old, a Dose of ‘Slow Medicine’

I think it is not just important for older patients, I think all ages will benefit.

This paper discussed the pressures those who practice Slow medicine may face.

Dr Michael Finklestein is a strong proponent for slow medicine you can read his thought on his website and his Huffingtonpost articles.

As he says

“In our fast-paced world, we often look for quick-fix solutions to our health challenges, not realizing that these “solutions” in fact may contribute to our problems. Most health challenges are the result of an imbalance in our bodies and lives, and most quick-fix solutions actually exacerbate these imbalances. If, instead, we take a Slow Medicine approach – identifying the root cause of our health challenges, then creating a thoughtful, step-by-step, and long-term response to it – we effectively bring ourselves back into balance.”

If you are interested in benefiting from Slow Medicine, the next time you book an appointment with your doctor, ask how long you get for a standard appointment, and if you think you deserve more than 8, 12 or 15 minutes, ask for a double or even a triple slot, it may make for a less time-stressed appointment.

And, finally I’m sorry if I am running late one day, someone maybe needing my slow care!

Doc, those new tablets just aren’t working so good….

Conversation overheard by the consulting room fly

“Hi Mr Brown, what have you done today?”

“Oh not much Doc, those new tablets you gave me for my back aren’t working as good as my last lot”

Hmmm, checking the prescription record and seeing no change in the medication.

“I haven’t changed your tables for a while, what happening?”

“Those new green tablets for my back pain, well they don’t work as good as the white ones. Hang on I’ve got those tablets in my pocket.”

Living in a world where there is supposedly generic equivalence I wondered if Mr Brown was inadvertently taking the wrong tablet. After all the TGA website suggests,

“A generic prescription medicine works in the same way as the existing medicine. What matters is the active ingredient, which is the same in the generic brands and the existing brand.”

Mr Brown handed over a packet of tablets which contained exactly the same medication as the one prescribed. Except that the brand I prescribed was indeed white and these were green.

Can the colour of tablet really affect how a patient may perceive its effectiveness?

Well yes it would seem!

Delving in to the BMJ from 1970, a trial in 48 patients with anxiety found that changing the colour of oxazepam tablets from red to yellow to green affected the response to the medication. Anxiety symptoms responded better to green and depressive symptoms responded better to yellow. Adverse effects were found not to be colour related. Unfortunate for the authors, despite the trend statistical significance was not achieved.

The colour of a placebo tablet has been found to influence patient’s perception of effect. an earlier study from 1962, revealed that the “maximum” placebo effect was obtained when the patients were given a placebo of the preferred color and the least effect obtained with the non-preferred color.

A more recent Dutch study found  perceived action of coloured drugs showed that red, yellow, and orange are associated with a stimulant effect, while blue and green are related to a tranquillising effect. It has been found that red stimulants work better than blue.   707cbd96c92af08d2c6bcec1af06c708

There has also been found a difference in efficacy between tablet and capsule of the same medication and shape and size of tablets.

Strange creatures aren’t we.

“Well Mr Brown, what i think you need to do it have a chat with your pharmacist and make sure you stick to the brand which you think works better.”

A What rush?

<<Rant Alert>>

Thanks TGA

It would seem the TGA would now like Australian doctors speak more like our cousins across the Pacific Ocean in America, that is. There is a updated list of the politically correct names we should all now be using for a select group of drugs. I know these are really the International Nonproprietary Names but it seems that most of the names are being changes to what Americans call their drugs rather than what generations of Australian doctors have called them.


adrenaline 6adrenaline 9adrenaline 3 adreanline 3

Adrenaline shall now be called epinephrine. the sight of a white pointer rushing at you on a small yellow kayak, the feeling as you catch a 100 foot wave or jump from a perfectly good plane  or a solid mountain top, or as you touch 300kph in top gear will now forevermore be an EPINEPHRINE RUSH. Doesn’t really sound the same does it?

Noradrenaline, the alpha receptor specialist, likewise shall be known as norepinephine. Must venlafaxine now be called a serotonin, “norepinephrenergic” reuptake inhibitor? Maybe the Americans were getting confused with North American Aerospace Defense Command when someone called for a box of Norad?

Amethocaine my old friend, a sight for a sore eye, now is tetracaine but it may be better if you have four eyes.

Apparently amphoterin gains a “B”. Not sure what happened to amphotericin A. Maybe the “B” is for better.

All the phenobarbitones are now phenobarbitals but that just doesn’t sound right, too aggressive, these drugs are supposed to be more sedate. Amylobarbital, barbital, secbarbital, nembutal (well that one seems to have snuck in for a while), thiopental…

There are few changes that just seem stupid. Where am I to put methylrosanilinium chloride? Oh, if you told me it was crystal violet then maybe I’d  have a better idea.

I will not be moving the “u” and writing an “o” in frusemide. Just to make that clear. It’s like calling my best mate “Buroce”, sorry Bruce I’m not making fun of you it just won’t happen.

Maybe I can drop the “e” from eformetrol, it might make it sound less rude.

Lignocaine remains lignocaine in my mind and you can put that lidocaine and epinephrine right back and give me what I asked for sister!

There are bunch of other changes which just confuse me like dosulepin instead of dothiepin.

There is a list of minor changes too. Such as we are now supposed to drop the “y” in amoxycillin an change it to a “i”. Also pericyazine become periciazine. Surely there are enough vowels in there already, give the consonants a go please. And of course, son’t forget about the “ph” in cephalexin, cephamandole, cephazolin, cephalothin…..  I see even Wikipedia still call this group cephalosporins. Okay a couple with the “f” have already settled into our local formulary …. ceftriaxone, ceftazidime, and cefotetan….

Its not just antibiotics that loose the ph its also Phytic acid becomes fytic acid. I guess it goes the way of telephone, physiotherapy, phallus, physics and farmaceuticals. Dammed its happened already. Mooo

We loose the “o” in oestrogen and all its cousins like oestradiol and oestriol. It is a word rooted in the latin word oestrus.  Bit like orthopaedic, paediatric and gynaecology…..

Tioguanine, etacrynic acid, beclometasone  and indometacin all seem to be missing a “h” Do the INN committee members have something about touching the tongue to their toot?

Its wong I tell you all wong. See you need that extra consonant otherwise you’ll be making fun of all sorts of people.

Give me Paraffin – soft white any day over soft white paraffin.

Enough….read the list. As I read through the list I wonder how many TGA committee meetings in Canberra it took to devise this list. Or was someone bored one Friday afternoon. No new drugs to approve, hey let’s change some names?

Yep Thanks TGA for surrendering to all things America, sorry INN.

At least we bought a French submarine…. Hopefully they will be launched with a nice bottle of Australian Champagne oops sparkling white, preferably from the Clare or Barossa valley.

Oh by the way, we are still apparently permitted to call paracetamol, well paracetamol. So shove that non-INN acetaminophen suppository up your bum America.

<<Rant Over>>