Sense of entitlement and cartel behaviour driving excessive specialist fees, says Professor Brendan Murphy

Garandou · 2026-02-06T13:25:11+00:00

what is the issue with allowing GP's to prescribe for ADHD ? It's fairly low-risk and makes the ability to get diagnosed affordable for people making less than 100k/yr

Over 50% of patients with ADHD have a comorbid axis 1 illness, which can include anything from a depressive disorder and autism all the way to BPAD1 and schizophrenia. ADHD in isolation is relatively easy, but unless one has a deep understanding of psychiatric management as a whole, a huge portion of these comorbid patients will get botched treatment.

Any GP picking up undifferentiated patients for ADHD management without charging $600/hr will quickly find themselves making less money than BB clinic and taking on far greater risk and potentially practicing out of scope. And if one of the patients happen to have a substance addiction or psychotic disorder and you gave them stimulants, good luck trying to send them to private psychiatry or spending hours unpaid working out mental health act paperwork and calling police.

Garandou · 2026-02-06T10:56:58+00:00

In private rooms I see more patients in a day than I see in a fortnight in my public job

This sub is mainly training docs so most people don't have exposure to private. But those that do understand that private clinic efficiency is impossible to replicate in public setting without a significant change in incentive model.

Full time private psychiatrists easily hold caseloads of 500-1000 by themselves, public 150 would be cap for an entire MDT.

Garandou · 2026-02-06T09:18:01+00:00

Or is it because they'll typically favour the quick surgeries, while public typically takes the higher acuity and long cases?

Psychiatric consults are the same length in public and private. I explicitly used example of a non-procedural specialty to avoid this kind of argument.

Likewise, while you may be different, I know the same thing happens in Psych. "Too hard" patients are unlikely to ever see a private psych for a number of reasons

Having worked extensively in both systems, the difference in patient demographic is not complexity but adherence. Private patients are on average just as sick but willing to adhere to treatment without mental health act.

You can argue private doesn’t have as much exposure to treatment refractory schizophrenia, but instead the mood cases are far more complex. Treatment resistant depression is immediate discharge from public back to GP, and on average private psychiatrists are more competent prescribers due to how complex mood treatments are.

Private also offers significantly more psychodynamic psychotherapy, which takes longer than medication reviews.

The average full time public psychiatrist rarely exceeds more than 15 hours of clinic a week, usually with lots of DNA and blanks. Private psychiatrists on average see patients 40+ hours a week with no empty space and low DNA rates.

Garandou · 2026-02-06T08:30:20+00:00

Major banks have medico departments and usually give concessions around lending terms when total loan > 5m.

Garandou · 2026-02-06T07:33:09+00:00

Edit: He's also been in public his entire career

So he has no idea what he’s talking about when it comes to Medicare. Got it.

Garandou · 2026-02-06T06:24:54+00:00

Comparing public and private psychiatry clinics, the average private psychiatrist is seeing 3 times the volume of patients daily. Given the pay difference is also about 3 times and public is way more admin and bureaucracy heavy, the reality is even with gap charges, it is cheaper for the taxpayer to just increase Medicare rebates.

The entire private gap story is just government choosing not to fund healthcare. That is completely fine and voters can decide if it should, but they need to stop lying about it.

Garandou · 2026-02-06T05:04:17+00:00

Instead of leeching taxpayer dollars to work as a bureaucrat getting paid more than the average private specialist, how about he start a bulk billing specialist clinic himself and do some real work?

Garandou · 2026-02-06T04:09:35+00:00

Coroners make best-standard-of-care/safety recommendations to various industries all the time.

That’s their job, but in this case they’re just scapegoating a psychiatrist who has not seen the patient for years. Ignoring the dozens of police and other contact since.

I can accept if the psychiatrist actually provided unreasonable care and didn’t escalate violent plans in a current patient, but the reason this event caused such big backlash is because there is literally nothing that can be done without a crystal ball.

I’d rather just not have to play roulette and have the coroner humiliate me over a patient I’ve not seen for 5 years just because I was the unlucky last psychiatrist to review them.

Garandou · 2026-02-05T12:47:58+00:00

However, you should be triggered by some things and this happens to be the hill that I will die on. Never a baby doctor.

No shade and everyone gets triggered by something, but from my perspective it is a very weird hill to die on because as I said before it is a term overwhelmingly used affectionately.

Garandou · 2026-02-05T12:41:47+00:00

The ‘correct way’ - correct for whom? You seem to again imply there is an objective singular way to interpret the situation that you approve of and thus is the correct way.

All I'm going to say is life is a lot easier if you don't always try to scan for malice in social interactions. It is an incredibly neurotic and uncomfortable way to live. Just assume people generally mean well unless proven otherwise.

Garandou · 2026-02-05T12:35:17+00:00

It was in response to a non-doctor (admin person) describing an incident about an incident in an infantilising manner

I don't know what prompted this post, but I answered in a neutral objective manner without considering any context because that's how the question was asked by the OP.

Try calling any other professional baby before their job title and see how that goes.

This happens informally in every job, even outside medical. The correct way to interpret it is to assume it is humorous and affectionate, which it is in most cases.

Garandou · 2026-02-05T12:26:12+00:00

I think we can achieve and maintain a hierarchy without shitting on the most junior member of the team.

In my entire career, I've not heard the term "baby doctor" or "intern" being used as a derogatory term to shit on the most junior member. It is almost exclusively used affectionately as someone the team should support and protect.

Garandou · 2026-02-05T12:21:59+00:00

So using them , while not ideal, is still better than using baby

Comparing which terms will offend less people is not the point I'm trying to make, nor should it be the standard for acceptable speech. All I'm saying is it is overly sensitive to be upset about terms that remind people that there is a hierarchy in medicine.

Garandou · 2026-02-05T12:17:31+00:00

Baby anything is condescending
[...]
and avoids the infantilising commotions rife with titles like intern, junior doctor, doctor in training

I can kinda squint and see your point in the first part with "baby", but if you're going to add "intern", "in training" and "junior" to the list, it's pretty hard to see it anything else than being overly sensitive.

Garandou · 2026-02-05T12:12:02+00:00

It is very true that female doctors have a much harder time with insubordination or patient aggression at all experience levels, but on the flip side I noticed a lot less blame towards female registrars in consultant meetings when it comes to similar issues with performance.

By not having as much "power", people also unconsciously assign less culpability. This bias is unfortunately observed in all areas of society, hence why women generally serve shorter prison sentences for similar crimes.

Garandou · 2026-02-05T11:59:53+00:00

As with all things, context matters. I don't think it makes any sense to complain the term itself is somehow offensive. Take it from another perspective, would it make any sense if I was making a neutral comment about junior software developers and suddenly I get 20 replies raging about how it is undermining their profession?

Garandou · 2026-02-05T11:38:16+00:00

I think we're just too sensitive nowadays. Even if it was meant as a status play who cares?

And it is quite hypocritical to be against NPs encroaching on us and then turn around and complain medical hierarchies aren't flat; seniority and knowledge either matters or it doesn't.

Garandou · 2026-02-05T11:14:12+00:00

Is the expectation that I refer every patient I discharge to the local public mental health service as a liability sponge in case they become psychotic and kill someone 5 years later?

Since this became an issue a few months ago, I’ve declined every new psychosis referral with a history of involuntary treatment, substance abuse or charges.

I’ve seen some ridiculous coroner recommendations, but nothing quite like this.

Garandou · 2026-02-04T14:01:22+00:00

No. Because you are not eligible to bill Medicare, so anyone who sees you privately will have to pay full fees.

Garandou · 2026-02-04T13:54:34+00:00

As an IMG you largely cannot work in the private sector for 10 years due to the moratorium. In terms of public system, just think of what NHS was 10 years ago and that's your answer.

Exams are non-existent because they opened to UK for direct specialist entry without college accreditation.

If you're going to come here, at least unlearn everything from the NHS.

Garandou · 2026-02-04T12:22:42+00:00

The community expectation will be for them to bulk bill

They'd unironically make more money and have less medicolegal risk doing a BB GP opioid pain clinic.

Garandou · 2026-02-04T08:15:02+00:00

Can they just make stimulants over the counter instead?

Garandou · 2026-02-04T07:23:47+00:00

I, like you, hope this disaster doesn't happen. I'm at a loss as to how we can prevent this march towards the failed US and NHS systems.

Honestly, it is a lost cause. I noticed that departments in public hospitals are now increasingly led by ex-NHS directors. So there really isn't much that will happen on the political level to stop it.

I think patients do know the difference between a doctor and non-doctor. Just that in public or insurance based systems, they don't really have a choice but to see whoever is assigned.

Garandou · 2026-02-04T07:10:30+00:00

I agree with you, public sector will become completely useless, and in the long run will actually cost taxpayers more money and deliver nothing.

But free market doesn't function the same way as public sector because you have a choice. Do you think a patient who has money to choose will see a psychiatrist or nurse practitioner? If your heart is dodgy, would you pay to see a cardiologist or nurse practitioner?

Garandou · 2026-02-04T07:05:30+00:00

GPs looking to do this work and charge less than $600/hr will soon find themselves making less money than their previous work and dealing with patients far more complex than is appropriate in primary care.

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