The Complete Confessions of a GP
Benjamin Daniels
Confessions of a GP and Further Confessions of a GP together in one volume.Benjamin Daniels is angry. He is frustrated, confused, baffled and, quite frequently, very funny. He is also a GP. These are his confessions.
The Complete Confessions
Dr Benjamin Daniels
Copyright (#u9540845d-d86e-56bf-a3c9-5eed3417bedb)
The Friday Project
An imprint of HarperCollinsPublishers 1 London Bridge Street London SE1 9GF www.harpercollins.co.uk (http://www.harpercollins.co.uk)
This ebook first published in Great Britain by HarperCollins Publishers Ltd 2015
Copyright © Benjamin Daniels 2015
Cover design © HarperCollinsPublishers Ltd 2015
This book contains two previously published titles: Confessions of a GP and Further Confessions of a GP.
Benjamin Daniels asserts the moral right to be identified as the author of this work.
A catalogue copy of this book is available from the British Library.
All rights reserved under International and Pan-American Copyright Conventions. By payment of the required fees, you have been granted the non-exclusive, non-transferable right to access and read the text of this ebook on screen. No part of this text may be reproduced, transmitted, downloaded, decompiled, reverse engineered, or stored in or introduced into any information storage and retrieval system, in any form or by any means, whether electronic or mechanical, now known or hereinafter invented, without the express written permission of HarperCollins.
Ebook Edition © April 2015 ISBN: 9780007569755
Version: 2015-06-27
Contents
Cover (#u65759714-9cfa-5abc-9757-3fab283cd733)
Copyright (#u863ca01f-48a8-5a77-ab40-060179498463)
Title Page (#ub6e1c072-3280-5578-acca-caba4bc1af7a)
About the Author (#u83f768af-4ffe-5dc0-a2b8-772e015b7f25)
Disclaimer (#u38eeefb0-d261-5257-9ecd-adb06a05e4e8)
Confessions of a GP (#u8f7dd87c-1f9f-513a-9231-d6c9d4ac3cc7)
Further Confessions of a GP (#litres_trial_promo)
Also in the Confessions Series
About the Publisher (#litres_trial_promo)
About the Author (#u9540845d-d86e-56bf-a3c9-5eed3417bedb)
DR BENJAMIN DANIELS is the pseudonym of a doctor currently working for the NHS. He can be reached at drbenjamindaniels@hotmail.co.uk (mailto:drbenjamindaniels@hotmail.co.uk) and @drbendaniels1
The events described in this book are based on my experiences as a GP. For obvious reasons of privacy and confidentiality I have made certain changes, altered identifying features and fictionalised some aspects. Nonetheless, it remains an honest reflection of life as a doctor in Britain today. This is what it’s like. These things really happen.
Contents
Cover (#u8f7dd87c-1f9f-513a-9231-d6c9d4ac3cc7)
Who am I? (#u89e7bc6e-1e99-5c11-9108-c495b6c58af5)
Introduction (#ufa2c7815-5509-5457-974f-b0a4ea11ceb5)
Mrs Peacock (#ub5e6699f-3132-5722-ae93-85194bb86c8f)
Tom Jones (#uf5a2ff6a-e570-5f39-9894-8162dd922a19)
Targets (#u7448b00f-05d0-5ef4-8f7e-14a5e72ed713)
First day (#uea1dae54-4a8a-589b-9467-85fc0bdb026d)
Jargon (#ua8677cb1-7b13-57c6-aa1f-30725f2b5d24)
Proud to work for the NHS (#u93d42508-f11e-5bf1-a8b5-69e812f7ef94)
Drug reps (#u39743af1-5c87-59d6-92d7-7c28702d8935)
Mr Tipton, the paedophile (#u9bc2e0d1-35d2-5bfa-94a5-bb9bc13f80a2)
Average day (#ua1847ebc-2c04-5b44-b40a-f4458d71b2c7)
Tara (#u1a356022-d910-5c3b-9c71-5029827433fa)
Sex in the surgery (#u2d4db418-dc24-50e4-a3de-ba039e64cd8c)
The elderly (#u54362986-04b5-5a08-9902-c3053975b6e3)
Bums (#uba020cda-3af5-5d11-8761-6dbd85acc9bc)
Julia (#u56643b21-bf86-5e2b-ab1c-75081ad9c79f)
Good doctors (#ucd91f27b-8974-5e17-99f4-a7f721636030)
Connor (#u15d6f8b1-8cb8-5015-a53a-942e6b1cc74b)
Janine (#u410cf9b4-f82e-5922-bbf6-c1548b481146)
Saving lives (#u2ea2d080-8c24-5a49-a425-51299393535c)
Kirsty, the trannie (#u8da4add7-fe90-5e90-b423-edb43a7035d8)
‘It’s my boobs, Doc’ (#u6aacd137-db4f-525f-918a-b43d47f24885)
Mr Hogden (#u20caa4a3-553d-531b-ba14-53fc908363b4)
Small talk (#ubb12e7d0-4c57-5738-ae0c-e883c807e680)
Notes (#u2b0695cc-eec7-5571-92eb-45837184d9b4)
Lists (#u37fe15dd-9e75-5b0c-8027-512ee5f5f970)
Ten minutes (#u35b00cbe-70b6-59de-b75a-6a5a639386ea)
Alf (#uc78d543b-88fa-5ab4-8c0f-d02ce85661fb)
Meningitis (#uc42cc258-12d9-51c5-ab4a-e9df40676adc)
Uzma (#u816fb39b-697c-5c80-a48a-4d9de6ab6c49)
Africa (#u70662df7-5dc0-5ef4-8cd1-ab67cfa87b45)
Evidence (#u9c4e6dee-95e0-5828-bd12-e6cd66da476b)
Carolina (#uc67e2013-1122-59f6-8228-2dce1adfb5ac)
Lee (#u2fd03151-8599-506e-82e0-334c4853778f)
Hugging (#u40d6141b-c1da-5e6b-ba5b-069ed845f430)
Tough Life Syndrome (#u844240f9-555e-5cb4-90da-0c092d005c77)
Mrs Briggs (#u040d1b4f-4c49-5882-ac42-7d90b7f9d43d)
Betty Bale’s cat (#u62c83502-fda8-55b0-9ff6-12f3636794d6)
Vaccines (#litres_trial_promo)
Darryl (#litres_trial_promo)
The pat dog (#litres_trial_promo)
Rina (#litres_trial_promo)
Dos and don’ts (#litres_trial_promo)
Home births (#litres_trial_promo)
Michael (#litres_trial_promo)
Alternative medicine (#litres_trial_promo)
Thai bride (#litres_trial_promo)
Dead people (#litres_trial_promo)
Holistic earwax (#litres_trial_promo)
Obesity register (#litres_trial_promo)
Dr Arbury (#litres_trial_promo)
Body fluids (#litres_trial_promo)
Racism (#litres_trial_promo)
Sleep (#litres_trial_promo)
Magic wand (#litres_trial_promo)
Cannabis (#litres_trial_promo)
Sick notes (#litres_trial_promo)
Drug reps … again (#litres_trial_promo)
Mistakes … I’ve made a few (#litres_trial_promo)
Dying (#litres_trial_promo)
Happy pills (#litres_trial_promo)
Top 1 per cent of the population (#litres_trial_promo)
Computers (#litres_trial_promo)
Kieran (#litres_trial_promo)
Peter (#litres_trial_promo)
Granny dumping (#litres_trial_promo)
Aggressive conduct disorder (#litres_trial_promo)
Ed (#litres_trial_promo)
Camouflage man (#litres_trial_promo)
Memories (#litres_trial_promo)
Fighting (#litres_trial_promo)
Class (#litres_trial_promo)
Tingling ear syndrome (#litres_trial_promo)
Gary (#litres_trial_promo)
Beach medicine (#litres_trial_promo)
Gifts (#litres_trial_promo)
Politics (#litres_trial_promo)
Passing judgement (#litres_trial_promo)
The examination game (#litres_trial_promo)
Sex (#litres_trial_promo)
Money (#litres_trial_promo)
Angela (#litres_trial_promo)
I don’t like some of my patients (#litres_trial_promo)
Boundaries (#litres_trial_promo)
Smoking (#litres_trial_promo)
Angry man (#litres_trial_promo)
Maintaining interest (#litres_trial_promo)
The future? (#litres_trial_promo)
Tariq (#litres_trial_promo)
Babies (#litres_trial_promo)
Read on for some brand-new chapters from Dr Daniels … (#litres_trial_promo)
Why do people get sick? (#litres_trial_promo)
Malcolm (#litres_trial_promo)
A pair of glasses (#litres_trial_promo)
Stewart (#litres_trial_promo)
NHS reforms (#litres_trial_promo)
Barry (#litres_trial_promo)
Tuition fees (#litres_trial_promo)
Please don’t outsource our receptionists (#litres_trial_promo)
Fit to work? (#litres_trial_promo)
Royal Wedding (#litres_trial_promo)
Abortion (#litres_trial_promo)
Taking responsibility (#litres_trial_promo)
France vs UK (#litres_trial_promo)
The NHS is brill (#litres_trial_promo)
My patients are brill (#litres_trial_promo)
Who am I?
Humans have a universal desire to be listened to and share their stories of pain and suffering. My job as a GP is to listen to those stories. Sometimes I interject with some suggestions or medications, but more often I am simply a passive observer of the soap operas that are people’s lives. With regular appointments, I watch the characters develop and the narratives unfold. Although some of my patients have an overinflated view of my significance, I really am just a walk-on part in their lives. I’m like the extra in the corner of the Queen Vic who tries his best to play a small role in one or two of the storylines, but in reality rarely affects the progress of the plot or the big ending. The advantage I do have is that I get to watch the story unfold from a unique and fascinating angle. Being a doctor gives me a privileged insight into the more private and often bizarre aspects of human life and, with that in mind, let me share some slices of my working life with you.
I love my job and have no regrets about choosing to become a doctor and then a GP. This is quite fortunate really, as my decision to study medicine was made as I chose my A levels at the tender age of 16¼. At this time my only real reservation against becoming a doctor was the knowledge that I would have to endure chemistry A level. I couldn’t really think of any other reason why I shouldn’t be a doctor. What could be better than swanning around a hospital full of beautiful nurses and ‘saving lives’? People would think I was great and ultimately this would lead to me finally getting a girlfriend. As an awkward 16-year-old with bad skin and greasy hair, most of my career aspirations were based on what profession would give me the best opportunity of gaining me some interest from the opposite sex. I had accepted that my carnal ambitions would ideally be achieved by being in a boy band or playing Premiership football, but unfortunately my lack of talent in both these departments led to the inevitable choice of medicine. I chose my A levels in the year that ER first arrived on our screens. A poster of George Clooney in a white coat was on every girl’s wall. Of course I wanted to be a doctor!
On my university application form, I had the good sense to not write that I wanted to be a doctor so I could ‘save lives and hence get laid’. I scribbled down something about my love of ‘working as part of a team’ and my ‘fascination with human sciences’. To be fair, I suppose these statements were also true, but it is so hard to pick a career aged 16. The real world of work is always such a mystery until you enter it. When my mate Tom applied to teacher-training college, he wrote that he wanted to ‘help young people flourish and fulfil their true potential’. After a five-year tour of duty in an inner city comprehensive school, like us medics, he is just trying to get to the weekend without being punched or sued.
Although I’m now a GP, my training required me to spend many long years working as a hospital doctor. I completed five years at medical school and then spent several years working in various hospital posts gaining the experience needed to become a GP. I was a junior doctor in surgery, psychiatry, A&E, paediatrics, gynaecology, geriatrics and general medicine. I also broke up my training with a three-month stint working in Mozambique. All in all I loved working as a hospital doctor but have absolutely no regrets about leaving it to become a GP.
Introduction
I can still fondly recall the first diagnosis I ever made. As with many others that followed, it was spectacularly incorrect, but it still holds a special place in my heart. In my defence, I was just a mere boy at the time, wet behind the ears and only a few weeks into my first term at medical school. I was sitting in the local Kentucky Fried Chicken and spotted a man slumped unconscious in his plastic seat. A wave of excitement flooded over me. This was what it was all about! This was my vocation! With the limitless enthusiasm of youth and inexperience, I bounded over to undoubtedly save his life with my new-found wealth of medical knowledge.
It didn’t take me long to conclude that this gent had suffered from a spontaneous pneumothorax. This was not based on clinical signs and symptoms but more that this was the condition that we had learnt about that morning in a tutorial and so was the first and only diagnosis that sprung to mind. With an air of self-importance, I explained to the KFC manager my diagnosis and instructed him to call urgently for an ambulance. Looking thoroughly unimpressed, he wandered out from behind the counter and roughly manhandled the unconscious man from his seat and threw him out of his restaurant. My first-ever patient spectacularly regained consciousness, uttered a few obscenities addressed to no one in particular and staggered off down the street. The KFC manager in his far superior wisdom had, in fact, made the correct diagnosis of ‘drunk and asleep’ and prescribed him a swift exit from his premises.
I can see why the professor chose to teach us innocent medical students about a spontaneous pneumothorax that morning. It is, in fact, a wonderful feel-good condition for doctors. An otherwise healthy person collapses with a deflated lung and then the clever doctor diagnoses it with his stethoscope and sticks a needle between their ribs. With a triumphant hissing sound, the lung inflates and the patient feels much better. The professor was trying to help explain the normal functioning of the lung and what could go wrong. He was also trying to encourage us to embrace the wonderful healing abilities we could have as doctors. Back during those early days of medical school I believed that most of medicine would be that straightforward. Someone would be unwell, I would do something fabulous and then they would get better.
Funnily enough, despite a spontaneous pneumothorax being the first medical condition I ever learnt about at medical school, I have, in fact, never actually seen one since. Looking back, I wonder if actually a far more useful and accurate introduction to being a front line NHS doctor would have been a tutorial on how to remove a semiconscious drunk bloke from a waiting room:
‘Would everyone please welcome our guest speaker today. He has a long and celebrated career working in numerous late-night fast food outlets and will be giving you his annual demonstration on how to prepare yourselves for spending your futures working in the NHS. Do take notes on how he skilfully removes the inebriated gentleman while remaining entirely unsoiled by any body fluids and simultaneously evading drunken punches. You will be tested on this in your end-of-year exams, so do pay attention.’
When I think back to that KFC, I can still recall my shock at what I perceived to be the terrible ill treatment of this poor man. The callous, heartless actions of the restaurant manager only increased the feeling that my true vocation was to become an amazing doctor in order to cure just such vulnerable people who needed my help …
Ten years later, after a long day of inner city general practice, my brain was heavy with the multitude of sufferings that I had encountered. Chronic pains, domestic violence, addiction, depression, self-harming and a fairly big helping of broad-spectrum misery were the principal orders of the day. After many hours of putting my heart and soul into my patients’ problems, I knew that my competency that day would be judged not on my diagnostic skills or my bedside manner, but by how many targets I had reached from the latest pointless government directive. While finishing the day reading the latest newspaper headline about how GPs were lazy money-grabbers, it was almost a relief to receive an emergency call from reception to tell me that a man had collapsed in the waiting room.
Rather than springing up into life-saving action, I heaved myself out of my blissfully comfortable chair and ambled down to the waiting room. Over the last ten years that limitless enthusiasm had been gradually broken down and replaced with a defeated resignation. I took no satisfaction in this time getting my diagnosis spot on. Still waiting for that spontaneous pneumothorax to heroically cure, I was greeted instead by one of our local street drinkers in a drunken stupor in the children’s play area of the waiting room. Using the expertise I perfected during endless Friday and Saturday night shifts in A&E, I skilfully escorted the intoxicated man from the surgery back on to the street.
In a wave of sad nostalgia I wondered what that naïve 18-year-old me would think about what he had become. Would I have even bothered to have gone on to study medicine if I could have foreseen how so much of that initial hope and optimism would drain away? Not even out of my twenties yet, I began to wonder if being a doctor was anything close to the career I thought it was going to be. As I returned the drunk homeless man on to the street, I offered him an appointment to come back and see me the following morning when he was sober, explaining about organising an alcohol detox. ‘I’ll be there, Doc,’ he told me as he shoved the appointment card into his pocket. We both knew that he’d miss that appointment, but at least we were mutually left with a faint glimmer of hope for something better.
Please don’t imagine that this book is about me looking for sympathy or commiserations about my broken dreams, or assume that I have lost my empathy and respect for the people who expectantly seek my help or advice. I guess it’s just that the often grim reality of practising inner city medicine is not quite what I had expected it to be. I no longer dream of miracle cures and magic bullets and I have definitely given up waiting to dramatically re-inflate that collapsed lung. Instead, I acknowledge that my role is to listen and share the pains, concerns and sufferings of the people who sit before me. I offer the odd nugget of good advice and provide some support at times of need. Perhaps just occasionally I even make a small difference in someone’s life. The intention of this book is simply to give an honest but light-hearted insight into some of the joys, frustrations and absurdities of being an inner city NHS GP today. I hope you enjoy it.
I have only been a GP for three years but I do genuinely love the job. I like the variety and getting to know my patients. I find it challenging and rewarding. Sometimes I even make a diagnosis and cure someone! I’m currently working as a locum which means that I work in different GP surgeries in different parts of the country, covering other GPs when they are away. I also still do some shifts as an A&E doctor from time to time. Some of my posts have just been for one day, others have been for over a year and I get to see the good, bad and ugly side of general practice, patients and the NHS. I love my job and think that it is one of the most interesting out there. I hope that after reading this book you might agree with me, or if not at least realise that it isn’t just about seeing coughs and colds.
Mrs Peacock
Like parents, doctors are not supposed to have favourites but I have to admit to being rather fond of Mrs Peacock. She is well into her eighties and her memory has been deteriorating over the last few years. Most weeks she develops a medical problem and calls up the surgery requesting me to visit. When I arrive, the medical problem has been resolved or at least forgotten and I end up changing the fuse on the washing machine or helping her to find her address book, which we eventually locate in the fridge. As I tuck into a milky cup of tea and a stale coconut macaroon, I reflect that my medical skills probably aren’t being put to best use. I imagine the grumbling taxpayer wouldn’t be too pleased to know that having forked out over £250,000 to put me through my medical school training, they are now paying my high GP wages in order for me to ineptly try to recall which coloured wire is earth in Mrs Peacock’s ageing plug.
Mrs Peacock needs a bit of social support much more than she needs a doctor so when I return to the surgery I spend 30 minutes trying to get through to social services on the phone. When I finally get through, I am told that because of her dementia, Mrs Peacock needs a psychiatric assessment before they can offer any social assistance. The psychiatrist is off sick with depression and the waiting list to see the stand-in psychiatrist is three months. I’m also reminded that Mrs Peacock will need to have had a long list of expensive tests to exclude a medical cause for her memory loss. Three months and many normal test results later, Mrs Peacock forgot to go to her appointment and had to return to the back of the queue.
Through no fault of her own, Mrs Peacock has cost the NHS a small fortune. Her heart scan, blood tests and hospital appointments all cost money and we GPs don’t come cheap, either. Mrs Peacock does have mild dementia but more importantly she is lonely. She needs someone to pop in for a cup of tea from time to time and remind her to feed her long-suffering cat. It would appear that this service is not on offer, so, in the meantime, I’ll continue to visit from time to time. When the coconut macaroons become so inedible that even the hungry cat won’t eat them, I’ll think again about trying to get Mrs Peacock some more help.
Tom Jones
The term ‘presenting complaint’ is what we use when we describe what the patient comes in complaining about – i.e. the patient’s words rather than our diagnosis. Normally as a GP the presenting complaint will be ‘back pain’ or ‘earache’ or ‘not sleeping’. Elaine Tibb’s presenting complaint was different. When I said, ‘Hello Miss Tibbs. What can I help you with today?’ she said, ‘I’m having pornographic dreams about Tom Jones.’ Her words, not mine.
For the more common presenting complaints, most doctors will already have a check list of questions in their heads. For example, a female patient says, ‘I’ve got tummy pain’ and I say, ‘Where, and for how long?’ and ‘Have you got any vaginal discharge?’ When faced with the presenting complaint of pornographic dreams about a celebrity, I was left hopelessly speechless. When discussing Elaine’s sexual fantasies, I was very keen not to know where, for how long and if there had been any vaginal discharge. Unfortunately, I didn’t get a chance to point this out to Elaine before every minuscule aspect of the dreams was described in surprisingly graphic detail.
I am rarely left speechless by a patient’s opening gambit, but as with Elaine, there are always a few that do leave me at a complete loss. My personal favourites are:
When I eat a lot of rice cakes, it makes my wee smell of rice cakes;
I masturbate 10 to 15 times per day – what should I do?
I ate four Easter eggs this morning and now I feel sick;
My husband can’t satisfy me sexually;
When I was in church this morning, I was overcome by the power of the Lord;
I think my vagina is haunted.
Elaine is a classic example of someone that we GPs see fairly regularly. She was odd and eccentric, but not quite mentally ill. She was slightly obsessive and delusional but not really harming herself or anyone else. Admittedly she didn’t work, but she functioned reasonably well from day to day and didn’t really have any insight into the fact that other people found her to be a tad unusual. Instead, Elaine generally saw most of the rest of the world as slightly peculiar and felt it was just her and, of course, her darling Tom Jones who were the only normal ones. Looking through her patient records, I noted that she did once see a psychiatrist a few years back. He diagnosed her as having ‘some abnormal and obsessive personality traits but no active psychosis’. This is psychiatry speak for ‘slightly odd but basically harmless’
‘He does love me, you know, Doctor. If he met me, he would know it straight away. We’re made for each other.’
‘Isn’t Tom Jones happily married and living in America?’
‘No no no! He loves me, doctor.’ Elaine would have happily spent all afternoon telling me about her Tom Jones fantasies, but I felt that we needed to move things on. I used the classic GP phrase that we pull out of the bag when we feel that we’re not getting very far. ‘So Elaine, what are you hoping that I’m going to do for you today?’
‘Well, doctor, I need you to write Tom a letter. It would sound better coming from you. He’s a doctor as well. Well, not a real doctor, but I’m sure he’d be a wonderful doctor if he wanted to be. He’s very kind you know and oooh so gorgeous and anyway, I’m sure if you just explained everything he would see sense, I know he would.’
Basically, I was being asked to stalk Tom Jones on Elaine’s behalf. I could imagine the letter.
Dear Tom,
Please will you leave your wife, family and LA mansion and move into a council bedsit with a slightly odd woman with straggly hair and a duffel coat that she has been wearing since 1983. It will make my life slightly easier as she won’t keep coming to the surgery and annoying me with her graphic descriptions of your imaginary sex life.
Best wishes,
Dr Daniels
Stalking is defined as a ‘constellation of behaviours in which an individual inflicts upon another repeated unwanted intrusions and communications’. Elaine probably would have quite liked to have stalked Tom Jones, but I don’t think she really had it in her. For Elaine, her problems with relating to everyday folk had resulted in her focusing all her energy on an imaginary relationship with a person whom she would never meet. I guess this was a good way to protect herself from the struggles and potential rejections of real-life relationships. Whatever the psychological explanation, I’ll never be able to listen to ‘It’s Not Unusual’ in quite the same way again.
Targets
Lucy, the practice manager, popped her head around the door: ‘I’ve put you down for a visit to see Mrs Tucker. She’s had a funny turn and fallen over. Perhaps you could diagnose her as having had a stroke?’
It is January and our Quality and Outcomes Framework (QOF) targets are due in April. None of our patients has had a stroke in the last nine months. This should, of course, be a cause for celebration, but Lucy is not happy. If no one has a stroke before April, we will miss out on our ‘stroke target’. The government tells us that if a patient has a stroke, we need to refer him/her to the stroke specialist and then we’ll get five points! But if no one has a stroke, we miss out on the points and the money that comes with them. The more QOF points the practice earns, the more money the partners take home as profit. The practice manager also takes her cut as an Easter bonus if the surgery gets maximum points. In the world of general practice, points really do mean prizes.
Some older GPs hate disease guidelines. They feel that they take away our autonomy as doctors and rob us of our integrity and ability to make our own clinical decisions. I myself don’t begrudge guidelines at all. Strokes have been poorly managed in the community for years and some good research has shown that if someone has a stroke or a mini stroke and we sort out their cholesterol and blood pressure and send them to see a stroke specialist, we can genuinely reduce the chance of them having another stroke.
Mrs Tucker is 96 and lives in a nursing home nearby. She is severely demented and doesn’t know her own name. In her confusion she wanders around the nursing home and frequently takes a tumble. She had fallen over again today and could well have had a mini stroke. Having said that, she could just as easily have simply tripped over a stray Zimmer frame or slipped on a rogue Murray Mint. She was back to her normal self now and common sense told me that this lady would not benefit from a whole load of tests and new medications that in the long run would probably only increase her confusion and make her more likely to fall over.
I’m allowed to be puritanical because I’m not a partner and so don’t make any money from the QOF points. But would I have been tempted to diagnose Mrs Tucker as having had a stroke if I knew it meant that I would pocket some extra cash in April? Amazingly, in the vast majority of practices that I have worked in, the doctors are incredibly honest about achieving their targets truthfully. However, shouldn’t we remove the temptation altogether? Surely, doctors should be able to make sensible decisions about what is in the best interest of our patients without needing targets and cash incentives?
First day
I can still remember my first day as a doctor very clearly. It is something that I had been looking forward to since I first chose my A level subjects eight years earlier. Now the actual day had finally come I was absolutely shitting myself and wondering if I wanted to be there at all. We spent most of the first day having induction-type talks. These consisted of a fire safety talk and an introduction from a medical lawyer on how best not to get sued. Not particularly confidence boosting.
As the induction day drew to a close, most of the other new doctors went to the pub. Not me though. I was doing my first ‘on call’ on my first-ever night as a doctor. This may have been the short straw for some but, although frightened, I was excited and keen to get my first on call over with. This night would be the making of me, I thought to myself. By this time tomorrow, I would be feeling like an old pro and be regaling heroic stories of my life-saving antics to my admiring colleagues in the pub. It was going to be like losing my virginity all over again. My brand-new shirt was ironed and although a couple of sizes too big, my white coat was starched and gleaming. I had a sensible haircut and a stethoscope round my neck. I looked at myself in the mirror astounded that I really was a doctor!
I picked up my pager at five that evening and sat there looking at it timidly. This small black box would come to be hated by me during my future years as a hospital doctor. This box would wake me from sleep and interrupt my meals. When completely overloaded with work and feeling like I couldn’t cope, this small inconspicuous little box would bleep and tell me that I had another five urgent things to deal with. Of course I was unaware of all of this on that first innocent evening. Instead, I had a naïve excitement that I was finally considered important enough to have my own pager and that it might actually go off. I had been practising how I should best answer it:
‘Hello, it’s Dr Daniels, vascular surgical house officer.’
That’s right, my first job was as the junior in the vascular surgery team. I didn’t really know what vascular surgery was, but I liked the sound of it. Perhaps I could drop the house officer bit and just answer by saying: ‘Hi. Dr Daniels, vascular surgeon.’ Hmm, that would sound much more impressive. I could just picture the attractive nurse swooning on the other end of the line.
To my surprise, at about ten minutes past five my pager did go off. I took a deep breath and answered the call: ‘Hi. Dr Daniels, vascular surgeon.’ There was a sigh from the other end of the telephone. It was my consultant and new boss. ‘You are not a vascular surgeon, you are my most junior and least useful helper monkey. Some poor bastard has popped his aorta and I’m going to be in theatre with the registrar all evening trying to fix him. I need you to order us a chicken chow mein, a sweet and sour pork and two egg fried rice. Have them delivered to theatre reception.’ The phone went dead. That was it. All those years of study and my first job as a doctor was to order a Chinese takeaway. Consultant surgeons have a wonderful way of ensuring that their junior doctors don’t get above themselves.
Over the next hour my pager started going off increasingly frequently until it built up to what felt like a constant chorus of bleeps. Jobs that would take a few minutes for me to do now, took an hour back then because I was so new and inexperienced. I decided that the cocky doctor role didn’t suit me so I went for the pathetic vulnerable new doctor approach. It worked and the nurses soon began to feel sorry for me. They offered to make me tea, showed me the secret biscuit cupboard and helped me find my feet. Just as I was beginning to gain a little confidence, my pager made a frightening sound. Instead of the normal slow, steady bleep there was a stream of quick staccato bleeps followed by the words ‘Cardiac arrest Willow ward … Cardiac arrest Willow ward.’ To my horror, that was the ward that my consultant covered. That meant that I should really be there. I started running. The adrenaline was pumping, my white coat was sailing behind me as I zipped past people in the corridor. I was important. It felt great! Suddenly, as I got closer to Willow ward, a terrifying thought dawned on me, ‘Oh my God. What if I’m the first doctor there!!!! I’ve only ever resuscitated a rubber dummy in training exercises. I’ve never had to do the real thing.’ To my left was the gents’ toilet. Doubts began to race through my head. ‘Perhaps I could just nip in there and hide for a bit. I can reappear in a few minutes once the cavalry has arrived.’ It was tempting, but I bravely decided to keep on running and meet my fate.
Lying in a bed was a frail old lady with her pyjamas ripped open and her torso exposed. She was grey and lifeless and I can remember her ribs protruding out of her chest wall. A couple of nurses were frantically running around looking for oxygen and the patient’s notes, while another nurse was doing chest compressions. To my relief, a remarkably relaxed-looking medical registrar was standing at the head of the bed and calmly taking charge. A monitor was set up and it was clear even to me that the wiggly lines on the screen meant that the patient needed to be shocked. A few other doctors soon turned up and I was pretty much a spectator as they expertly performed a few rounds of CPR (cardiopulmonary resuscitation) followed by a set of shocks. It was all very dramatic but the woman didn’t seem to be making any signs of a revival. Thinking that I had managed to escape my first cardiac arrest as an onlooker only, I began to consider sneaking away, aware of how many mundane jobs were waiting for me to be done on other wards. Unfortunately, the relaxed-looking registrar spotted me and called me forward. ‘This one’s not coming back; shall we let the house officer have a go with the defibrillator?’ I had just done my CPR training and it was all still clear in my mind. This was my big moment. For some reason, I had it in my head that if it was me who shocked her, she would suddenly come round. What a great story that would be, I thought as I stepped up to the bed. The one thing that the instructors had really emphasised in the resuscitation training was the importance of safety. I had to make sure that all the doctors, nurses and oxygen masks were clear of the bed before shocking the patient. I stepped up and took the paddles. Lifting them out of the machine I carefully placed them on the woman’s chest. Looking all around me, I started the drill: ‘Oxygen away, head clear, feet clear, charging to 360, shocking at 360.’
BANG. My adrenaline had been pumping but I hadn’t expected that. I had stayed on my feet but had been thrown backwards with a jolt. That never happened with the dummies. I must have been looking slightly dazed and the registrar glanced over at me with faint amusement. ‘You’ve electrocuted yourself, you prat.’ Unfortunately, he was right. I had checked closely to make sure that the bed was clear of bystanders before I gave the electric shock, but I hadn’t realised that on running to the ward, I had shoved my stethoscope into the pocket of my white coat and as I was leaning over the patient, the nicely conductive metal tubes had been lying on the patient’s left hand.
As if to rub salt in the wound, my first pathetic effort at resuscitation led the woman to go straight into asystole (flatlining) and the registrar called it a day. The correct thing to have done would have been to report my electrocution as a critical incident and give me a bit of a check-over, but instead the registrar just disappeared off the ward chuckling to himself. I had made his night and he called me ‘Sparky’ for the rest of my six-month spell at the hospital. I was left to carry on with the boring jobs on the ward and by the following morning everyone had heard of my disastrous first night. Perhaps it was an early indicator that I was better suited to the slightly less dramatic world of general practice.
Jargon
At my secondary school I was known as Benny Big Nose. Not the most charming of nicknames, but nevertheless a beautifully simple and succinct summary of my name and most prominent facial feature. I sometimes wish medicine could be as straightforward. Why do we use long-winded medical jargon to describe something rather simple?
Purulent nasal discharge – snot; viral upper respiratory tract infection – a cold; infective gastroenteritis – the shits; strong urinary odour – stinks of piss.
One reason for medical jargon is so that we doctors can write something in the notes that if the patient were to read, they wouldn’t take offence and complain. There was a time a few years back when patients had no right at all to see their own medical notes. I was recently looking through the old paper notes of one retired farmer and the sole entry for 1973 was ‘Patient smells of pig shit.’ How beautifully jargon free.
When I first qualified, I loved all the medical jargon. I felt that it made us sound clever and elite and I got off on the fact that I could have a chat with a fellow medic on the train. However, it only takes an interaction with someone who uses jargon that you don’t understand to realise how annoying it can be. Current letters from our managers at the PCT (Primary Care Trust) have just this effect on me. What do phrases like ‘performance-based target strategies’ and ‘competence managed commissioning’ mean. They certainly don’t seem to bear any relevance to my daily routine of listening to people’s health grumbles and trying to make them feel a bit better.
Patients are always happiest if you skip the jargon and say it how it is. I find that replacing the phrase ‘stage-four renal impairment’ with ‘knackered kidneys’ or ‘mitotic growth’ with ‘cancer’ is generally appreciated. We all like to have things explained in terms we can understand and I just wish that NHS managers would write me letters in a language that I could comprehend.
It was Darren Mills who first named me Benny Big Nose. The last I heard, he was spending some well-deserved time at Her Majesty’s pleasure. His straightforward and direct manner seemed to get him in trouble from the teachers and later the police. However, Darren, if you’re out there, I’d like to say thank you for teaching me the valuable lesson of saying it how it is. You usually don’t cause as much offence as you think you might and most people will appreciate your honesty.
Proud to work for the NHS
One weekend I was doing a locum shift in A&E and saw a middle-aged German couple who had been involved in a car accident. They had been on a driving holiday around the UK and had crashed their car into a ditch. Fortunately, they weren’t severely hurt but an ambulance was with them within ten minutes and the paramedics gave some basic first aid before ferrying them to hospital. They were then seen by me and I organised some X-rays to make sure that the man didn’t have any neck injuries and to confirm a suspected dislocation of one of the woman’s fingers. The man’s neck X-ray was fine and I injected some local anaesthetic into the woman’s finger and popped the dislocated joint back into place. The healthcare assistant got them a cup of tea and a sandwich each and one of the nurses then cleaned and dressed a few of their cuts and scratches. Finally, the receptionist let them use her phone to call their car hire firm and organise a taxi back to their hotel.
As I let them know that they were free to go, the German man got his wallet out and tried to give me his Visa card. I explained that he didn’t have to pay me so he then started giving me his address so that he could be billed at home. I literally had to spend ten minutes convincing him that the treatment he had received was free of charge. ‘But everyone has been so good to us,’ he protested. ‘I wouldn’t have got any better treatment back home. Why do you British spend so much time complaining about your health service?’ It was one of those moments where I simply felt an overwhelming pride to be a part of the NHS. Of course, there are days when I spend a lot of time apologising for the inadequacies of the NHS, but overall I still believe that if you are genuinely unwell or have an accident, there aren’t many places on the planet where you would get a better service.
Sitting around with a bunch of GPs recently, I was surprised by how many thought that there should be a charge to be seen in A&E or by a GP. The general consensus was that £5 would be just enough to keep out some of the time-wasters and make people think twice before pitching up to see us. I have to say I couldn’t disagree more. I appreciate that the NHS isn’t free because we pay for it with our taxes, but it is free at the point of delivery and I feel that is something fundamentally vital in maintaining some of the original ideals of Nye Bevan and the other founders of the NHS. A charge would keep away some of the more vulnerable people who needed our help most and suddenly change the dynamic and mindset of the patients who would now be paying directly for our services.
Drug reps
Sixteen tablets of a supermarket’s own brand ibuprofen cost just 35p, while 16 tablets of Neurofen cost £1.99. This is strange to believe considering they really are exactly the same medicine. The drug company that makes Neurofen uses clever advertising and packaging to convince us to pay over five times more money than we need to.
Drug companies are very good at overcharging us for medicine. In the world of prescription drugs, millions of pounds are wasted by the NHS because doctors prescribe expensive ones when they could be prescribing much cheaper versions of exactly the same medicines. How do the pharmaceutical companies hoodwink us into doing that? Again, it is all about marketing. Young and attractive drug reps come and promote their drugs, while buying us lunch or even taking us out for dinner at posh restaurants. They feed us biased information on why we should use their more expensive medicine and give us free pens and mugs sporting their brand. (There are now much stricter rules than there used to be about how much drug reps can spend on us doctors. For example, the free gifts that they give us now have to be under the value of £5 and when drug reps take us all out for a slap-up meal, there has to be an ‘educational’ component to the evening rather than a completely uninterrupted session of good food and expensive wine. The drug companies’ all-expenses-paid trips to ‘conferences’ in the Caribbean have stopped, too.)
I used to attend the lunches and dinners. As I pocketed the free gifts and scoffed down the expensive nosh, I convinced myself that we doctors were too ‘savvy’ to be influenced by colourful flip charts and pretty smiles. The pharmaceutical industry, of course, knows that this isn’t the case. A few hundred quid taking some GPs out for dinner is peanuts compared to the money they can make if one or two of us start prescribing their drug.
In the USA, pharmaceutical companies employ ex-American football players and cheerleaders to sell their products. Doctors are suckers for a pretty face like everyone else. The attractive female reps are sent to sell their products to the predominantly male surgical consultants, while the pretty-boy male reps sell to the more female-dominated obstetric and paediatric departments. Fortunately in this country, our retired sports stars tend to fall ungracefully into alcoholism and gambling addiction rather than trying to sell us overpriced medicines. I can’t imagine even the most star-struck doctor being convinced to prescribe an antidepressant promoted by Gazza or a painkiller endorsed by Vinnie Jones.
As well as constant pressure from drug reps, GPs also face resistance from patients when trying to change medication. Whenever I can, I try to switch my patients from the more expensive medicines to the cheaper ones that do the same thing. Unfortunately, this can be very unpopular with patients. Often they get used to a certain packet and tablet colour and no amount of persuasion will convince them to switch. One elderly lady once stormed into my surgery furious that I had changed her medicine:
‘You told me that the new medicine was the same as the old one!’
‘Yes that’s right, Mrs Goodson – same medicine, but different name.’
‘Well, I know that’s nonsense because when I try to flush these tablets down the toilet, they don’t float like the old ones did.’
Drug reps have the cheek to claim that they are helping to educate us by updating us on the latest scientific research. This is, of course, nonsense as their only interest is flogging their drug and earning a commission if prescribing rates of their drug increase on their patch. They give ruthlessly one-sided presentations that show their pill to be wonderful and ignore the parts of the research that don’t paint their drug so favourably.
Having finally realised that I will only ever get biased information from the pharmaceutical industry, I now refuse to see any drug reps. They hover around the reception desk like prowling hyenas, only to be batted away by the fierce receptionist. Not having the time or inclination to read all the medical journals myself, I rely on the local NHS pharmacist to keep me up to date with the new medications on the market. She is a fount of knowledge on all the latest scientific research and doesn’t work on commission. Like me, she has the best interest of the patient at heart, while also keeping half an eye on the NHS budget. There really is no such thing as a free lunch and so I’ll pay for my own, thanks.
Mr Tipton, the paedophile
I had been asked to go on a home visit to see a patient I hadn’t met before. Mr Tipton was in his fifties and complaining of having diarrhoea. There was some kind of gastric flu going round at the time, but normally a 50-year-old could manage the squits without needing a doctor’s visit.
As I skimmed through his notes, there was one item that stood out. In between entries for a slightly high blood pressure reading and a chesty cough was ‘imprisonment for child sex offences’. Mr Tipton was a paedophile. There were no gory details of his offences but he had spent six years in prison and had only recently been released.
Mr Tipton lived in Somersby House. Despite the pleasant sounding name, Somersby House is a shithole, a 17-storey 1960s tower block as grey and intimidating on the inside as it is on the outside. As I waited an eternity for the lift to climb the 17 floors, I wondered if the strong smell of stale urine was coming from one of my fellow passengers or the building as a whole. The grey-faced natives eyed me suspiciously; I was looking conspicuously out of place in my shiny shoes and matching shirt and tie. A mental note was made to keep a spare tracksuit and baseball cap in the car to disguise myself on my next visit.
I was annoyed and ashamed by how uncomfortable I felt in Somersby House. When I started medical school I felt distinctly ‘street’. While most of my compatriots were privately educated somewhere in the Home Counties, I went to an inner city comprehensive. Why was I feeling so bloody middle class? Medical school had not only desensitised me to death and suffering, it had also turned me into a snob.
I finally got to Mr Tipton’s flat. After several minutes of knocking on the door and shouting through the letter box, he finally answered. Walking unsteadily with the aid of a Zimmer frame, he was wearing a filthy grey vest and nothing else. As I followed him into his flat, his bare buttocks were wasted and smeared with dried faeces. The flat was like nothing I had ever seen. There were beer cans and cigarette butts in their hundreds. The floor was brown and sticky and I tried desperately to manoeuvre myself down the corridor without touching anything.
It was the bedroom that was truly shocking. It transpired that Mr Tipton had been pretty much bedridden for the last few days with a bad back and he hadn’t been able to make it to the toilet when the diarrhoea struck. There was shit everywhere! His bed consisted of a bare mattress and a coverless duvet. Both were covered in an unfeasible quantity of faeces that looked both old and recent. There were cider bottles filled with his urine and an empty takeaway wrapper covered in vomit. It was truly grim. Amazingly, as we arrived in his room, Mr Tipton calmly laid himself back on the mattress and pulled the shitty duvet over him. I donned some gloves and half-heartedly had a prod of his belly. I made a few token comments about letting viruses take their course and then fled.
I gave social services a call and asked them to go round to do an ‘urgent assessment of his care needs’. In other words: ‘Come round and clear up this shit.’ I made it very clear to the social worker that I didn’t think that Mr Tipton required any more medical input as I had done a thorough assessment and diagnosed a self-limiting viral gastroenteritis. I hoped she wouldn’t see through my bullshit and realise that I was, in fact, just desperately trying to wash my hands of Mr Tipton and make him someone else’s problem.
On my drive back to the surgery, I wondered why Mr Tipton had allowed himself to lie in his own shit for the last three days. Perhaps he was in some way allowing himself to be punished for his awful crimes. Or was it just that he had a dodgy back and couldn’t get to the phone? Maybe there was simply no one else whom he knew he could call on. I often visit lonely, isolated people for whom the GP is their only contact with the outside world. Normally, I reach out to these abandoned people with some compassion and kindness. Why hadn’t I done this for Mr Tipton? Reflecting back, I know that my knowledge of Mr Tipton’s crimes influenced my behaviour towards him. Although I couldn’t have offered him much more as a doctor, I could have offered him a great deal more as a human. The Hippocratic oath tells us that it is not our place to judge our patients but only to treat each one with impartiality and compassion. I think I agree with this in principle but offering kindness and empathy to a paedophile covered in shit isn’t always easy.
Average day
I sometimes think that people have an odd preconception of what makes up the typical day for a GP. These are the exact patients that I saw one morning, a wet Tuesday in November in a typical practice somewhere in the south of England. None of the consultations are outlandish or exciting enough to deserve their own chapter, but they are a very typical reflection of a GP’s average morning.
1 A seven-year-old boy having tummy aches. Mum was very worried, as her nephew had had a kidney transplant at a similar age. The tummy aches only occurred on mornings before school and after finally managing to keep Mum quiet for a few minutes, I asked the lad a few questions and he admitted that another boy was bullying him at school. Mum left the surgery and stormed straight up to the school.
2 A very nice woman in her thirties with six-month-old twins. She was finding it all a bit much and was very tearful. She did actually have symptoms of postnatal depression and was worried that it could be affecting her relationship with her children. We had a long chat about possible options, including counselling and antidepressants. She would be coming back to see me in a couple of days to let me know what she had decided to do and so I could see how she was getting on. I also wrote a letter to the health visitor to see what other support she could get.
3 A 60-year-old woman worried about the appearance of yellow lumps around her eyes. I explained they looked like cholesterol deposits. She told me that there was no point in her having a cholesterol test, as she refused to take any Western medicine and therefore wouldn’t take any cholesterol-lowering medication even if her cholesterol was high. She was also convinced that her diet couldn’t be any healthier than it already was. I told her about risks of having a stroke or a heart attack but I was happy that she was entitled to make her own informed choice not to have the test. I made sure I documented this carefully so she couldn’t come back and sue me at a later date.
4 A very nice woman in her fifties with breast cancer. She had chemotherapy and radiotherapy over the summer and thankfully her cancer seemed to be in remission. She told me that she lay in bed at night and every time she felt the slightest tingle in her fingers or an ache in her leg, she was convinced that it was the sign of her cancer coming back. We had a long chat and I tried to reassure her that her fears were normal and understandable. I put her in touch with a cancer support group.
5 A middle-aged woman with a slightly sore knee for two days, which was getting better. I went through the motions of examining her but everything looked normal. I couldn’t really work out what she was expecting me to do for her. She seemed happy enough with my reassurance.
6 An 80-year-old man who had had some diarrhoea over the weekend, which had since settled. He actually wanted to talk about the current legal wrangling he was having with his niece who was trying to evict him from his family home. I listened for about 15 minutes but was already running very late so had to cut him short and move on to the next patient.
7 A 30-year-old woman with a cold. She had come in specifically for antibiotics and she made this clear from the start. I examined her fully and then explained in much detail why antibiotics weren’t going to help her as she had a viral infection. She was very insistent that she wanted antibiotics as she had an important work presentation to do on Friday! She was not happy at all when I refused to prescribe her antibiotics.
8 A 40-year-old man involved in a mild car accident over the weekend. He had some very mild muscle aches in his neck but nothing that needed to be seen by a doctor. He was only here for insurance purposes in case he decided to make a claim at a later date. I was slightly annoyed that he had used up an urgent slot for this. This is an example of one of the few instances where I feel we should charge patients to be seen.
9 A fairly straightforward tennis elbow. However, the man was a self-employed mechanic so when I advised him to rest his arm, he gave me a resigned smile and said, ‘I’d love to, mate, but who’s going to run my garage?’ I referred him to a physio and advised painkillers.
10 A three-month-old baby with a cold. Very cute. She was absolutely fine and smiled throughout my examination. A smiling baby always helps lift my spirits, especially halfway through a busy morning.
11 A very anxious woman who was convinced she had had an allergic reaction to her latest blood pressure medication. She had a history of lots of unusual medication allergies. Perhaps they were genuine allergies or perhaps there was a degree of hysteria. She was far too frightening for me to argue with so I stopped the medication and agreed to try yet another one.
12 A woman in her late sixties with a cough and breathlessness. She thought she had a chest infection but on closer inspection it looked to be actually due to a build-up of fluid in her lungs because of problems with her heart. I spent some time explaining the likely diagnosis and started her on some new medications and also ordered various tests.
13 A patient didn’t turn up – frustrating, as many patients phoned this morning wanting an appointment but were told that there were none available. I have to admit that it was a relief for me in some ways. I was running late by now so I had the chance to catch up a little bit.
14 A very odd case. A 38-year-old woman came in to see me. She was seven weeks pregnant and had been trying to get pregnant for years. Previously, she had been seen in the infertility clinic and had had two miscarriages. She told me that she wanted an abortion because she had felt so unwell since becoming pregnant and couldn’t cope with the symptoms. It was also a bad time for her to be pregnant. She had just been to the hospital for a scan which showed a normal pregnancy so far. She was flying next Thursday, so wanted the abortion before then. I’m sure there was something she wasn’t telling me. My suspicion was that the pregnancy was the result of an affair but I’m just guessing. I referred her to the specialist clinic and I know that they do a long and detailed assessment prior to considering an abortion.
15 A 17-year-old girl seen with her mum. She had a long history of being seen by lots of specialists. Mum was convinced that her daughter had ‘never been well due to a weak immune system’, although all tests have been normal. She was being schooled at home. All a bit weird and I wasn’t keen on being dragged in too deeply as I was not her normal doctor. I looked through the notes and saw that despite having apparently ‘never been well’, she did manage to get herself pregnant last year and have an abortion and was also recently seen in A&E after getting into a drunken fight outside a pub. Hmmm. They just wanted a repeat prescription of her normal medication, so that was easy enough.
16 An 80-year-old man who arrived 20 minutes late and couldn’t remember why he’d come to see me. He lived alone and drove everywhere. I suggested that we assessed his memory but he refused. I also suggested that if his memory was poor, maybe he should stop driving until he had an assessment from the DVLA. He refused this as well. I decided to contact the DVLA myself. It was a break in confidentiality and his driving might have been fine, but if he killed someone in an accident … I wrote the letter.
I finished the morning surgery late and grabbed a sandwich before rushing off to do a couple of visits:
Visit 1. A 78-year-old man who had had a mini stroke the night before. He had had 11 previous mini strokes and was on all the right medication to control his blood pressure, keep his cholesterol low and thin his blood, etc. He had recovered fully since the previous night and my visit wasn’t really necessary medically, but his wife was anxious and I spent 20 minutes reassuring her that she was doing all the right things and she thanked me repeatedly for coming out to see them.
Visit 2. A 57-year-old man who couldn’t get out of bed that morning. He was previously fairly well. Initially, I thought he was being a bit precious but then I noticed that the whites of his eyes were a bit yellow (jaundice) and on examining his abdomen, found he had a big liver. Unfortunately, my gut instinct was that he probably had cancer. He asked me what I thought was wrong and I said that I thought there were all sorts of possible causes and I wouldn’t like to commit until he had had a scan. Once back at the surgery, I make a referral to get him seen urgently by the bowel and liver specialist. Should I have said I thought he had cancer? I wouldn’t want to worry him unnecessarily if he just had gallstones or something completely benign.
So there we are. That was my morning. There were also a few extra phone calls and prescriptions to sign. The nurse popped in inbetween patients to ask me a few questions and I had to dictate some letters and sign some forms. I had a quick cup of tea and got myself ready for the afternoon surgery.
That was exactly what I did that morning. I have no idea if that fits your expectation of an average GP’s morning but there it is and probably fairly typical for most GPs. It was, perhaps, unusual in its absence of drug-abuse problems and sick-note requests, but that was probably mostly because the practice was in quite a middle-class area. Fortunately for me, I found the morning interesting, challenging and rewarding. It was a typical morning, but would still be completely different from yesterday and tomorrow.
Tara
‘Doctor, you fucked up my medication again. That antidepressant you gave me was fucking useless and I need another sick note.’
Tara is taxing; we call them ‘heart-sink’ patients. When she walks into my consulting room my heart sinks to the floor and I often find myself hoping that it will stop altogether.
I try to view Tara with compassion. She is a vulnerable adult who grew up in an abusive, socially deprived family and she needs support and patience. The problem is that when running late on a Friday afternoon, my empathy is often overtaken by frustration and annoyance. I’m ashamed to admit it but rather than offer the time, patience and support Tara requires, I often find myself wishing I was somewhere else.
I sort out Tara’s medication and then ponder what to write on the sick note. Tara is 25 and has never worked. She doesn’t have a physical disability or a neat diagnosis to put on the dotted line. She isn’t depressed or psychotic, although she has seen a multitude of psychiatrists, psychologists and counsellors. The only firm diagnosis Tara has ever been given is ‘borderline personality disorder’.
I find the concept of personality disorders difficult, but my limited understanding is that someone with this diagnosis has a personality that doesn’t really fit in with the rest of society and they struggle to cope with all aspects of modern life. Most would agree that our personalities arise from a combination of nature and nurture, but in the case of Tara, growing up with an extreme lack of anything that could be called nurture is the principal problem. People with borderline personality disorders tend to act like stroppy teenagers. They often only see things in black and white and fly off the handle easily. They don’t have a particularly good idea of who they are and always seem to fall into stormy, damaging relationships. They have low self-esteem and often self-harm as a way of expressing their frustrations with life.
Stroppy teenagers grow up, but people with borderline personality disorders don’t. They struggle to cope with the adult world and require a huge amount of support and understanding from those around them. Despite being able to rationalise all this, I still find my consultations with Tara madly frustrating and I would love to prescribe her a twice daily kick up the arse. I am not proud that I feel like that about my most regular patient but I know that she also brings out similar feelings in the other doctors at the practice. Some smart-arse psychoanalyst would tell me that my ambivalence towards Tara is a reflection of my own feelings of failure in my inability to help her. I’m sure that is true but I can’t help but wish she didn’t come and see me quite so often.
I do occasionally have a ‘Conservative moment’ and feel righteous about why a physically fit 25-year-old has never worked and probably never will, but you only have to spend a few minutes with Tara to realise that her chaotic existence just wouldn’t cope with work. When she doesn’t like something, she either cuts herself or flies into a rage. She is a mess emotionally and no employer in their right mind would want her working for them. She has had input from all sorts of well-meaning and well-funded services over the years, but seeing a supportive social worker, health visitor, GP or psychiatrist for 15 minutes a week hasn’t managed to counteract the harm caused by 25 years of growing up in an abusive and damaging family.
Sometimes I worry that doctors write off patients with personality disorders too quickly. Some people go so far as to claim that it is a ‘made-up’ diagnosis that doctors put upon patients with mental health issues that are challenging and don’t fit tidily into any other diagnosis. There is no pill that cures a personality disorder so we label the person as a lost cause and withdraw all help and support. This seems a shame given that many of the chronic diseases we do treat can’t be cured. We don’t give up on our patients with diabetes because they can’t be cured. Instead, we do our best to control their symptoms as best we can and try to work with them to give them the best possible quality of life.
After a bit of reflection, I promise myself that I’ll be a bit nicer to Tara next time she visits. I’ll try to listen harder and be more supportive. I’ll give her more of my time and won’t rush her out the door. Maybe she’ll open up a little more to me? Maybe she won’t even notice? At least I will feel like a slightly nicer doctor for a few minutes.
Sex in the surgery
According to a study in France, 1 in 10 male GPs questioned have had a relationship with a patient and 1 in 12 admitted to having actively tried to seduce a patient. One French doctor reportedly stated, ‘It is obvious that some patients like us and we are not made of wood.’ I have to say, I was quite surprised by the results of this study. When compared to the general population, I would say that my doctor friends are probably on the lower end of the scale when it comes to morals and good behaviour. Despite this, I can honestly say that I don’t think that any have had a relationship with a patient or even considered it. As medical students and junior doctors, we got up to all sorts of debauchery both sexual and otherwise, but somehow having sex with a patient never really figured. It is perhaps one of the few taboo subjects that remain among us. We will happily sit round in the pub competing to see who had made the worst medical error as a junior doctor, or recalling past drunken sexual adventures with the unfortunate student nurses who had fallen foul of our charms, but even admitting to finding a patient attractive just doesn’t happen.
When I started my medical career, my non-medical friends seemed to imagine that I would have all sorts of saucy ‘Carry on Doctor’ moments with beautiful female patients. They were disappointed when I explained that as a hospital doctor, I rarely had a patient under 65. My days were spent looking at fungating leg ulcers and sputum samples, rather than pulling splinters out of the behinds of young Barbara Windsor lookalikes.
Since moving to general practice, I do have young female patients. There is also more of an intimacy that develops between doctor and patient. It is less about the proximity of the physical examination, but more about the openness and intimacy of the consultation. The patient is able to disclose their deepest, darkest feelings and fears, often revealing secrets that they wouldn’t divulge to their closest friends or family. It is part of the privilege of being a doctor and it is our job to listen and be supportive. Often the GP might be the only person in an individual’s life who does listen to them without judgement or criticism and it is this that can make us the object of attraction.
In my career as a doctor, I can think of three female patients who have made a pass at me. One was a lonely single mum, one was a lonely teenager and the third was a lonely foreign-exchange student. They all visited me regularly and offloaded their fears and worries. I sat and listened when no one else would; I nodded and made supportive noises; I was encouraging and made positive suggestions as I handed them tissues to mop up their tears. Vulnerable people can mistake this for affection. It is easy for a lonely person to forget that I’m being paid to listen to them. These three women fell for me because, unlike in a real relationship, the baggage was offloaded in one direction only. I didn’t get to talk about my regrets and fears. I wasn’t allowed to display my needy and vulnerable side. If my love-struck patients had to hear all my shit, I’m sure my desirability would have quickly dissolved.
I do care about my patients and I try my hardest to empathise, but ultimately my patients are not my friends or family members and once they leave my room, I move on to the next patient and problem. This may seem cold and callous, but if doctors got emotionally involved with all our patients and their unhappiness, our work would consume us and send us spiralling into depression ourselves. This does happen to some doctors. We call it ‘burn out’ and it doesn’t benefit doctor or patient.
The Hippocratic oath states: In every house where I come, I will enter only for the good of my patients, keeping myself far from all intentional ill-doing and all seduction and especially from the pleasures of love with women or with men.
Many people, including at least 1 in 10 French doctors, probably feel that this is out of date and that consenting sex between two adults shouldn’t be frowned upon just because one happens to be the other’s doctor. I have to say that I agree with the Greek fella in this case. He clearly recognised the uniqueness of the doctor–patient bond and the vulnerability of the patient in this relationship. A sexual liaison that forms in this environment can never be equal, as the doctor will always hold a position of power and trust. In general, the medical profession’s governing bodyagrees with this and in the UK, quite rightly, doctors are still in a whole heap of the brown stuff if they have a relationship with a patient.
The elderly
My first patient of the morning is Mr A. He is 35 and has a sore ear. He only comes to the doctor about twice a year. I look inside and it is blocked with wax. During his ten-minute appointment I have explained the diagnosis, had a bit of a chat and sent him on his way with some ear drops. The medication is cheap, he gets better and I feel happy as a doctor that I have cured my patient. I am also running on time and know that I will get to the coffee before all the nice biscuits have been eaten by the receptionists.
My second patient of the morning is Mrs B. She is 87 and has come in with painful legs, a sore back, dizzy spells and some breathlessness. It takes her nearly half of her appointment time to shuffle in from the waiting room and take off her four cardigans. She is lonely and socially isolated and really wants to chat. She is a bit forgetful and not very good at giving me a clear story about what hurts when and where. She is already on a multitude of drugs, which she often forgets to take. After a long, disjointed consultation, she departs after 30 minutes without any of her symptoms really being treated and leaves me feeling like I’m not a very good doctor. She will be back next week with a new list of problems. My subsequent patients are annoyed because I am running late and by the time I get to coffee, I am left with a couple of broken, stale digestives.
One of the joys of being a GP is having a close and supportive relationship with elderly patients, but they really do take up the lion’s share of our workload. By definition, the ageing process means that as we get older, more and more things go irreversibly wrong until we finally die. This can be quite hard for both the doctor and the patient to accept. Of course, there are fantastic sprightly 90-year-olds who never visit the doctor and moping 20-years-olds who spend their lives in my waiting room. But generally speaking, the older you get, the more you see your GP.
Treating elderly people with multiple complex medical and social problems is one of the more challenging areas of our work. The goal is to work as part of a team to maintain the person’s dignity and autonomy, while pacifying anxious relatives and navigating through the bureaucracy that is the NHS and social services. Elderly patients are often fantastically appreciative and working with them can be extremely rewarding. Having said all that, it is bloody hard work!
I worked once in a city practice in a young trendy part of town. There simply weren’t many elderly people who lived there. I saw more patients in less time and didn’t do any home visits. I had less disease targets to worry about because few of my young patients had chronic conditions such as heart disease and diabetes. I sat in a trendy coffee shop during my lunch hour, while my GP colleagues around the country traipsed round nursing homes and arranged home helps and hospital admissions. My job was certainly easier but also less rewarding and less interesting.
I recently read that Harold Shipman’s murders were motiveless. I don’t think they were. Most GPs could think of several frail, vulnerable elderly patients who take up a lot of their time. Shipman murdered his. One of the hardest parts of being a GP is taking care of elderly people wanting help for untreatable degenerative diseases. Most of us find that listening and offering some practical support and advice is the best we can do and actually very much appreciated. Shipman clearly viewed things differently and felt it was his right to murder his elderly frail patients. I imagine he enjoyed the power but I also think he was motivated by reducing his workload.
Bums
Intimate examinations can be awkward for both doctor and patient. Fortunately, a good explanation and reassurance from the doctor can make the whole procedure a lot less difficult. When the patient doesn’t speak very much English, the situation can be that bit more uncomfortable. This was the scenario I faced with Olga, a young Bulgarian woman who came to see me.
‘Pain in bottom, Doctor,’ she said in a very broad Eastern European accent.
I began to ask a few questions about what sort of pain it was. Was it related to going to the toilet? Was there any blood in the poo? These are all the normal questions that would usually give a doctor a fairly good idea of what the diagnosis might be. The problem was that each question was met with blank confusion. Olga had clearly found out how to say ‘pain in bottom’ but was unable to understand any word I said. Despite a brilliant attempt on my part to mime diarrhoea and constipation using a mixture of diagrams, sound effects and facial expressions, I was getting nowhere. Feeling completely useless, the only option I had left was to examine her. I motioned towards the couch and mouthed out the word ‘EXAMINATION’ very slowly and loudly. Olga seemed to understand, so I pulled round the curtain to give her some privacy as she undressed.
As those of you who have had the misfortune to have had your bottom examined by the doctor will know, we generally expect you to drop your trousers, jump up on the bed, pull your knees up to your chest and lie on your side facing away from the doctor. I usually have a blanket handy so the patient can remain covered until the examination itself takes place. Normally, the whole ordeal is quick and relatively painless – well, painless for me, anyway. Unfortunately, it would appear that things are done slightly differently in Bulgaria. I pulled back the curtain to find Olga naked from the waist down leaning over the couch with her bottom pointing to the ceiling. ‘No no, you need to be up on the bed!’ I cried. ‘ON THE BED,’ I repeated slowly and loudly. I pulled the curtain across again and after a few polite moments went back in. This time Olga was on all fours on top of the couch still with her bum pointing up in the air. After much gesticulating and loud slow explanations, I was still no closer to having Olga in a position in which I could examine her. I motioned for her to get off the bed and got on myself lying in the correct position. ‘LIKE THIS, YOU SEE.’ I was lying curled up on the bed while my half-naked patient was standing beside me still looking very puzzled. It was a moment that I was very glad wasn’t interrupted by a receptionist bringing in a cup of tea.
I did finally manage to examine Olga’s bottom, only to find nothing unusual at all. In theory I should have done a rectal examination as well, but poor Olga had faced enough already and inserting my finger up her back passage without her really being able to understand my explanation of what I was doing seemed a bit unfair, bordering on abuse. I managed to book her in for an appointment another time with an interpreter present but she didn’t turn up, possibly having somewhat lost faith in me.
I recall another difficult rectal examination back when I was an A&E doctor. An elderly lady called Ethel had been brought in by her husband, Lionel, because of her having some tummy pains and bleeding from her anus. Ethel herself was quite demented and also very deaf. Lionel was a retired vicar and now caring for Ethel full time at home.
After taking a history from Lionel and feeling Ethel’s tummy, I needed to do a rectal examination. It was important to make sure that there wasn’t a blockage in the rectum causing her symptoms. ‘I'm going to need to examine your rectum, Ethel.’ ‘You what, love? I can't hear you.’ ‘I need to put a digit up your back passage, Ethel,’ I say again a bit louder and into her good ear. ‘What’s he saying, eh?’ ‘I’M GOING TO HAVE TO PUT A FINGER UP YOUR BOTTOM.’ This time I was shouting at the top of my lungs. It was only a set of curtains that separated us from the rest of the A&E department and, as you can imagine, curtains aren’t particularly soundproof. The entirety of the A&E department was now aware of Ethel’s impending rectal examination but, unfortunately, Ethel wasn’t. Her confusion was such that she couldn’t really comprehend what I was doing or why. Despite my best efforts to put her at ease, she was getting increasingly agitated. I put on a pair of gloves, moved her into as comfortable a position as possible and gently eased my right index finger into her anus. Suddenly, there was an almighty shriek. ‘Oooh, Lionel. Stop it, Lionel. You know I don’t like it that way. If you’ve got to put it in, at least put it in around the front.’ Poor Lionel was standing outside the cubicle in full view of all the patients and staff who were trying to hold back their giggles. He looked very embarrassed as he made his way back into the cubicle.
Julia
Julia was young, attractive and articulate.
‘I need you to section my boyfriend Andy. He’s completely mad and unreasonable and yesterday he smashed up my moped for no reason.’
I wasn’t expecting that one.
‘Your boyfriend doesn’t sound very nice but we aren’t going to be able to section him.’
‘But he’s mad! It wasn’t just any moped. It was my twenty-first birthday present. I drove it everywhere. It was my most precious possession! He knew that!’
I was tempted to explain that there wasn’t a special subclause in the Mental Health Act that allowed us to section people if the moped they smashed up was a very special birthday present. I held back and instead explained how a person would need to have a mental disorder and pose a risk of harming themselves or others before they could be sectioned.
‘He is a risk to me. He beats me up!’ Julia then proceeded to lift her shirt to reveal an impressive array of bruises on her torso.
‘Why don’t you leave him? There is a local domestic violence support group. Perhaps I could –’
Julia interrupted me. ‘He needs me. He says he would kill himself if I left him and I couldn’t have that on my conscience for the rest of my life. He needs help and all you’re telling me to do is leave him. He was abused as a child and so was his mum. His whole family is fucked up. I’m all he’s got.’
I wasn’t sure where to go from here. From the outside it seemed so straightforward. Leave, run away, start again. Julia had a lot going for her. She could have a whole new life. It clearly isn’t this straightforward as there are thousands of women like Julia who don’t leave or run away or start again. I would never really understand the complexities of Julia’s violent relationship but one thing was very clear. When she said that Andy had nobody else, what she was really saying was that she didn’t have anyone else. She was alone and, however difficult and abusive her relationship was, she clearly felt that it was all she had.
I was feeling guilty now. Initially, I hadn’t really been taking Julia seriously. I had thought that she wanted her boyfriend sectioned because they had had a tiff. It was now clear that things were more complex. Deep down Julia knew that I wasn’t going to section Andy but she was crying out for help and somehow it was me who was expected to provide this help. At medical school I had learnt about the role of mitochondrial antibodies in primary biliary cirrhosis and the parasympathetic nerve distribution to the salivary glands. It wasn’t the greatest preparation for dealing with a vulnerable desperate woman who got beaten up every day by the man who supposedly loved her. Regardless of my lack of training, at that moment I was all she had and I had to do my best.
‘If you leave him and he harms himself, that’s not your fault.’
‘Is that the best you can do? He needs help.’
Andy was a patient at another practice and I had never met him. I couldn’t really speculate what he needed but psychotherapy is usually our get-out clause when faced with a difficult psychological issue that is complex and not fixed with a tablet.
‘Maybe psychotherapy would help Andy?’
Julia looked hopeful until I explained that there was a two-year wait for psychotherapy in this town.
‘That’s really useful, thanks a lot.’
‘You have to leave him,’ I said again. I tried to say it with compassion but I really did feel it was her only option. Julia got up, left and slammed the door. I clearly hadn’t handled that very well. I had failed again. Would another doctor have handled that better? What would a counsellor have said, or a priest or even bloody Jeremy Kyle? I was not sure if Julia would come back to see me. If she did, maybe next time I’d just listen.
Good doctors
What makes a good doctor? I seem to remember being asked something like this during my medical school interview. The interview panel yawned through my contrived answer that mentioned some naïve nonsense about being caring and good at working in a team. As part of our target-based existence, the patient plays a large role in deciding if we are good doctors or not. The Labour government introduced patient satisfaction questionnaires as part of our performance targets.
During my training year I saw a middle-aged woman with stomach pains. I was very concerned and referred her urgently to the hospital because I thought she might have stomach cancer. She was seen and investigated within a week and turned out to simply have bad indigestion. When the snotty letter came back from the consultant, I was feeling a little red in the face. I had made an inappropriate expensive referral to the hospital and had caused unnecessary anxiety to the patient. I could just imagine the consultant grumbling into his endoscope as he cursed me for adding to his already busy day.
The patient and her husband, however, thought the sun shone out of my arse. ‘That wonderful Dr Daniels arranged for me to be seen so quickly.’ She bought me a very nice bottle of single malt to say thank you and told anyone who’d listen how fantastic I was. My poor medical judgement earned me a rather nice bottle of whisky and if my patient got to fill in one of the patient satisfaction questionnaires, I’d have been reported as the best doctor in the world.
Most medical practitioners have an idea whether they’re being good or bad doctors. On a Friday afternoon when I’m drained and tired, I know that I’m not giving my all. I try my best to remain professional but have to admit that I find it that bit harder to resist inappropriate requests for hospital referrals, sick notes and antibiotics. As GPs, we are supposed to be the ‘gatekeepers of the NHS’ but sometimes it can feel much easier to leave the gate permanently ajar rather than carefully defend the NHS hospital waiting lists by fending off the worried well. I’m very popular with my patients on a Friday afternoon because they are getting what they want, but I’m not always practising good medicine. Making the patient happy isn’t always the same as being a good doctor.
When I started as a GP I was told that it was easy to be a bad GP but hard to be a good one. A good doctor won’t prescribe antibiotics for a cold and won’t refer every patient with a headache for an expensive MRI scan. A good doctor should also be able to explain to the patient why he’s not agreeing to their demands, but sometimes, however hard you try, the patient leaves feeling dissatisfied and the doctor goes home feeling distinctly unpopular. It is a difficult balance to run on time but give each patient adequate individual attention, to allow patient choice but not give in to inappropriate demands, to keep referral rates low but make sure the patients get the expert input they need. I’m still not sure exactly what a good doctor is, but it is certainly more complex than earning a few smiley faces on a government questionnaire.
Connor
‘It’s my kids, Doctor. They’re little fuckers. I can’t control ’em no more. Something’s gotta be done about it. My youngest, Connor, was brought home by the police the other day.’
‘How old is Connor?’
‘He’s three.’
I rack my brains trying to think what a three-year-old could possibly do to get himself in trouble with the police.
‘They caught him putting rubbish through the neighbours’ letter boxes.’
‘Was he out on his own?’ I ask incredulously.
‘Oh no, Doctor, Bradley and Kylie was with him, but they was the ones telling him to do it.’
I skim through the notes to see that older siblings Bradley and Kylie are six and seven, respectively.
Mum Kerry is actually very likeable. She is a stereotypical council estate mum. Only 25, but already has three kids with three different men who are all now nowhere to be seen. Life is hard for her and she has very little support. She genuinely wants the best for her kids and really wants help.
Unfortunately for her, the entirety of my knowledge on child behaviour comes from having watched a couple of episodes of Supernanny on TV. I’ve never been the sternest of people and given the way my cat walks all over me, I’m probably not the best person to ask about discipline.
‘I think he’s got that DDHD condition. You know, where they’re little shits but it’s ’cause there’s something wrong with the chemicals in their brain and that.’
I’ve met lots of parents whose children have had a diagnosis of attention deficit hyperactivity disorder (ADHD). The parents love the label because it now excuses the bad behaviour. The kids run riot round my consulting room, rifling through my sharps bin and using my ophthalmoscope as a hammer. Mum and Dad do nothing to stop them and then say, ‘Sorry about the kids, Doc. It’s the ADHD – nothing we can do … brain chemicals and that.’
I don’t disbelieve that ADHD exists but perhaps it has been overdiagnosed in recent years. The main symptoms are lack of concentration, being easily distracted and not being good at listening. I could probably persuade myself that Connor has these symptoms, but I’m not sure that they are related to brain chemicals. I guess some children are more prone to developing these symptoms than others, but in most cases isn’t parenting more likely to be the most significant factor rather than a brain disease?
I’m not going to send Kerry’s kids to the child psychiatrist. The wait is long and I don’t want these children labelled as psychiatrically unwell. I’ve heard there is a specialist social worker locally who gives individual and group parenting skills classes. Kerry is perfect for her.
Kerry comes back a couple of weeks later to let me know how it went.
‘I really like my parenting support worker. She told me I mustn’t call ’em little fuckers no more but instead they are good children with some c.h.a.l.l.e.n.g.i.n.g behaviour.’
She goes on to tell me about how she is now rewarding good behaviour, setting consistent boundaries and using the naughty corner. Hold on a minute, I could have told her that. This parenting adviser must have watched the same episode of Supernanny that I saw.
Janine
Janine is nine years old and about 13 stone. She waddles into my room and then Mum waddles in after her. My room feels very small.
‘It’s her ankles, Doctor. They hurt when she runs at school. She needs a note to say that she can sit out games.’
‘Did you fall over or twist your ankle, Janine?’ I always try to engage with the child themselves if possible. Janine looks at the floor and then shakes her head. ‘How long have they been sore?’ Eyes still to the floor, this time I get a shrug.
‘Right, let’s have a look at these ankles then.’ I try to be engaging and smiley, stay positive and encouraging. I prod and poke her ankles and get her to move them around a bit. My examination is a bit of a show most of the time and today is no exception. One look at Janine walking into my room showed me that her ankles were basically normal. I try to make my prodding and poking look like it has purpose, but it is purely a performance for the benefit of Janine and her mum. I want them to think that I am taking them seriously, that I am genuinely looking for some ‘underlying ankle pathology’. As I prod away, I try to remember the names of some of the ankle ligaments … no joy there. Perhaps I’ll just try to remember which is the tibia and which is the fibula … no, just confusing myself now.
‘Right … Well, I can’t find any swelling or tenderness in those ankles … and she’s walking okay …’ This is the make or break moment … How am I going to put this tactfully? I am standing at the top of the diving board but do I have the bottle to make that jump? I could just write the note, prescribe some paracetamol syrup and climb quietly down the ladder. No, Daniels, come on, it’s your duty to say something. Right. Here goes. ‘Some children find that … erm err … that being a bit … erm …’ (Say it, Daniels, just say it)‘… erm overweight can make their joints hurt sometimes.’ I had done it. I had jumped!
Janine’s mum looks me straight in the eye. Her face looks like a pitbull slowly chewing a wasp. ‘It’s got nothing to do with her weight,’ she says angrily. ‘Janine’s cousin is as skinny as a rake and she has problems with her ankles, too. It’s hereditary.’
What can I say to that? My courageous leap got me nowhere. I belly-flopped painfully. Can I prove that Janine’s ankles hurt because she is fat? No. Is Janine’s mum going to accept that weight is an issue? No. I either argue on fruitlessly or accept that I am beaten and salvage the few scraps of the patient–doctor relationship that are still intact.
‘She can still do swimming!’ I shout as they waddle away, sick note and paracetamol prescription already tucked snugly into Mum’s handbag. It is a final attempt to redeem myself, but a poor one. I can picture Janine sitting in the changing rooms munching on some crisps while the rest of her class runs around outside. Beneath the many layers of abdominal fat, her pancreas would be slowly preparing itself for a lifetime of insulin resistance and the debilitating symptoms of diabetes that occur as a result. Meanwhile, her joints, straining under her weight, would be struggling to cope and the resulting damage would eventually develop into early onset arthritis.
Did I miss my chance to make a difference? Have I been a shit GP again? Are doctors slightly egotistical even to consider that a few well-placed words of advice from us can breach deeply entrenched lifestyle and dietary habits? ‘Hold on, kids, no more sugary drinks and turkey twizzlers for us. Dr Daniels thinks we are overweight and thank goodness he pointed it out or we would never have noticed. He’s given me a wonderful recipe for an organic celery and sunflower seed bake and we’re swimming the Channel at the weekend.’
Saving lives
A few years back I spent a stint working in a hospital in Mozambique. Each morning the American consultant would start the ward round with a prayer and then shout boldly and, with not the slightest hint of irony, ‘Come on team, let’s go save some lives!’ The rest of us would then cringe internally, roll our eyes at each other and then follow him round the morning’s array of sick and dying Africans. There are a surprising number of Western doctors filing around the wards of African hospitals. I’m not always sure of the motives but there we were: an American cardiologist, two British GPs and a French nurse. Between us, we had years of expensive medical training and lots of letters after our names. As we wandered through the wards, we didn’t really save many lives. The majority of our patients were dying of AIDS-related illnesses or malaria. There were no anti-AIDS drugs (antiretrovirals, ARVs) and even our malaria medication supply was low because of a robbery at the hospital pharmacy (an inside job).
Meanwhile, 30 miles outside of town, Rachel, a 22-year-old from Glasgow with no letters after her name, really was saving lives. Rachel had dropped out of her sociology degree and had been working in a call centre before deciding to come and do some voluntary work in Mozambique. She had raised some sponsorship from back home and was touring the rural villages with a troop of local women. All she had at her disposal was a basketful of free condoms and a few hundred subsidised mosquito nets. Accompanied by information and education in the form of songs and posters, her campaign was a raging success. She later e-mailed me to say that malaria deaths had reduced and that she was hoping to have an equally good result with HIV transmission rates.
At the same time, my learned colleagues and I made clever diagnoses on the ward and skilfully inserted chest drains and spinal needles. Occasionally, we did save a life and it was quite exciting when a patient got up and went home after being at death’s door. As we waved them off, we knew that ultimately they would be back. They couldn’t afford to pay for the full course of medication, and it was only a matter of time before they were unwell again and back in our hospital. We were briefly prolonging lives rather than saving them.
Regardless of the country it is practised in, most of hospital medicine is painting over the cracks rather than fixing the wall. Lives are saved by preventing illness rather than curing it. If you are 64 and admitted to hospital in the UK with a heart attack, it will be all blue lights and running around. After emergency heart scans, a dashing young doctor will probably give you a whack of clot-busting medicine into your veins and it could save your life. At age 16, this was just the kind of exciting medicine that I imagined my job would be. I have been that doctor and at times it is genuinely quite glamorous and exhilarating. Sometimes, it does make a real difference and lives are saved. The patient and family will thank you and you’ll feel pretty good for a bit.
Since I have been a GP, on balance I have probably saved far more lives than I did during my time as a hospital doctor. It is my job to try to prevent you from having a heart attack rather than save your life immediately after you’ve had one. It is far less glitzy and dramatic, but by helping patients control their blood pressure, give up smoking and reduce their cholesterol, I have probably helped prevent or at least delay many hundreds of heart attacks. This might sound like a pathetic attempt to try to elevate GPs and combat an inferiority complex put upon us by years of derogatory comments from our hospital colleagues, but I genuinely think it is true. In the same light, the pressure groups who pushed for the government bill for the smoking ban in public places or who pressed for the introduction of the compulsory wearing of seat belts will have saved more lives than all of us put together.
Public health doctors are those who rather than treating individual patients, look at the bigger picture of health trends across the country and the potential interventions that could help. The rest of the medical profession sneer at public health doctors even more than they do at GPs, but the conclusions of public health doctors influence big decisions made in Parliament and can save and improve many lives. The problem faced by public health campaigns in the UK is the tendency for people to react to being told what to do. In Mozambique, Rachel wasn’t faced with angry villagers demanding the ‘choice’ not to be given free condoms or complaining about the ‘nanny state’ forcing them to sleep under mosquito nets. Getting the balance in the UK is difficult. The opposition to wearing seat belts 30 years ago and the smoking ban more recently was huge. Our role as GPs is trying to tread the fine balance between giving useful advice and encouragement to make good lifestyle choices whilst not being too paternalistic and patronising.
Kirsty, the trannie
Kirsty had once been a married man with three children, but over the last five years she had spent many thousands of pounds having surgery to become a woman. She had her chin made less square, breast implants and, most importantly, her male organs surgically transformed into female organs. (In post-op trannie circles this is known as having your ‘chin, tits and bits’ done.) As well as the surgery, there was the electrolysis and oestrogen tablets, not to mention the huge amounts of money spent on boutique clothes, expensive make-up and a Gucci handbag that my wife would die for. The only problem was that Kirsty still looked overwhelmingly like a man. She was six foot two and had broad shoulders and stocky legs. Her 1980s perm and size-eleven feet squeezed into a pair of size-nine stilettos didn’t help. Kirsty looked like a rugby bloke who had been badly dressed up as a woman by his mates on a stag do.
‘How do I look, Dr Daniels?’ Kirsty asked as she flicked her hair and fluttered her fake eyelashes in the worst attempt to be flirty that I’ve ever seen. ‘I’ve had my boobs redone again. Do you want to have a look?’
‘No, no, that’s erm fine … I’m erm sure that they did a good job.’ Kirsty is such a regular at the surgery that she no longer feels the need to have a medical problem to present. She is quite happy to pitch up for a chat and a gossip. She always has a story to tell and is a nice break from the dreariness of afternoon surgery.
For those of you who are interested, the operation is called ‘male to female gender reassignment surgery’. There are various techniques but the most popular appears to be cutting off the testicles and inverting the penis. The penile and scrotal skin are combined and used to line the wall of the new vagina and to make the labia. The surgeon makes a clitoris using the part of the penis with the nerve and blood supply still intact. According to the surgeon’s website, this enables some patients to orgasm. I haven’t yet asked Kirsty about this but I’m sure she would happily tell me all about it given half a chance.
Despite the extrovert exterior, there was a real sadness about Kirsty. The sacrifices that she had made to change her gender were extraordinary. She gave up her marriage and children (only one of whom still talks to her). She lost her job and many of her friends and the pain she describes of the surgery and recovery period is unimaginable. Kirsty now lives slightly on the fringes of society. She is stared at in the street and struggles to find acceptance at every corner. It seems amazing to me that she would have put herself through this much to make the change.
Kirsty, however, has absolutely no regrets. She told me that five years earlier she felt that her only choices were to have the operation or commit suicide. In the nicest possible way, Kirsty is a bit of a drama queen but I genuinely think she means this and the doctors at the practice who knew her as a man agree that she was pretty close to ending her life back then.
Empathy is defined as an ‘identification with and understanding of another’s situation, feelings and motives’. I like Kirsty but I can’t really empathise with her, as I just find it so hard to imagine what it would be like to be so unhappy with the gender I was born with. Kirsty is quite astute and I think that she has spotted this in me. As she left, she said, ‘It’s fucking hard being me, you know. You should try being a trannie for a day.’
I did once lose a bet at medical school and had to spend an evening out dressed as Smurfette. I’m not sure it really corresponds to empathising with the emotional and physical turmoil experienced by a transsexual; however, being painted completely blue and wearing a dress and blonde pigtails, it did take me a hell of a long time to get served at the bar.
‘It’s my boobs, Doc’
Stacy was in her late thirties but the years of smoking and sunbeds made her look much older. She stormed in and sat down with the look of someone who wasn’t going to leave until she got what she wanted. ‘It’s my boobs, Doc.’ I must have had a slightly puzzled look on my face, so in order to enlighten me she lifted her top to reveal her large and extremely distorted breasts. They looked like two oval-shaped melons surrounded by a layer of puckered skin and had two nipples drooping off the ends. They were pointing at awkward angles and looked completely disconnected from the rest of her body.
‘Something needs to be done,’ she demanded. ‘I ’ad ’em done ten years ago but they need redoing.’
It turned out that the original surgeon was happy to ‘redo’ them and his letter from 1998 did clearly state that her breasts would need repeat surgery after ten years. The problem was that he was charging 10K for the redo and, according to Stacy, she didn’t have that sort of money. ‘I need ’em done on the NHS, don’t I?’
My sympathy for Stacy was limited. Yes, she did have hideously deformed bosoms but the local breast surgeons were rather busy removing cancers. I didn’t really feel that she should qualify for NHS treatment. I began to try to explain that I wouldn’t be referring her today when Stacy began rummaging through her bag, eventually emerging triumphantly with a copy of a women’s magazine. She opened it up to a double-spread headlined: ‘My Fake Boobs Burst and Nearly Killed Me’. I read on to see that, like Stacy, this woman had had a breast augmentation in the 1990s, but ten years later her implants ruptured and left her in intensive care with blood poisoning.
The prospect of Stacy being poisoned by her exploding fake breasts might have entertained a lesser doctor than me, but then Stacy pointed out the part of the article showing that the poisoned implant lady was taking her GP to court for not referring her earlier. I could see in Stacy’s eyes that nothing would give her more pleasure than suing my arse for every penny she could. Defeated and broken, I made an apologetic referral to the surgeons as Stacy looked on smugly.
Two weeks later Stacy stormed back in with the letter from the surgeons stating that she didn’t qualify for the operation because of ‘PCT funding guidelines’. It was the perfect scenario for me. I didn’t really want NHS money spent on Stacy’s new boob job but could now blame some faceless managers for it not being done. I was off the hook and happily faked sympathetic noises as Stacy complained about how unfair the world was. A month later Stacy found the money to get her breasts redone privately.
Mr Hogden
I was spending a few weeks working in a very pleasant rural practice. It was nice to have a break from the poverty-fuelled social problems of the inner cities. I had dug out a few ties that I had long since stopped wearing and also rediscovered my best posh accent that I had last used for my medical school interview in 1996. Surrounding the surgery was a collection of very pleasant villages with big houses and twee thatched cottages. It was fox-hunting and green welly territory. During a sweltering few weeks in July, it was a pleasure to be cruising around the countryside doing my home visits rather than stuck in city traffic jams cursing the lack of air conditioning in my car.
Driving down a small country lane, I came across a row of small run-down bungalows. They looked a little out of place in contrast to the rest of the local housing. They were the area’s small quota of council housing that the rest of the village tried to ignore.
The patient I was visiting was called Mr Hogden. He lived quietly with his sister in one of the less well-kept bungalows. He was only in his early forties but hadn’t left his bungalow for nine years. The medical notes seemed to suggest that this was due to a history of agoraphobia, but more obvious on meeting him was that there would be no way Mr Hogden would have fitted through the door. He was fucking enormous.
Mr Hogden resided in the smallest room of the bungalow. It was about the size of a double bed and was taken up entirely by Mr Hogden himself sprawled out on the floor. He had long since broken his bed and now spent his time on a very old, filthy-looking mattress on the floor. Each of his limbs was made up of several huge rolls of fat with a hand or foot poking out at the end. His head emerged out of a humungous mass of lard that was his torso.
The sight of Mr Hogden sprawled out on the floor was a bit of a surprise but it was the smell that I really struggled with. The bungalow was like an oven in this hot July sunshine and there was only a tiny window in the room that barely let in any air or light. Flies were buzzing around in their hundreds and as my eyes slowly adjusted to the dimly lit room, it became apparent where they were coming from. Unfortunately for Mr Hogden, the flies had found that the warm sweaty crevices between his rolls of fat were a perfect place to lay their eggs. Emerging from his legs and body was a legion of maggots. The sight of the maggots and the horrendous smell were almost too much for me and despite priding myself on a strong stomach I had to do my utmost not to vomit.
‘You’ve got to help me, Doctor,’ Mr Hogden pleaded with me as he watched me take in the horror of his predicament. Despite the terrible state in which he was living, this was the first time that Mr Hogden had called out a doctor in the last ten years. He had managed to get to the toilet and back up until now and he simply spent the rest of his time lying on his mattress watching a tiny television that was mounted on the wall of his bedroom. His sister brought him his meals and Mr Hogden had quietly grown enormous without bothering a soul. Until now that was. This was yet another of those moments where I felt completely useless and, like all good cowards, I fled. To be fair, what was I going to do? I could have crouched down and picked the maggots out of Mr Hogden’s groin creases but I would have vomited. The flies would have fed off the regurgitated contents of my stomach, only adding to his problems.
I called the district nurses. I felt bad. I did. Really. No, I did. I warned them what to expect and when I bumped into them a few days later, they were amazingly stoical about the whole clean-up operation. They put me to shame. I went back to see Mr Hogden the next week. The maggots were gone but he was still lying on the floor of his squalid little room. We had a chat and talked about how we were going to sort things out. His expectations were low. All he really wanted was to be able to spend his days sitting in the lounge on a sofa and watching the television like a normal person. He was too heavy for the current sofa – hence the filthy mattress on his bedroom floor.
I was feeling guilty about my near-vomiting experience during our first meeting so decided to make it my mission to get him a new sofa. I phoned round endlessly and eventually social services agreed to supply a specially reinforced sofa for the bungalow. I had absolved myself. A few weeks after the sofa arrived I received a phone call from a hysterical Mr Hogden. ‘Please, Doctor, come round, please.’ Worried that the maggots were back, I avoided lunch and headed over. Mr Hogden was sitting on his brand-new sofa and had been there since it had arrived. Unfortunately, the effect of now sitting upright meant that his huge weight was now all being placed on to one pressure point on his bottom. He had not moved from his sofa since it had arrived and had developed unpleasant pressure sores on his bottom. The material of the sofa had gradually begun to stick to the infected sores and Mr Hogden was phoning me to tell me that he was now completely stuck to the sofa and couldn’t move at all.
I couldn’t quite comprehend what he was telling me over the phone, but as I arrived I saw that he was quite right. The material of the sofa and the sores on his bottom had become one. It was impossible to see where Mr Hogden ended and the sofa began. It was not a pretty sight and he had the same pleading look in his eyes that I had witnessed during the maggot incident. He was in a great deal of pain and I was feeling helpless again. I couldn’t believe that he had let his sores get so bad without calling anyone. He really needed to go into hospital but this was easier said than done. The first job was to cut him out of the sofa, which required a fair bit of teamwork, a set of garden shears and a very strong stomach. The next task was the more difficult job of physically getting Mr Hogden to hospital. I had ordered a specially reinforced ambulance with a strengthened trolley but, unfortunately, despite best efforts, Mr Hogden just couldn’t be fitted through the door. Four paramedics, a nurse, a medical student (I had to bring him along to show him that general practice wasn’t boring), several of Mr Hogden’s neighbours and I all tried to find different angles or ideas to get him out of the bungalow. In the end the fire brigade had to be called to cut out a wider door. They were reluctant and made Mr Hogden sign a disclaimer promising that he wouldn’t try to sue them for damaging his bungalow. Eventually, we got Mr Hogden to hospital. The next day my placement ended and I’ve no idea what happened to him. I hope he’s lost some weight and perhaps gained some quality of life.
Small talk
Drew was a very good-looking guy. He was in his early twenties with big muscles, perfectly chiselled features, blonde hair, blue eyes and a probably fake but nonetheless healthy-looking tan.
‘I’ve got a painful testicle, Doctor. Wondered if you’d have a look at it.’
I was the only male doctor to have worked at this practice for over a year and my first few days were spent seeing a queue of relieved men worried about their genitalia. Some had been worried about their ‘bits’ for months but had been too embarrassed to expose themselves to one of the female doctors.
So there I was, gently rolling Drew’s testes between my fingers, looking for lumps. It can be a slightly uncomfortable situation for the patient in every sense of the word, so I decided to try to make a bit of small talk to put him at ease.
‘So Drew, what do you do for a living?’
‘I’m a film actor.’
‘I thought you looked familiar. Have you been in anything I might have seen?’
‘That depends, Dr Daniels, I only really do gay porn.’
‘Ah, probably not then, no. You … erm … must have one of those familiar-looking faces I guess. Definitely wouldn’t have seen you in a film. Nothing against porn or anything, except the degradation of women and all that … well, not many women in your films, I should imagine …’
There was now only one person in the room who was uncomfortable and it wasn’t Drew. I really should remember to limit my small talk topics to the weather and city centre parking problems.
Notes
It is always drummed into us how important it is for us to keep clear, coherent and detailed medical notes. These are apparently real extracts from medical notes. They have been doing the rounds as an e-mail.
1 She has no rigours or shaking chills, but her husband states she was very hot in bed last night.
2 Patient has chest pain if she lies on her left side for over a year.
3 On the second day the knee was better, and on the third day it disappeared.
4 The patient is tearful and crying constantly. She also appears to be depressed.
5 The patient has been depressed since she began seeing me in 1993.
6 Discharge status: alive but without my permission.
7 Healthy-appearing decrepit 69-year-old male, mentally alert but forgetful.
8 The patient refused autopsy.
9 The patient has no previous history of suicides.
10 Patient has left white blood cells at another hospital.
11 Patient’s medical history has been remarkably insignificant with only a 40-pound weight gain in the past three days.
12 Patient had waffles for breakfast and anorexia for lunch.
13 She is numb from her toes down.
14 While in ER, she was examined, X-rated and sent home.
15 The skin was moist and dry.
16 Occasional, constant infrequent headaches.
17 Patient was alert and unresponsive.
18 Rectal examination revealed a normal-sized thyroid. (Thyroid gland is in the neck!)
19 She stated that she had been constipated for most of her life, until she got a divorce.
20 I saw your patient today, who is still under our car for physical therapy.
21 Both breasts are equal and reactive to light and accommodation.
22 Examination of genitalia reveals that he is circus-sized.
23 The lab test indicated abnormal lover function.
24 The patient was to have a bowel resection. However, he took a job as a stockbroker instead.
25 Skin: somewhat pale but present.
26 The pelvic examination will be done later on the floor.
27 Patient was seen in consultation by Dr Blank, who felt we should sit on the abdomen and I agree.
28 Large brown stool ambulating in the hall.
29 Patient has two teenage children, but no other abnormalities.
30 The patient experienced sudden onset of severe shortness of breath at home while having sex, which gradually deteriorated in the emergency room.
31 By the time he was admitted, his rapid heart had stopped, and he was feeling better.
32 Patient was released to out patient department without dressing.
33 She slipped on the ice and apparently her legs went in separate directions in early December.
34 The baby was delivered, the cord clamped and cut, and handed to the paediatrician, who breathed and cried immediately.
35 When she fainted, her eyes rolled around the room.
Lists
Please don’t bring a list of problems when you see your GP. I understand that you might not get to the surgery very often. Perhaps you have to sweat blood to get an appointment. Maybe you had to plead with your boss for the morning off and then beg our receptionist to squeeze you in. In fact, it is probably so difficult for you to get an appointment with your doctor, you’ve saved up all your niggling health queries that have been building up for the last few months and thought it would be better to get them all sorted out in one visit. Please don’t!
We have ten minutes per appointment. That isn’t very long, but we GPs pride ourselves in dealing with even quite complex problems during that short period of time. We have to get you in from the waiting room, say hello, listen to your concerns, take a history, examine you, discuss options, formulate a plan, write up your notes and complete any necessary prescriptions or referrals … all in just ten minutes! It’s amazing that we ever run to time. However, if you have saved up four problems to sort out, then that leaves just 2.5 minutes per problem. That isn’t very long and we’ll either spend 40 minutes with you and annoy the rest of the morning’s patients by running very late, or we’ll only half-heartedly deal with each problem and probably miss something important. This is clearly bad for your health and our indemnity insurance premiums.
If you do have a list of several problems, please warn us from the start and tell us what they all are. I’ve frequently had patients tell me that they are here to talk about their athlete’s foot and then after a leisurely ten minutes casually mention their chest pains, dizzy spells and depression on the way out of the door. If you have got several problems you want addressing, try booking a double appointment or decide what problem needs to be dealt with that day and book in another time for the others. Moan over. Ta.
Ten minutes
I see the ten-minute appointment as the patient’s time to use as they so wish. Most patients will fulfil the time in the conventional way with a discussion of a health problem that we then try to collectively resolve. However, any GP will tell you that not all consultations run like this. For example, one of my patients uses the time to tell me about the damp problem in her spare room and another about the affair that she is having with her boss that nobody else knows about. I have one patient who comes into my room, sits down and strokes a toy rabbit in complete silence. Initially, I desperately tried to engage her in conversation, but I have long since given up and now I get on with some paperwork, catch up with my e-mails and check the cricket score on-line. When her ten minutes are up, she gets up and leaves. She doesn’t even need prompting, a perfect patient!
Some people would consider these patients time-wasters but I don’t have any reason to judge a person’s motives for coming to see me. I’m not working in casualty. You don’t have to have an accident or emergency to see me. I’m a GP, which basically makes me the arse end of the NHS. If you turn up on time and leave after ten minutes, I’ll let you talk about anything. In fact, the three above-mentioned patients are among my favourites. My patient with the damp trouble has been updating me on her ongoing problem for months now. She enters my room agitated and upset and then erupts into a monologue on the woes of damp and the turmoil it is causing her. I do very little during the entire consultation other than pretend to look interested and reassure her that it is all going to be just fine. I do gently point out to her when her ten minutes are up or she would stay all afternoon. She is always eternally grateful that I have listened to her and insists that I have made her feel much better. She then happily goes to the desk to book herself in to see me at the same time next week. I also now know the difference between rising damp, penetrating damp, internal damp and condensation!
As for my patient who is having an affair with her boss, I always enjoy her visits. She is a solicitor’s secretary in her early twenties and has been shagging the much older married solicitor for some time. Each visit I get the latest instalment in graphic detail and I am left with an EastEnders-type cliffhanger to keep me in suspense until the following week. During the last visit she told me she was pregnant. The solicitor offered her £5,000 to have an abortion but she really loves him and wants his child. What was she going to do? Ten minutes come to an end – cue EastEnders closing music: dum … dum … dumdumdum … Okay, so yet again not exactly a great use of my expensive training and broad medical knowledge, but I like the intrigue.
I am not completely anal about only spending ten minutes with each patient. Some things take more than ten minutes to sort out and if it is urgent and important then I’ll just have to run late. Last week I saw a young woman who had been sexually assaulted by her uncle. She wanted to talk to someone about it and for some reason she chose me. I listened for nearly an hour because that is how much time she needed. My subsequent patients were annoyed by my lateness, but she was by far the most important patient I had seen all week and the sore ears and snotty kids had to wait.
Alf
It’s a Sunday and I’m working a locum shift in A&E to make a bit of extra money. I used to work in A&E during my hospital training and quite like going back to work the odd shift. It helps keep me up to date with my A&E skills and also makes me happy that I’m not a full-time A&E doctor any more. I pick up the notes for my first patient of the shift, open the curtains and lying on a trolley in front of me is Alf.
‘Oh bloody ’ell. Not you. You’re bleedin’ everywhere, you are.’
Although these were Alf’s words, they also very closely reflected my own thoughts.
I had been visiting Alf at home all week as his GP and then I turn up for a shift in A&E to get a bit of excitement and escape from the daily drudge of general practice … and there is Alf lying in front of me.
Alf is in his late eighties and lives alone in a small run-down house that he can’t really look after. Alf’s notes state that he has had 23 A&E admissions in the last five years, which qualifies him to reach the status of ‘frequent flyer’ in A&E talk. If hospital admissions could earn you loyalty points, Alf would be able to cash his in for two weeks of dialysis and a free boob job. Unfortunately, all Alf’s hospital admissions have actually earned him is a bout of MRSA and a collective groan of disappointment from the A&E staff when they see him being wheeled into the department.
Given the large amount of time Alf spends coming in and out of hospital, you would think that he had a huge list of complex medical problems but, in fact, Alf doesn’t really have much wrong with him physically. His admissions have been almost purely ‘social’. This means that Alf is admitted to hospital costing a large amount in time, resources and money, because he can’t really look after himself at home. When they talk about bed crises and patients on trolleys in corridors, it is because patients like Alf are lying in hospital beds that they don’t really need.
This is what happened to Alf this week. I got a phone call from his worried neighbour on Monday saying she had heard him shouting through the wall. I couldn’t get into the house so I had to call the police to break the door down. Once inside we picked up Alf, who was basically fine but had fallen over as he often does. Sometimes there are specific reasons why elderly people fall over such as blood pressure problems or irregular heart rhythms. Sometimes elderly people just fall over because they are frail and have poor balance. Alf falls because he refuses to use his three-wheeled Zimmer frame (‘it makes him feel old’), because his house is filled with clutter that he refuses to allow to be tidied away and, finally, because he is still rather partial to a large scotch after lunch.
On the Monday I gave Alf a check-over and he was fine. He hadn’t bumped his head or broken his hip and insisted that we all ‘bugger off’ and leave him in peace. Alf looked terrible. He was thin and bony with filthy clothes, long straggly grey hair and quite frankly in need of a good wash.
‘How do you feel you’re getting on at home, Alf?’
‘Fine, now piss off and leave me alone. The race starts in 20 minutes.’
‘What about if I got you some help around the house? Perhaps someone to clean up a bit and maybe give you a hand getting washed and dressed in the mornings?’
‘I’ve been looking after myself perfectly well for 70-odd years, I don’t need you lot interfering.’
‘How about just some meals on wheels to get some meat on those bones?’
‘I’m a very good cook, thank you very much.’
Alf had been offered support at home numerous times before, but he had always declined. He was a grown-up and knew his own mind. He sometimes forgot things but he wasn’t demented and was entitled to make his own decisions about his own house, health and hygiene. When I got back to the surgery, I phoned social services and asked them to make an assessment. I was specifically going against the wishes of my patient, but Alf was in desperate need of some support and if some nice friendly social worker came and had a chat over a cuppa, perhaps Alf could be persuaded … Needless to say the next day the social worker phoned to say that after a brief conversation through the letter box, she had been given the same ‘bugger off’ as the rest of us.
I can completely see where Alf is coming from. He has lived a long hard life and has managed independently, making his own decisions and doing his own thing. Why should he suddenly have strangers in his house interfering? He wasn’t harming anyone other than himself, so why didn’t we just leave him alone? I imagine his biggest fear was being carted off to a nursing home and losing his independence completely.
My problem was that as Alf’s GP, I had a duty of care for him. That and the fact that his bloody neighbour always called me first when she heard him shouting and swearing through the wall. At least we had a spare key now and so I visited Alf three times that week and each time I picked him up, checked him over and was given the same emphatic ‘bugger off’ when I offered to bring in some help.
On Sunday morning, the surgery was closed so when Alf fell over, the neighbour just called 999. The paramedics decided to bring in Alf despite his protests and here he was, looking uncomfortable and unhappy on the trolley in front of me. As ever, I checked him over and, being in A&E, I had the advantage of being able to get a quick ECG (electrocardiograph – heart scan) and urine sample checked. They were both normal and predictably Alf just wanted to go home. The problem was that there was no hospital transport on a Sunday to take him home. The ambulance crew wasn’t allowed to take him and he didn’t have any money for a taxi. We had no choice: Alf had to be admitted to a hospital bed. As he was being admitted to a medical ward, he was subjected to the obligatory blood tests and chest X-ray. Then he would be assessed by the physios and the occupational therapists who would each in turn be told to ‘bugger off’, until eventually Alf would be sent home only to fall over a few days later and hence the cycle would be repeated.
The government in its wisdom has worked out that patients like Alf are costing an absolute fortune because he is part of the 10 per cent of frequent flyers who are responsible for 90 per cent of hospital admissions. The problem is that it is very difficult to keep patients like Alf out of hospital. Even elderly people who do accept help still fall over or become confused when they get a simple infection. Carers, neighbours and relatives do their best but they don’t have medical training and when faced with an old person on the floor, they often call an ambulance. I don’t have an answer for what to do with patients like Alf. Perhaps smaller cheaper community hospitals or specially adapted nursing homes that offer short-term care would be a better option. It is such a shame that A&E departments full of well-trained staff and expensive equipment are seeing their beds filled up with social admissions like Alf rather than the accidents and emergencies that they are intended for.
Meningitis
Every six months or so, a newspaper will print an article with a headline something like: ‘GP MENINGITIS BLUNDER – My GP diagnosed my child as having a cold, ten hours later she was in intensive care with meningitis.’ This is the sort of story that terrifies every parent and every doctor. For GPs who are also parents, it is a double-fear whammy.
Meningitis is a frightening condition for GPs because it tends to affect children and young people and if we miss it, the patient can be dead within hours. The difficult truth behind the scaremongering headlines is that any child who is seen by their GP in the first few hours of meningitis will probably be sent home with some paracetamol having been told that they have a viral infection. Early meningitis symptoms are generally a fever, feeling a bit lethargic and not being very well. We see bucket loads of children like this every week. The symptoms of a rash and neck stiffness that give away the diagnosis are only seen much later on, by which time the child is already quite sick.
I know an excellent and experienced GP who sent home a child who then went on to develop meningitis. It is a horrible diagnosis to miss but only rarely is it a ‘blunder’. The only thing we GPs can really do for the thousands of snotty feverish children we see every day is educate the parents as to what danger signs to look out for and when to bring them back to see us.
I’ve only seen meningitis a handful of times and thank goodness never as a GP. The first time I saw it was the most memorable. I was working in casualty and a dad carried his four-year-old child into the waiting room. I took one glance at the child and went straight to the drugs cupboard, whacked some penicillin into his vein and called the paediatric registrar instantly. Despite the fact that I had never seen meningitis before, the diagnosis was obvious. The child looked really bloody sick. He was floppy and completely disinterested in anything around him. This was not a clever diagnosis. No doctor in the world would have sent this child home. Several hours earlier when the child was just a bit hot and bothered but still happily watching Disney videos and playing with his brother, the diagnosis would have been much more tricky. If I’d seen the child at this stage, I could easily have sent him home and become the next day’s ‘blunder doctor’ newspaper headline.
I am always happy to see children and babies in my surgery and will do my best to fit them into a full surgery if Mum or Dad is worried. In fact, seeing kids is one of my favourite parts of being a GP. The main difference between children and adults is that kids are very rarely unwell. The truth is since I’ve been a GP, I’ve probably seen well over a thousand children and babies, but I am yet to see one that was unwell enough for me to be really worried. Meningitis is really scary but also pretty rare. I understand that this might not be that reassuring if it is your own child that is hot and miserable and that is why I’m always happy to see kids and to reassure parents. As a parent myself, I do realise that it is hugely anxiety-provoking to have this small person for whom you are solely responsible and whom you love overwhelmingly and unconditionally. We doctors are equally anxious when our kids are unwell and I once heard of a GP rushing her infant to see an ear, nose and throat specialist as she was convinced her child had a nasal tumour. She was understandably very embarrassed when the specialist then removed an impressively big but definitely benign bogey from her child’s nostril.
A few kids need a good check-over before I’ve reassured myself that they can go home, but the vast majority are obviously fine as soon as they walk through the door. This may seem a bold statement to make when I’ve previously talked about how easy it is to miss meningitis early on. However, these borderline kids are the minority of children we see. If a child skips into my consulting room and gives me a smile, they haven’t got meningitis. I can’t say that they won’t develop meningitis in 12 hours’ time but then I couldn’t say that any well child wouldn’t develop meningitis in 12 hours’ time. Unfortunately, that is the nature of the disease. In the same way that it took me about one second to decide that the child with meningitis was really sick, it takes me about one second to decide that 99 per cent of the children I see are completely fine.
When I say that the vast majority of the children I see are ‘fine’, I don’t mean that they are not unwell. What I mean is that they don’t have meningitis or any life-threatening condition that needs hospital admission right then. They also almost certainly don’t need antibiotics as they invariably have a viral infection. It’s important that I don’t use the word ‘fine’ to Mum and Dad as they have been up half the night with a miserable crying infant. These children are ill but not ill in a way that I can do anything about. It is just part of being a child.
Kids get ill because they haven’t been exposed to lots of the bugs that we have. They are going to be snotty for much of their early years and often spend the vast majority of their first couple of winters going from one viral infection to another. Children need to build up their immune systems and, unfortunately, the only way they can do this is to be unwell. I often think that new parents are a bit unprepared for this part of parenthood. Children will have recurrent ear infections, coughs that last for weeks, sore throats that are really sore and funny spotty rashes that don’t quite look like anything in my dermatology textbook. All these things are just part of being a kid and staying up all night comforting them is part of being a parent. It’s not much fun at the time but it’s normal. I would love to be able to give an instant cure for these childhood illnesses but, unfortunately, I can’t. My job is simply to listen to the parents, do a quick examination, offer encouragement and reassurance and make sure that Mum and Dad come back if they are worried. A generation or two ago when big extended families lived together, this reassurance was given by Grandmother or Auntie, but nowadays parents can be quite isolated, hence it is often the GP that fills this role.
Soothing anxious parents is definitely one of the hardest parts of my job. Many are very happy with some sensible reassurance. Others are looking for antibiotics and won’t be happy unless they leave with them. We all want the best for our child and seeing them unwell is hard to bear. I think some parents feel that they are letting their child down if their snotty and coughing infant doesn’t get antibiotics. In direct contrast, as I strive to be a good doctor, I am trying to hold back from giving antibiotics. It can be a difficult battle that can go either way.
To try to swing the encounter in my favour, I have developed a battle plan. The first thing that I do is try to empathise and say how the child definitely does have a very bad infection – be it a cough or ear infection or sore throat, etc. I sympathise about how hard it is for the whole family when a child is up all night coughing and crying, etc. Vital is me then telling the parents what a great job they are doing with regular paracetamol and lots of cuddles. My aim is to make them feel that I am on their side and that I realise how exhausted they are with no sleep and a miserable child. Then I explain why antibiotics aren’t appropriate to treat viruses, but still offer them as an option. If I’ve done my job well, they say no, but feel that it is their decision. Finally, I make sure that they will come back and see me if they are concerned and tell them about the worrying symptoms of meningitis to look out for.
If I’ve succeeded, they don’t come back, as the parent feels more confident and the natural course of these viruses is that the child gets better. Ideally, they also feel a bit more confident about managing the child at home next time they are poorly. When these consultations go well, they are great. When they go badly, they are a disaster and usually either end up with the child getting an inappropriate prescription for antibiotics or an anxious parent getting very upset and dragging their child to A&E.
Uzma
It’s 6.30 p.m. and my last patient has just walked in. I’m running on time and I’m due to meet a few friends for a drink after work. Working in offices, they have been in the pub for ages and have a pint waiting for me. If I can just get through this last patient quickly, whizz through some paperwork, I’ll be in the pub by seven.
Uzma comes in. ‘I need the repeat of my pill, Doctor.’
Happy days! Contraceptive pill checks are a boring part of general practice but quick and easy. I do a speedy blood pressure reading, ask if there are any problems, which invariably there aren’t, and then the patient is out of the door within a few minutes.
Just as I’m generating the prescription, Uzma seems to be welling up. I’m torn now. I am a nice sympathetic doctor. Honest! It’s just that I’m tired and drained and I can practically taste my pint. I really don’t fancy spending the next half-hour listening to a weeping 16-year-old. I contemplate pretending not to have noticed, but it’s too late. The tears have arrived. They are unmistakable, especially as they are now dripping on to my blood pressure machine. I sink into my seat and prepare myself for a long evening.
‘So Uzma, you seem a bit upset?’ Not exactly reading between the lines, given her quiet sobs have now turned into loud wailing.
‘I can’t go home tonight, Doctor; they all hate me. Everyone hates me.’ More wailing and tears. ‘They blame me for everything and always take my brother’s side.’ Wail wail. ‘My parents don’t understand me. We’ve had a massive fight. There’s no way I’m going home tonight. No way!’
Uzma’s parents are from Pakistan. Perhaps they are forcing her into an arranged marriage or trying to make her drop out of school? I saw a Tonight special with Trevor McDonald on this sort of thing. Perhaps I can really help this young woman. I’ll need to get social services and the police involved tonight and find her a place of safety.
‘Uzma, are your parents very strict with you? Are they trying to make you do things you don’t want to do? Do they hit you?’
‘Hit me? God no.’ Uzma looks at me like I’m an absolute idiot. ‘They all just hate me ’cause they’re losers. My sister Nadia, yeah. Oh my God, she’s such a bitch. Only because she’s jealous ’cause she’s got a big arse and no boys fancy her and my mum is always moaning at me about doing my homework and she never says nothing to my brother. He does whatever the fuck he likes.’ Like the tears, the words are now unstoppable. There are no breaks for punctuation, but only the odd pause to wipe her tears and blow her nose before the next torrent of adolescent anguish is released.
My interest is diminished again. There aren’t going to be forced marriages or honour killings. This is just an ordinary 16-year-old having a hissy fit after a row with her parents. Uzma’s mum and dad seem fairly liberal all in all. They probably wouldn’t be too happy if they knew she was shagging Darren who works in the garage but then that’s not a cultural thing, nobody would want their daughter shagging Darren from the garage.
Uzma is still crying her eyes out and is refusing to go home. What the hell am I going to do now? I need some help with this one. I’m rubbish at comforting crying teenagers. Why on earth has this girl come to see me about all this? Surely there must be far better qualified people to deal with this than me. Someone trained in understanding the emotional turmoil of adolescence, someone who finds it rewarding to address teenage angst on a regular basis. Someone with endless patience and empathy and someone who wasn’t supposed to be in the pub 20 minutes ago! As she sobs, I do a quick Google search for teenage counsellors in the town. I get a few numbers and phone them but just reach answerphones. They’re all in the bloody pub, lucky buggers.
Just as I’m wondering how I’ll ever get home, Uzma’s phone rings. It is one of those annoying ringtones that is extra loud and the start of an R&B track that I don’t recognise because I’m over 20. The tears stop almost instantaneously and she answers the phone, ‘’Old on a minute, Doc. Wassup, Letisha … Is it? … Is it? … Oh my days! … Are you chattin’ for real! … I’m just with the doctor and that … I’ll be right there.’
The anguish suddenly vanishes. ‘Sorry, Doc, I’ve got to go. My friend Letisha just got dumped. I’ve got to go round and find out what’s going on.’
Before I can say a word, Uzma is gone. Speechless, I sit in silence pondering the mysterious world of the 16-year-old.
Africa
During a holiday in East Africa, I visited some old friends from medical school who were working in a small rural hospital in Kenya. Rob and Sally had been GPs in the Midlands until they decided to sell their house, quit their jobs and commit to three years in Kenya setting up and running a rural hospital.
Rob proudly showed us round. They had been in Kenya for two years and had achieved an enormous amount for the local community. Thanks to their tireless work, there is now an organised maternity unit and a well-equipped medical ward. Rob has also set up an AIDS clinic with free testing and, most importantly, free access to AIDS medication. It is the only one of its kind in the whole region. Rob and Sally have also pushed hard for education and disease prevention and have spearheaded a campaign to encourage mosquito nets. As a result, they have significantly reduced malaria deaths.
Not only had Rob and Sally been working hard treating patients, they have also been single-handedly planning and managing the changes and improvements to the hospital mostly with funds they have raised themselves. My targets in England for the year might be to get a few patients to lose some weight or cut my diazepam prescribing. Rob and Sally’s targets were to build a maternity ward and prevent 100 local children from dying of malaria.
Rob asked me to help out with the HIV clinic for the day. There was no appointment system. The patients arrived en masse in the morning and sat patiently outside my room all day until the last one was seen at about 6 p.m. Not a single person complained about waiting and each one thanked me with genuine gratitude and warmth when the consultation finished. It truly was a humbling experience.
My most memorable patient was Cynthia. She had set off from a neighbouring village the night before and, despite being weak with advanced AIDS and TB, she walked the entire 12 miles and spent the night sleeping in the doorway of the hospital along with many other of the morning’s patients. She didn’t speak any English so a nurse was translating for me. Cynthia was 24 but looked much older. Her two children had both died aged around 18 months and, although never given a diagnosis, they almost certainly died from AIDS-related illnesses. Cynthia’s husband, from whom she contracted HIV, left her once she could no longer work and he realised that she wouldn’t be able to produce any healthy children for him. Cynthia was alone and her only means of income was digging in the fields. She was still getting up each day and attempting to work, but her AIDS was advanced and she was too weak to dig. The medications for her AIDS and TB were free and were helping, but what she really needed was something decent to eat. ‘Where are you going to get your next meal?’ I asked via the interpreter. She shrugged her shoulders and then after a long silence looked me in the eye and asked me a question in her native tongue. Waiting for the translation, I assumed that Cynthia would be asking for some money or food. To my surprise, what she actually asked me for was a job. Even in her weak state, Cynthia clearly still felt that she should earn her way and hadn’t even considered a hand-out. One of the previous patients had given me six eggs to say thank you for the mosquito net I gave him, so I gave them to Cynthia and she left with at least some basic sustenance to help her muster the energy for her long walk home.
As an idealistic sixth-former applying for medical school, I imagined spending many long years working in the poorest and neediest parts of the world. The reality is that apart from my brief experience in Kenya, my only other time practising medicine abroad was three short months in a hospital in Mozambique soon after I qualified. The reality of working in an African hospital was really hard. The facilities were limited, the bureaucracy made me want to tear out my hair and the extent of the corruption was terrifying. The experience was incredible and although it was some years ago, I think of that time often and it helps put both my work and life back in the UK into perspective. I’m a more experienced doctor now and could potentially be much more help back in that hospital in Mozambique, but the question is: do I have the motivation to go back?
Rob is a GP with a similar amount of experience to me. The week before we arrived in Mozambique, a woman came to the hospital in the middle of the night in labour with an arm presentation. This means that the baby’s arm had been born but the rest of the baby was still inside the womb and basically stuck. Rob, like me, had spent a few weeks on an obstetrics attachment as a medical student but that was pretty much the sum of his experience of delivering babies. Suddenly, as the only doctor around and ten hours from the next nearest hospital, Rob had to do something. The woman needed a Caesarean section, but there simply weren’t the facilities at hand. He tried desperately to push the arm back in and deliver the baby but to no avail and the baby died. The mum was extremely weak from loss of blood and exhaustion. The baby needed to be taken out or the mum would die too. Rob cut off the baby’s arm and managed to deliver the remainder of the dead baby.
Rob saved that woman’s life and I have the utmost respect for him. If he had decided to stay in England, that woman would have undoubtedly died. Throughout this book I’ve moaned a bit about the fact that I went to medical school to save lives and make a difference but instead I keep lonely old ladies company and dish out sick notes to the work shy. I haven’t ruled out the possibility of returning to Africa to practise some genuine ‘life-saving’ medicine, but right now I’m not sure that I have the emotional strength to hack the arm off a dead baby at three in the morning.
Evidence
I was being dragged round town on a Sunday morning and, despite the fact that I really fancied a coffee and some cake, my wife wanted us to try out one of the new trendy juice bars that had sprung up. The man behind the counter had a silly pointy goatee and a ponytail. I asked him what an acai berry was given that it was going to make up one-fifth of my five berry smoothie. ‘It’s hand picked from the shores of the Amazon, man.’ (I doubted this.) ‘It’s got 100 times the vitamin C of an orange so a real natural high. You’ll be feeling great all morning and it’ll keep those colds at bay.’ He looked really pleased with himself as he handed me my smoothie and I wondered what other nonsensical medical advice he gave out to his customers. ‘Eat a papaya and cure your verruca.’ ‘Eat some raspberries and your friends will like you more.’ I was desperate to tell Mr Goatee Man that there was no evidence to suggest that eating excess vitamin C was of any benefit in keeping colds away and that it wouldn’t give me a ‘boost’, why would it? Added to this was the fact that if I received any more than 200mg of vitamin C, I’d simply shit and piss out the excess so might as well stick to an orange, which was much tastier and cheaper. My wife knows me too well and gave me a look that meant stay quiet and don’t embarrass her in public. I took my smoothie and sat down. Irritatingly, it was really nice and made me feel quite revitalised.
Mr Goatee Man and his smoothie are part of a growing trend of advertising and marketing of ‘healthy products’ with huge claims about medical benefits without any evidence to back them up. This might seem like a typical rant from a closed-minded doctor, but I genuinely have nothing against my patients taking many herbal remedies and dietary supplements. Many of our medicines originate from plants so perhaps some of them may have genuine medical properties. Saint John’s wort, for example, is shown in clinical trials to be effective in the treatment of depression. What I object to is health food companies playing on people’s fears and anxieties with regard to their health by making unproven medical claims to sell their excessively expensive products.
Doctors work by the rules of something called ‘evidence-based medicine’. The principle of this is that if I want to prescribe you something, it should be of proven benefit. In the past doctors gave out all sorts of tonics and pills based on guesswork and trial and error. I’m sure some of these medications were effective and helpful, but many would have been no better than a placebo. Nowadays we are supposed to apply some evidence to everything we prescribe. If you come to see me with high blood pressure, I can think of 10–20 different pills I can start you on. As the patient you need to put your faith in me giving you the most effective pill for your condition. I can make a decision based on my own experiences over the years after having tried a few different pills on a few different patients. Or I can make my decision founded on a trial of over 10,000 people with high blood pressure that looked with minimal bias at which drug or combination of drugs seemed to reduce blood pressure most effectively and with the fewest side effects. These studies are by no means perfect and as an individual you may not respond in the same way that the majority of people did in the study. However, isn’t that a more accurate way of deciding your medication than by me choosing which tablet I most like the name of, or which medicine has the prettiest drug rep who takes me out for lunch most often?
Soon after my smoothie, I was stopped in a shopping mall by a guy selling eucalyptus cream for diabetics.
‘How does this work?’ I ask.
‘Well, mate, you know diabetics, yeah? They have bad circulation to their feet and get foot ulcers.’ (I can’t fault him so far.) ‘Well, when you rub this cream into the foot, it improves the blood flow to the skin.’
‘Rubbing anything into your feet increases the blood flow.’
‘Well, the eucalyptus cream increases oxygen production in the soft tissues.’
‘How does it do that?’
‘Free radicals and that.’
‘Have you got any evidence to show that this works any better than, say, rubbing lard into your feet?’
Mr Eucalyptus Cream Man shows me the back of his jar of cream. It says, ‘Formulated specifically with diabetics in mind.’
‘That’s not really evidence, is it?’
‘Is it you who is diabetic?’
‘No.’
‘Someone in your family?’
‘No.’
‘Are you going to buy some of this cream, then?’
‘Absolutely no.’
‘Well, piss off and stop wasting my time. I’m trying to make a living here.’
Really, I’m just as guilty as Mr Eucalyptus Cream Man. Mr Dudd came to see me recently with a bad back. His back aches because, like him, it is 90 years old. The vertebrae are crumbling and his spine has no flexibility any more. He has tried codeine but this makes him constipated and drowsy and I’m reluctant to prescribe him anti-inflammatory tablets because these could give him a stomach ulcer and damage his kidneys. I decide to give him an anti-inflammatory gel to rub on to his back. There isn’t really any evidence that this is more effective for back pain than rubbing lard on to his back. I still prescribe it because I don’t want to say, ‘Sorry, Mr Dudd, your spine is as crumbly as stilton and there is bugger all I can do for you.’ Instead, he goes home and every morning Magda his Polish care assistant comes and gently rubs the ‘magic’ gel into his lower back. Mr Dudd thinks it is wonderful. ‘Thank you, Doctor. That gel really helps.’ That’s the thing about medicines that are shown to be no better than a placebo: they still work because placebos work. As long as the placebo is cheap and doesn’t cause any harm, I’m all for them. I am marginally better than Mr Eucalyptus Cream Man because his cream cost £25 and he was targeting vulnerable old people with diabetes who are worried about getting foot ulcers. My ibuprofen gel cost £1.25 and I made an old man very happy (with a bit of help from an attractive Polish care assistant). Interestingly, the cost of the painkilling gels varies between £1.25 and £12.75 depending on the brand, yet all are probably no more effective for back pain than lard, which costs 19p if you buy the no-frills version in Tesco.
Sticking to evidence-based medicine can be very frustrating. For years I had enjoyed advising my patients to drink lots of cranberry juice when they have a urine infection. They always loved this advice. It helped stop the bugs from sticking to the wall of the bladder I used to say. I don’t know where I got this information from but it sounded good and someone clever must have told me it at some point. I guess it was just one of those urban myths that we all buy into sometimes. Patients always love a risk-free natural remedy, especially when advised by the doctor. Unfortunately, a big study recently showed that although drinking cranberry juice can help prevent urine infections, it can’t actually rid you of the bacteria once you have an infection. Bugger, sticking to evidence-based medicine can be very boring sometimes.
Carolina
Carolina was 15 and, unlike the vast majority of teenagers who come to see me, she actually spoke to me in normal words and sentences rather than in grunts and shrugs. I had seen her on several occasions with minor problems, but this time she came in wanting to talk about going on the pill. She didn’t have a boyfriend but some of her friends were having sex. She didn’t feel ready to have sex yet but wanted to make sure that if anything unexpected did happen that she would be protected. She understood all about sexually transmitted infections and knew how important it was to use condoms. She had also looked up online all about the pill and how it worked. I suggested that she spoke to her mum about this but Carolina told me that her mum was a strict Catholic and she couldn’t talk to her about sex. We had a long chat and she decided that she was going to take the prescription for the pill away with her and then have a think about things before potentially cashing it in for the tablets themselves. I remember thinking to myself that if I ever have a teenage daughter, I hope she can talk as openly and honestly about sex as Carolina.
A month later I got an angry phone call: ‘Dr Daniels, it is Carolina’s mother here. I was just wondering if you could tell me the age of consent in this country.’
‘It’s, erm, 16.’
‘In that case, why have I found a prescription for the contraceptive pill under the bed of my 15-year-old daughter? It’s got your signature on it.’
It was an awkward moment. My first reaction was to ask what she was thinking looking under her daughter’s bed. Surely that must be the first rule of having a teenager. Don’t look under their beds, as you’ll only find something you don’t want to know about! Carolina’s mum was furious. It was a shame, really, as she came to see me fairly often herself and we actually got on quite well. She was one of those really grateful patients who always thanked me profusely even when I hadn’t really done much. She was Polish and I romanticise that in Poland they have an old-fashioned respect and admiration for their doctors long since vanished in the UK. The problem was that alongside the old-fashioned value of respecting doctors was the old-fashioned value of expecting your teenage daughter to keep her virginity until her wedding night.
The rules on prescribing the pill to minors are fairly clear. Girls under 16 can go on the pill without their parents’ permission. They must have capacity, which basically means that they are able to understand the decision they are making and the pros and cons. As the doctor, I am supposed to encourage the girl to speak to her parents but if I think she will have sex anyway it is recommended that the doctor prescribe her the pill. This was contested in 1983 by a Catholic mother called Victoria Gillick. She didn’t want her underage daughters being given the pill without her permission. She lost the case. Interestingly, although under-16s can make their own decisions about treatments that they want, they can’t refuse treatment. For example, if a 15-year-old has appendicitis and needs to be operated on but she or he declines surgery, the parents can overrule the decision.
For me, prescribing the pill for 15-year-olds is something that I do fairly frequently. Some people feel that as a GP prescribing the pill, I’m encouraging underage sex. As far as I’m concerned, teenagers are influenced by friends, music, TV and magazines. They’re not influenced by slightly geeky 30-year-old doctors with bad hair and Marks and Spencer’s trousers. She might later regret having her first sexual experience too young, but she’ll be more damaged by having an abortion or a baby. The decisions are much harder if the girl is 14 or 13 or if the boyfriend is much older. It is such a grey area. If Carolina had a boyfriend who was 16 or 17, I guess that would be okay. What if he was 20 or 25? When do I break confidentiality and call the police or social services? These sorts of issues are difficult to judge but faced by GPs every day. I imagine that doctors who have strong religious convictions or those who have teenage daughters themselves may view the whole issue very differently from me.
Back to Carolina’s angry mum. I was a bit stuck. I wanted to tell her how sensible her daughter was and that the very fact that the prescription hadn’t been cashed in demonstrated her maturity. The problem was that I owed Carolina her confidentiality and couldn’t really say anything to mum at all other than to explain that I was within the law to prescribe her daughter the pill. I did sympathise with Carolina’s mum. Although I remember feeling very grown up at 15, it is pretty young really. I wasn’t having sex at 15 but that wasn’t by choice. My combination of bad skin, unfashionable clothes and a disabling tendency to blush and then stammer awkward nonsense whenever within about 15 yards of a girl, meant that I didn’t lose my virginity until my late teens. Perhaps my opinions will change in the future, but at the moment I sort of feel that at around that age teenagers will want to be having sex. They will probably make mistakes and have experiences they regret, but if my teenage-girl patients can get into their twenties without getting pregnant or becoming riddled with venereal disease, then I’m probably doing a good job.
Lee
Lee was 36 and was just out of prison. He had been due to be my last patient of the morning but his appointment was at 12.20 and he turned up at 1.30, just as I was about to leave the surgery to do a visit and grab some lunch. I was in the office and could hear him getting slightly aggressive with the receptionist as she explained that I wouldn’t see him. It was only fair that I went out and gave her some support.
‘Are you the doctor? Will you just see me quickly? I need something to calm me down.’
‘No, you’re over an hour late so you’ll have to rebook in to see me or one of the other doctors this afternoon.’
‘Well, can you just give me something to help me sleep?’
I’m not a big fan of prescribing sleeping tablets such as diazepam. I try to avoid prescribing them myself, but looking through Lee’s medication list on the computer, I saw that he had a repeat prescription of diazepam still on his screen from before he went into prison. The computer showed he had been prescribed diazepam regularly for years and so I agreed to let him have a prescription for a week’s worth now with the plan to start cutting them down at his next appointment. I quickly printed and signed his prescription for diazepam and booked him an appointment for later that afternoon.
That was my one and only consultation with Lee. It took place in the reception area of the surgery and I dished him out a few pills to get him out of my hair so I could get on with my day. Lee didn’t attend his afternoon appointment and by the next morning he was dead, having taken an overdose the night before. I read and reread the automatic and very impersonal fax that is generated for every A&E presentation:
Dear Doctor Daniels,
Your patient was admitted at 03.45 with a presentation of overdose. He was discharged with a diagnosis of death.
I felt like shit now. Had Lee overdosed on the medication I prescribed him? I hadn’t seen Lee because I was hungry and tired from a long morning surgery and didn’t want to get held up. Was that a good excuse? If I had seen him properly and listened, maybe I wouldn’t have given him the prescription at all. Perhaps he would have told me a few of his worries, felt a bit better and not topped himself. Had I missed a rare chance to make a real difference? I had an unpleasant morning stewing over Lee’s death, imagining explaining myself to the judge.
‘So Dr Daniels, the deceased came to see you feeling vulnerable and desperate. He had a history of violence and depression. You were his only source of help and what did you do next?’
‘I gave him a week’s worth of sleeping pills and told him to bugger off, your honour.’
It didn’t look good, did it?
Suicide is a difficult case for GPs to deal with. We see depression and self-harm by the truckload but not many patients actually successfully kill themselves. When I was an A&E doctor, the cubicles were full of teenage girls who had taken eight paracetamol after a row with a boyfriend or parent. There were a lot more cries for help than genuine suicide attempts and most of the ‘overdoses’ were generally dismissed by A&E doctors as time-wasters. When I was working in psychiatry we saw the next step up. These were genuinely depressed people who took big overdoses and really wanted to die at the time. They only very rarely succeeded in causing themselves any real harm and still ended up in an A&E cubicle with the casualty doctors equally reluctant to have to treat them. Only one of my patients successfully committed suicide during my time in psychiatry. He was a nice young lad of 19 who was just recovering from his first episode of schizophrenia. He had just returned from a gap year travelling round Asia and was looking forward to starting university when he became really psychotic and unwell. He was hearing voices and getting very paranoid. He had to be sectioned and admitted to the ward but he started to improve with medication. I was really pleased with his progress and happy that he was ready to be discharged home. He was realising his potential future of daily medication, psychotic relapses and social stigma. He got into his mum’s car, took off his seat belt and drove very fast into a wall. It made me appreciate that, actually, if you really do want to die it isn’t that difficult.
I felt pretty shitty when that lad died. The consultant took me aside and said that a cardiologist can’t expect to stop all his patients from ever having heart attacks, he just has to look after his patients as best he can and try to prevent as many as possible. It’s the same being a psychiatrist or GP. You can’t expect to save all your patients from suicide. If I had done everything that I could for Lee, it would have been easier to take. It was the fact that I only really gave him a second-rate service that sat with me so uncomfortably.
After stewing all morning, I phoned the local casualty department to try to find out a bit more about what had happened. The A&E registrar told me that Lee had died of a heroin overdose. Apparently, it was thought to be accidental. ‘There’s been a dodgy batch of smack going round town. Caused a bit of a junkie cull. We’ve had a few of them expire over the last few days. Still plenty more where they came from, I suppose.’
I felt a massive wave of relief wash over me. It was heroin that had killed Lee, not the diazepam I had prescribed him. Lee was still dead and I had let him down as his doctor, but I lived to fight another day. Lesson learnt, I hoped.
Hugging
Would you think it was strange if your GP gave you a hug? Probably yes if you were just asking him to look at your athlete’s foot. What about if you were upset and needed some human contact?
One of the GPs near me has been suspended for the last two years for allegedly hugging his patients. He worked single-handedly for many years with no apparent problems, but two years ago, shortly after firing his receptionist, she reported him to the General Medical Council for having had ‘inappropriate contact’ with patients. A letter was sent to all his past and present patients and one or two of them then confessed that they felt he had been slightly inappropriately tactile with them over the years. Interestingly, nobody actually complained, but he was suspended and is still awaiting the conclusion of an investigation. He is an older GP, originally from Italy, and he claims that he was simply comforting upset patients. I’ve never met the doctor involved but I’ve met some of his ex-patients and they explained to me that they always assumed he was ‘just a bit Italian’ and was simply less reserved than us Brits. I have no idea if there is any truth behind the allegations, but it has made me very conscious of how I am with my patients.
I’m not sure whether there was more than meets the eye with regard to the Italian doctor, but I do think that cultural differences concerning human contact are important. I saw a very cute little three-year-old Italian girl once. She was very snotty and full of cold but basically fine. After reassuring the mum, she said to the little girl: ‘Give the nice doctor a kiss for looking after you so nicely.’ I was quite surprised. It just isn’t something we do here. I also wasn’t too pleased to receive a snotty kiss from a virus-ridden three-year-old.
There also seem to be cultural differences between nationalities with regard to women being examined by male doctors. The general rule for women appears to be that they tend to feel awkward about being intimately examined by a young male doctor until they have had a baby. It would seem that the experience of having legs akimbo and ten medical students trying to feel how dilated your cervix is provides an instant cure for ever feeling self-conscious. Eastern European women seem to feel no embarrassment about stripping off in front of the doctor. I saw a young Czech woman who needed her blood pressure taken. She was wearing a thick jumper and I couldn’t roll up her sleeve sufficiently to put the cuff round her upper arm. I asked if she could take off her jumper. She whipped it off without a care in the world and I was rather taken aback to find that she had absolutely nothing on underneath. Not even a bra. The Czech woman herself wasn’t bothered in the slightest and this was supported by her normal blood pressure reading. I dread to think how high mine had gone! Later that surgery a woman from Hong Kong came in with a lump on her back. She was absolutely horrified when I suggested that I would need to have a look and in the end I had to send her to a female GP.
I am often faced with somebody very upset and in floods of tears in front of me. They may be someone I’ve just met or perhaps a patient that I’ve known for some time and have built up a close relationship with. Regardless of this I just wouldn’t give them a hug. One of my GP friends says that he puts a consoling hand on the shoulder of his upset patients. He maintains that it is a comforting form of human contact but not too invasive. I just hand them a box of tissues and try to look sympathetic. I can’t think of anything more awkward than a patient asking me for a hug. Funnily enough, though, if they told me that they had rectal bleeding, I wouldn’t blink an eyelid about sticking my finger up their bum. Just one of those odd quirks of being a doctor, I suppose.
Tough Life Syndrome
I had a call to visit Jackie again. She is in her late thirties and lives in a tiny two up two down council house with her three teenage children. The house is thick with smoke and painfully cramped. The TV takes up most of the lounge and lying on the sofa in front of it was Jackie.
‘You’ve gotta help me, Doctor. It’s the pain. I can barely walk. Those pills don’t work. None of it works!’
Jackie has been a patient at my surgery for years. She switches from doctor to doctor and has been on almost every painkiller known to modern medicine.
‘Are you going to see Jackie?’ my colleague asked me as I picked up her notes and headed out of the door of the surgery. ‘She’s got the worst case of TLS I’ve ever seen.’ TLS stands for ‘tough life syndrome’. Jackie has had a really tough life and this now manifests as chronic pain and fatigue. Jackie was abused as a child and young teenager by her stepdad. She then ran away from home and worked as a sex worker for a bit before she became pregnant at 17 by an abusive partner. Two more abusive partners and two more children later, she was alone at 21 with three children and an alcohol problem. Her children are now teenagers. Her son threatens her and regularly steals her benefit money and her daughter is a heroin user. Her eldest son is constantly in and out of prison. It’s not exactly The Waltons.
Jackie has pain all over her body. Her abdominal and back pains have been fairly constant over the last ten years or so and now she has general pains in her legs, arms, chest and hands. Jackie has had multiple scans and X-rays that have all been normal. She has seen neurologists and rheumatologists who have examined her thoroughly and run specialist blood tests and scans looking for rare disorders. They all drew blanks. She was finally diagnosed last year with fibromyalgia. The definition of fibromyalgia is ‘fatigue and widespread pain in the muscles’. It is a diagnosis of exclusion which means that we diagnose it when we haven’t found anything else that could be causing the symptoms.
Officially there is no known cause for fibromyalgia, but time after time when I dig deeply in to the sufferer’s past, I find stories of trauma, abuse and unhappy childhoods. Perhaps in years to come they will find some odd hormone or virus that is responsible for this condition and find a cure, but in my experience it almost always occurs in people who have had tough and troubled lives and can’t articulate that pain verbally so it is expressed instead as physical pain.
I’m clearly not the first doctor to have recognised the likely association between Jackie’s physical symptoms and her emotional state. She has been tried on antidepressants and been referred to counsellors in the past, but she has always been reluctant to accept them. ‘I’m not depressed, Doctor. If you could just get rid of this pain then I’d be fine.’
Whenever I visit Jackie she wants me to try her on a new painkiller. Giving out a quick prescription is the easiest option for me as it is the quickest way that I can get out of the house. The problem is that I know that whatever I prescribe won’t work. She has tried every painkiller I can think of and now the only step up from here is morphine. I really don’t want to be responsible for making her a medicalised heroin addict; besides I know her kids will steal it and either take it themselves or sell it on the estate. Perhaps if I could just help her take some ownership of her condition and recognise the psychological element to it, maybe I could genuinely help her.
‘Jackie, why do you think you’re having all this pain?’
‘I dunno. You’re the doctor.’
‘It looks like you have had quite a hard time over the years.’
‘You can say that again.’
‘Some people find that going through large amounts of stress and upset can contribute to having physical pains and low energy.’
‘You think I’m making it up, don’t you? This pain is real, you know.’
‘I don’t think you’re making it up, Jackie. The pain is real but I just think that perhaps all the stress you’ve been through might be a big component to your symptoms.’
‘Nobody believes me. You doctors are all the same. You can’t leave me like this. I need something for the pain. I’m only 39 and I’ve not been out of the house for weeks. That can’t be normal, can it? You have to help me. I need something for the pain!’
‘I’m sorry, Jackie, but research has shown that fibromyalgia doesn’t really respond to painkillers. Some people find that gradually increasing activity levels and exercise can help. I could also refer you for some specialist talking treatment called cognitive behavioural therapy. There have been some studies to suggest that this can be useful.’
‘So you’re basically doing nothing for me.’
‘I’m not sure what more I can do, Jackie. I’m sorry.’
Doctors tend to deal with patients like Jackie badly. By simply organising more tests and giving more drugs we are positively reinforcing the idea of the sufferer having a medical illness that is the responsibility of the medical profession to treat. The years of hospital out-patient appointments and specialist referrals encourages the idea that the person is sick. It is a role that they subconsciously fill and become dependent on. Being labeled as ‘ill’ is a distraction from the fairly miserable social and emotional problems that are the underlying problem. In some cases being ‘ill’ is also a way of exerting some control on the people around them.
My best efforts at trying to gently persuade Jackie to start thinking about the connection between her physical and emotional health were clearly spectacularly unsuccessful and the next time she requested a home visit she specifically asked to see any doctor other than me. I know that this means I have failed, but I have to admit that it is a real relief to know that I won’t have to stand awkwardly in her lounge feeling helpless as I watch her suffer. One of my colleagues visits her instead and starts her on morphine.
Mrs Briggs
It is 3 a.m. on a Sunday night and I’m working on call for the ‘out-of-hours’ doctors. I get a call through to do an emergency visit. Before I arrive, I have only minimal information about what to expect. All I know is that I’m visiting Mrs Briggs who is in her seventies and has breast cancer.
When I arrive, five or six family members greet me at the door. I’m ushered upstairs in hushed silence and shown into a dimly lit bedroom. In front of me lies a skeleton of a woman. Pale and semi-conscious, she is quite clearly dying. In my years as a doctor I’ve seen many people die. In hospital it is all quite clinical. It is easier to think of them as the ‘stroke’ in bed 3 or the ‘lung cancer’ in cubicle 2, rather than as a real person. In the patient’s own home it is less easy to protect yourself from the enormity of somebody’s death. Surrounded by belongings and pictures of them looking healthy and contented during happier times, the dying person feels overwhelmingly real.
The daughter explains to me that her mum’s wish is to die at home and the family is determined to keep her out of hospital or hospice. Up until now she had been managing fairly well, drinking small amounts and her pain was well controlled with tablets. Unfortunately, over the course of the evening she had deteriorated quite rapidly and she was now agitated and seemed to be in pain. She was writhing around the bed and crying out. With end stage cancer, it is very unpredictable as to how and when someone will actually die. With heart attacks, it is easy to understand. The heart ceases being supplied with blood and oxygen so it stops and that’s it. A slow-growing tumour that spreads and eats you away from the inside makes you weak and frail but it is difficult to know exactly how and when it will finally kill you. I couldn’t be sure exactly what it was that was going to end Mrs Briggs’s life, but there was no doubt in my mind that she was going to die tonight.
One of the principal aims of palliative care is to keep the patient pain free until the end. Mrs Briggs was only semi-conscious and couldn’t answer my questions. I couldn’t be sure of exactly how aware she herself was of the pain, but she was certainly agitated and appeared distressed and I couldn’t leave her like this. It was also very upsetting for her family and they were desperate for me to do something. Mrs Briggs couldn’t take anything orally so I was going to need to give her an injection of something and that something was morphine. Since Harold Shipman, GPs have been extremely nervous about using morphine in this way. Dr Shipman used injections of morphine to kill his patients and so, understandably, my decision to inject a syringe of the stuff into Mrs Briggs wasn’t one to be taken lightly, especially as I knew that she could potentially die quite quickly as a result.
In an ideal world I would set up a syringe driver, which is a pump that slowly injects morphine automatically into the patient until the pain is controlled. But it was 3 a.m. and Mrs Briggs needed pain relief now. There was no way that I was going to be able to organise a syringe driver tonight. I took the family aside and explained that I wanted to give her an injection of morphine. I explained that it might decrease her level of consciousness but would ease the pain and agitation. The family was well aware that she only had a few hours left and they wanted them to be peaceful and pain free. They were happy for me to give the injection. I drew up the morphine into my syringe and slowly injected the clear fluid under her skin. In front of my eyes, her tense agitated body relaxed. I only gave her a few mils, but she had so little flesh on her that she didn’t need much for it to take effect. As Mrs Briggs’s writhing body calmed, so did the torment on the faces of her family. Her breathing became shallow and she slipped into a deep coma and died a few hours later.
Her family was immensely grateful. It wasn’t euthanasia, but perhaps my injection of morphine sped up her death by a few hours. Many of my day-to-day actions as a GP lead me to question the ethics of the choices I make. However, I never doubted that my decision to give Mrs Briggs morphine that night was the right thing to do. My fears about giving morphine are more about the family and how they might react. If I had thought that the family wasn’t on my side, I wouldn’t have given the morphine. Not because the wishes of the family are more important than the wellbeing of the patient, but because I wouldn’t want to have to defend my actions in court. Mrs Briggs would have suffered but I’m not prepared to be labelled as the ‘next Shipman’. People accuse doctors of playing God by choosing when patients live or die and sometimes we do, but as long as our decisions are made with compassion and not arrogance, I’ll make no apologies.
Betty Bale’s cat
Betty Bale is the only patient that I can remember from my first six-month stint as a doctor. She was admitted to my ward on my first day and was still in that same bed when I finished six months later. She was only in her late sixties but had suffered a severe stroke, which meant that she was pretty much completely paralysed. She could speak but it was slurred and she dribbled. It was always an effort to make out her words and even more of an effort for her to say them. She couldn’t swallow so had to be fed through a tube running straight into her stomach. All in all, it was a fairly miserable existence.
Strokes are unpredictable and some people recover all of their function, others none and most something in between. For the first few weeks, Betty had intensive specialist physio and speech therapist input, but it soon became clear that she wasn’t going to recover much of her movement. Previously independent, this was very difficult for Betty to accept. It was sensitively suggested by the consultant that she would need to go to a nursing home to be looked after. Betty’s speech was poor but she made it crystal clear where he could stick his nursing home idea. ‘I’m going home!’ she would shout as best she could. ‘I want to see my cat.’ Betty’s mind was as sharp as ever. She wasn’t confused about her diagnosis, she just hadn’t accepted it. If her disabilities had been more manageable, she could have gone home with carers visiting regularly. Unfortunately, Betty needed 24-hour nursing care because of her swallowing problems and severe paralysis.
Betty was taking up a hospital bed on an acute medical ward. It was a complete waste of resources as we were doing nothing for her, but she refused point blank to go to a nursing home and so what could we do? With intact marbles, we couldn’t ship her out against her will so we were stuck. Each morning we would do our ward round leaving Betty to last. Doctors hate feeling helpless so none of us really wanted to go in to see her. As the most junior member of the team, I was usually thrown in to say hello. My attempt at a friendly ‘good morning’ was always greeted with a stoical ‘I want to go home’ and invariably an ‘I want to see my cat.’ Betty had never married and had no children. She had painfully few visitors and we often heard her crying to herself as we hurried past her room. It was a miserable situation but one that seemed impossible to solve.
It was decided between the junior doctors and nurses that we were going to bring in her cat for a visit. We knew that if the consultant or, worse still, the infection control nurse found out, we would all be for the high jump, but after so many months of feeling so incapable of helping Betty, we decided we were finally going to do something for her. It was agreed we would sneak the cat in on her birthday. Like a military operation, the cat was picked up from Betty’s neighbour and smuggled on to the ward. The cat was a miserable old moggy with clumps of missing fur and she hissed at anyone who came close. We couldn’t believe that this was the precious creature that had been so desperately missed. Betty was, however, over the moon. ‘My cat, my cat!’ she cried. The cat herself seemed less than overwhelmed by the reunion but did at least allow Betty to hold her for a few minutes and even seemed to let out the odd token purr.
It would be nice to finish the story with Betty making a miracle recovery because of the amazing healing power of feline friendship, but that didn’t happen. Betty was still paralysed and eventually, after many reluctant months, did have to go to a nursing home. Betty’s case sticks in my mind because it shows how despite all the wonderful facilities that modern hospitals contain, it was a mangy cat that made one woman’s suffering lessen for a short period at least.
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