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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 body agrees 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.’
