‘So what can I do for you today, Mr Raymond?’
‘Well, the nurse mostly looks after my diabetes, Doctor, but I was too embarrassed to mention this little problem I’ve been having to her.’
‘What’s that then?’
‘I think the diabetes is affecting my erections. I can’t seem to get them any more and I was wondering if I could try some Viagra?’
The diabetes may well have been affecting his erections. There were other possible causes too, but Mr Raymond was aware that now he had been diagnosed with diabetes he was entitled to free Viagra on the NHS. I asked a few more questions and even examined him, but overall his complaint was fairly standard. With most of our diabetic male patients, I wouldn’t have thought twice about prescribing some Viagra or something similar, but for obvious reasons, I had reservations with Mr Raymond.
I knew that Raymond had sexually abused young children in the past. He had served his time and I had no reason to believe he was re-offending or even considering it. Perhaps he was completely rehabilitated and was in a healthy loving relationship with a consenting adult. The problem was I couldn’t help but worry that my prescribing him Viagra could potentially lead to further abuse of children. I wasn’t sure if Mr Raymond knew that I had a record of his previous offences, although my apparent awkwardness may well have made it fairly obvious.
‘Do you have a regular partner?’ I asked, attempting to enquire as if making light conversation.
‘Er, no, not exactly. I just, you know, like to still be able to have erections by myself, if you catch my drift.’
After a few moments of an uncomfortable silence, I broke it with some honesty.
‘Look, Mr Raymond, I know that you have a criminal record for sex offences in the past and I need to just make sure where I stand legally before I consider prescribing you Viagra.’
‘That’s all behind me, Doctor. I did a whole programme when I was inside. With this bad back of mine I barely even leave my flat, let alone get myself into any trouble.’
‘Look, I’ll find out the rules about this sort of thing and then I can decide. Come back and see me next week.’
I was relieved when Mr Raymond left, but I still couldn’t work out what to do. Mr Raymond had once abused children. The legal system had deemed him safe for release from prison and were it not for his medical condition he might well be able to have completely normal erections. I had no evidence to suggest that by me prescribing Viagra, children would be put at risk. What if he wasn’t abusing children, but was looking at child pornography? Would that make a difference? Perhaps he still fantasised about children but just used his own imagination to get aroused? When do I start having to be concerned about the ethics of this as his doctor? At what stage should I be allowed to pass judgment on when a man should or shouldn’t be permitted to have erections?
I decided to do some research on the matter, which is a posh way of saying that I Googled ‘prescribing Viagra to paedophiles’. The first pages that cropped up were about a French man who raped a young boy after being prescribed Viagra by his doctor in 2007. This served to prove that my greatest fear could potentially become a reality and it successfully increased my paranoia. Doctors belong to a defence union which can give advice at times like this. I called them up and the medico-legal expert told me that unless I had reasonable cause to fear that Mr Raymond was an active risk to children, I couldn’t justify refusing the prescription. She also told me that if I did refuse to prescribe him Viagra, Mr Raymond would be within his rights to make a complaint and take legal action against me. I documented this very carefully and was relieved that the law was so clear. I’m sure that many would be disgusted at the idea of a convicted paedophile receiving Viagra on the NHS, but the decision was out of my hands. To my relief, Mr Raymond never turned up for his follow-up appointment. Perhaps he was too embarrassed, or possibly, most likely, he bought some cheap Viagra online instead.
Hannah
The overwhelming desire to become a mother was so strong in Hannah it was almost palpable. It seemed to ooze from every pore of her skin. Ever since she had been my patient it was pretty much the only thing that she ever came in to talk to me about. All other physical ailments were put aside in order to concentrate on that most basic of human desires: to have a baby.
Hannah was now 42, and as each month passed her dream of motherhood slipped further and further from her grasp. There is plenty of talk in the media about career women putting their jobs first only to find that they have left it too late to have a baby. This wasn’t the case with Hannah. She would have happily started a family in her 20s, but she had quite simply never met the right guy. When she reached 37, Hannah decided against risking her chance of motherhood by waiting for Mr Right, and chose instead to embark on fertility treatments as a single woman. Our initial consultations were about the pros and cons of using an anonymous donor versus using the sperm of a generous gay friend. At first she battled to get funding for IVF on the NHS but failed, and so instead used all her savings to have cycles of fertility treatment privately. With each cycle came the drugs and the injections, followed by the hope and then, finally, in Hannah’s case, the overwhelming disappointment.
My job throughout all of this was simply to support her. I helped out practically by occasionally organising blood tests and letters to explain time off work, but mostly I was another shoulder to cry on when all the hope turned to despair. Hannah was putting her entire life on hold in order to have a baby. She stopped going out or having holidays. She spent every penny on fertility treatment. She turned down a promotion at work, because she didn’t want the stress of more responsibility affecting her chance to conceive. She even turned down a few nice blokes who asked her out, knowing that trying to get pregnant via donor sperm while in the early stages of a new relationship was just too weird.
Hannah was aware of how much the IVF was taking over her life. She had told me that she just wanted to know she had tried everything she could to get pregnant and if it hadn’t happened by the time she hit 40, she would take a deep breath and move on with her life.
However, when her 40th birthday came and went, she couldn’t quite let go. ‘I’m still having periods, Dr Daniels, and I feel healthy!’ she explained to me. ‘I couldn’t live with myself if I hadn’t tried everything I could to conceive.’
At the age of 41, after eight unsuccessful cycles, she had spent a total of £40,000. Her credit cards were maxed out and her flat had been remortgaged twice. She had borrowed money from her sister and mum. Finally, she came in to tell me that she had given up.
‘It’s a relief really, Doctor. It took so much out of me physically and emotionally. Even if I had the money I’m not sure I could put myself through another cycle. I’ve decided to adopt. There are children who need mothers and it seems selfish and stupid to be desperately trying to make a new baby when there are plenty of babies in the world who need a mother.’
The adoption process isn’t easy either, but at least it was a positive move rather than the continual pain of IVF. We went through the forms together and I completed the questions relating to her health. Up until the IVF, Hannah had been completely healthy, but during the last round of treatment they had found a cyst on her ovary that needed further investigation. Before I could complete the adoption paperwork, she needed to have her cyst investigated. I referred her to a gynaecology consultant and the news came back that it was ovarian cancer.
At first glance it might seem as though the IVF had saved her, as it was a scan during the IVF procedure that had picked up the mass on the ovary before she had any symptoms. In reality, it was highly likely that her fertility treatment had caused the cancer. The medication prescribed to stimulate the ovaries at least doubles the risk of ovarian cancer. So, after finally thinking that she was over all the unpleasant medical procedures that had plagued her during her fertility treatments, Hannah would now have to go through a whole lot more, this time to try to save her own life rather than create a ne
w one.
A year later, battered and exhausted, Hannah came back to see me, having finally been given the all-clear by the cancer doctors; the ovarian tumour had gone. She now wanted to get back on track with the adoption agency.
It was at this point that I had to break the awful news to her that now that she was a ‘cancer survivor’, they were unlikely to place a child with her for adoption. The risk of the cancer returning was still quite high and as a single mother if this did happen a child placed with her could become an orphan. I really didn’t think she’d be allowed to adopt a child now and I thought it best to be honest with her straight away.
Finally, Hannah’s grief erupted. The thought of adopting had been getting her through the horrors of her cancer treatment and now this door was closing on her too. She was absolutely devastated.
It was several months before I saw Hannah again. She literally bounced through my door like a Labrador puppy.
‘I’m pregnant,’ she beamed.
‘What?’
‘You heard me. I’m pregnant!’
‘How?’
‘Well, I’m not sure if you remember but my dad died a year ago and we finally got his affairs in order. I inherited some money and my sister agreed to go with me to a fertility clinic out in India. She donated an egg and well … voilà. I didn’t want to tell you that we were going, because I thought you might try to put me off.’
‘Well, I might have tried, but well, wow! Congratulations! How many weeks are you?’
‘I’ve just had my 12-week scan and everything looks fine. I didn’t really need to see you about anything in particular but I just wanted to come and let you know.’
‘I’m so pleased for you, Hannah, and I can’t wait to meet your new baby in the flesh in six months’ time!’
I could barely take the smile off my face for the rest of that day.
Ted
If anyone asks me the worst thing about being a doctor, my answer is always immediate: for me, it’s the constant fear of making a mistake. Every July a letter from the General Medical Council falls on my doormat. It is always a request to renew my annual subscription, but without fail, when I see who the letter is from, my heart races as I wonder if this could be the summons calling me to explain my incompetent actions to a courtroom full of grieving relatives and snarling journalists. It’s a fear that never goes away. It is something that every doctor has to learn to live with.
I was once three days into a holiday in Mexico when I woke up in a cold sweat, terrified that I had forgotten to do something for a particular patient sitting in a hospital ward 5,000 miles away. I couldn’t go back to sleep until I had called the ward to make sure the patient was okay. I was genuinely worried about that patient, but I can’t deny that there was a large helping of self-preservation in my fear. Making a mistake could cost me my job. Still, despite the general consensus that doctors are only in it for the money, we do care about our patients, and the idea that someone could come to harm because of my error is horrifying.
A surgeon knows that if he accidentally snips an artery when trying to remove a kidney the patient could die within seconds on the table in front of him. As a GP my mistakes are less acutely dramatic, but the potential consequences of my actions could be just as grave. Any headache could be a brain tumour, any feverish child could have meningitis and, as I discovered last year, any cough could be lung cancer.
Last April Ted came to see me with a bad knee. We had a chat about painkillers and I referred him to a physiotherapist. As he was leaving he asked me if there was anything I could do about his smoker’s cough. I suggested he gave up smoking, and he shrugged and walked out the door. Eight months later he was admitted to the emergency department with a collapsed lung due to lung cancer. When I looked back at the medical notes I made at that last appointment with me, I hung my head in shame. I wrote plenty about his knee pain and then at the very end it read: ‘Cough. Smoker. Advised to stop smoking.’ That was it: I hadn’t listened to his lungs, I hadn’t asked about weight loss or coughing up blood, and I didn’t request the chest X-ray that might have diagnosed his cancer earlier and saved his life. I even looked through the notes of some of the other patients I saw that afternoon. I spent nearly 30 minutes talking to a 20-year-old law student about her numerous self-diagnosed food intolerances, yet when Ted told me about his cough, I short-changed him with just a few seconds of my time.
I was dreading seeing Ted again when he came into see me after his diagnosis. However, when I apologised for not picking up his illness earlier, he laughed. ‘Dr Daniels, it was me who smoked all them cigarettes for all those years. I can’t blame you for me getting this disease. I was dreading coming in to see you as I thought you’d be cross with me for not taking your advice to give up the fags sooner. I was expecting you to say “I told you so”, not “I’m sorry”!’
I tried to explain my culpability: ‘But if I had sent you for a chest X-ray sooner, the cancer might have been curable.’
Ted gave me a generous smile. ‘Don’t blame yourself, Doctor. I don’t.’ With that, he left. Despite his generous forgiveness, every time I saw Ted I was awash with guilt.
There is a bad joke about doctors being able to bury their mistakes. This wasn’t the case with Ted. I saw him at work, but I also bumped into him in the supermarket with his wife. I even spotted him at the football with his grandson. It was as if he was everywhere I looked, and each time we met, his obvious deterioration was a reminder of my error. Even now that he has died, Ted’s wife comes to see me regularly. She remains oddly trusting of my medical opinion and completely unaware of the massive guilt that bubbles to the surface of my consciousness with her every visit.
The fear of making a mistake is indeed a terrible part of being a doctor, but on reflection actually making a mistake is truly the worst part of the job.
Should we name and shame doctors who make mistakes?
I’m not the only GP to have made a mistake; compensation payouts for medical negligence are going up, not just the number of cases but in the cost of the payouts. As a way of combating this, it has been suggested by the government that doctors should be named and shamed by publishing our mistakes and performance data online. The idea is that this will allow patients to choose their GP based on his or her track record, and that the resulting possibility of losing ‘customers’ (patients) will motivate us to improve.
It might also be suggested that the best way for GPs to reduce the chances of missing a serious diagnosis is for GPs to have a very low threshold for referring patients on for specialist care. The problem with this is that we are also under massive pressure to keep our referral figures down. The NHS is able to keep costs down in part because GPs successfully triage the ‘worried well’ away from busy hospitals and costly specialists. High levels of referrals are expensive and push up waiting time. Often those referred are already better by the time they see the specialist or could be equally well treated by their GP. There may well come a time when those doctors who are over-eager to send their patients to hospital will be penalised for using up too many resources.
GPs are under pressure from all sides, but at the same time there are some slip-ups for which we have to step up and take responsibility. I made a mistake with Ted and it is one for which I will hold up my hands up. If the current proposals go ahead, would my patients have the right to know about that previous blunder? Would they register with another doctor as a result? In an attempt at redemption I now ask all my smoking patients if they have a cough. If they have even the slightest throat tickle, they get sent for a chest X-ray. My practice has changed because I am scared that a future patient might come to harm due to my misjudgment. I’m not convinced that the added forfeit of damaging performance stats would really make that much difference.
I am ready to own up and take responsibility for my mistakes, but wouldn’t we all agree that the real key is trying to prevent errors being made in the future? Rather than spending money on dredging up my past in
order to rank me in a series of performance data statistics, perhaps it would be better to look for more positive ways to prevent future slip-ups. In our practice we have found talking openly about our errors helps. If a patient had a serious condition that was missed, all the staff look through the notes together to try to work out what we could do differently next time. If there is a field of medicine we feel our knowledge levels are lacking in, we encourage each other to get up to date on the latest research.
There were 300 million GP consultations in England in 2011 and just over 7,000 complaints made to the General Medical Council. That works out at around one serious complaint for every 42,000 consultations. Most GPs are good at their job and this is reflected in the ongoing high levels of trust in our profession. When mistakes are made we need to take responsibility for them, but we should also be encouraged to learn from them in an open and supportive environment. It really doesn’t seem to me that name and shame proposals are offering this. I would also suggest that they don’t really tackle the issue of persistently poor GPs either. If a doctor can’t learn from their errors and makes the same mistake time after time then surely something more serious needs to be done than simply publicly denouncing them on a government website?
Pseudocyesis
‘I think I’m losing my baby,’ wailed the lady sitting in front of me.
Karen was not one of my regular patients and had only registered with our surgery that week. She explained to me that she was 25 weeks pregnant and that up until now her pregnancy had been completely normal.
Further Confessions of a GP (The Confessions Series) Page 12