Confessions of a GP

by Benjamin Daniels

  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.

  Shit 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 SLS I’ve ever seen.’ SLS stands for ‘shit life syndrome’. Jackie has had a really shit 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 unofficially the cause is ‘shit life syndrome’. This is my opinion and I’m sure lots of people will disagree with me. 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 only ever occurs in people who have had tough and troubled lives and can’t articulate that pain verbally so it is instead expressed 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 exe
rcise 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.’

  In my career as a doctor I’ve probably seen about 20 cases of chronic fatigue and fibromyalgia. In all the cases, after delving deeply, the one common factor that seems to link all the sufferers is ‘shit life syndrome’. Maybe in the future I’ll meet someone who is struck down with the condition without any predisposing psychological problems, but I doubt it. Doctors tend to deal badly with patients like Jackie. By simply organising more tests and giving more drugs, we are positively reinforcing the idea of the sufferer having a physical illness that is the responsibility of the medical profession to treat. The years of hospital out-patient appointments and specialist referrals encourage the idea that the person is sick. It is a role that they subconsciously fill and become dependent on. Being labelled as ‘ill’ is a distraction from the fairly miserable social and emotional problems that are the underlying cause. In some cases, being ‘ill’ is also a way of exerting some control on the people around them.

  What would be more useful is if we could encourage patients like Jackie to take some responsibility and ownership of their condition and try to gently persuade them to start thinking about the connection between their physical and emotional health. This is easier said than done and my best efforts to do so clearly failed miserably.

  The next time Jackie requests a doctor she specifically asks 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.