Confessions of a GP

by Benjamin Daniels

  Our oddest patient was called Tommy. I’m not quite sure what his diagnosis was but he was on the ward because of his sexual disinhibition. He had never raped or sexually assaulted anyone but he used to expose himself a lot and masturbate in public. Tommy was fairly quiet on the ward and the other patients had learnt to tolerate his odd behaviours. They would quite happily sit in the TV room trying to guess the Countdown conundrum while Tommy would be sitting quietly in the corner wanking himself off over Carol Vorderman.

  Tommy’s behaviours seemed to be getting better with some help from the psychologist and we thought things were going well until the incident with the pat dog. A pat dog is usually a very docile oldish dog that occasionally gets brought round nursing homes and hospital wards. The idea is that spending some time with a friendly dog can make people feel a little better for a bit, maybe even help bring them out of their depression and anxiety. Everyone loves a big cuddly docile dog that likes being stroked.

  Trigger was just this type of dog. He was a ten-year-old Labrador who just adored being given attention. His owner was retired and enjoyed bringing him around to the hospital. While Trigger was being petted by the patients, Ted his owner would have a cup of tea and a chat with the nurses. It was a Wednesday afternoon and I was sitting in the nurses’ office writing up some notes. Trigger was in the lounge with the patients and Ted was in the office with us talking about his impending hernia operation. Suddenly, we heard barking. ‘That’s odd,’ said Ted, ‘Trigger never barks.’ We all rushed into the lounge to see a very upset-looking Trigger being chased around the room by a naked Tommy and his erect member. It shouldn’t have been funny, but it really was. We never saw Trigger or Ted again, speculating that the poor dog had posttraumatic stress disorder and had probably been retired early on health grounds.

  Rina

  ‘How can I help today?’

  ‘Pain, Doctor.’

  ‘Where is your pain?’

  ‘Pain all over, Doctor.’

  ‘Everywhere?’

  ‘Yes, Doctor.’

  ‘Head?’

  ‘Yes, Doctor.’

  ‘Legs?’

  ‘Yes, Doctor.’

  ‘Arms, chest, back, toes, ears?’

  ‘Yes, Doctor. All-over body pain, Doctor.’

  Rina is in her forties and from Bangladesh. She has been in England for many years but, unfortunately, she still speaks only minimal English. I’ve never seen her smile or look anything other than thoroughly miserable. She often comes in bruised and I suspect that she is hit by her husband, although she denies this. Over the years she has presented with numerous pains all over her body and we have never found a medical cause for them. We call it CHAOS, Constant Hurts All Over Syndrome.

  ‘Medicine to help me, Doctor? Please, thank you.’

  Rina comes to the surgery most weeks presenting with some pain or another. I’ve never found a cause for the pain and suspect it is related to stress and depression. Rather than fob her off with another painkiller, today I decide to do the right thing and try to treat her holistically. I’m going to treat the whole person. Explore her health beliefs and expectations. Do the right thing.

  ‘So, Mrs Miah, why do you think that you have so many pains.’

  ‘Pains all over, Doctor.’

  ‘Yes, but why do you think you are having so many pains?’

  Silence.

  ‘We have done lots of tests and they have all been normal. Some people find that when they have pains all over for a long time, it can be connected to stress. What do you think?’

  Silence.

  ‘Is there anything else that you’d like to discuss today? Any problems at home?’

  More silence.

  I think Rina has understood me but she still looks at me blankly. We both sit there in an awkward silence. Me wondering why she can’t talk about her emotions; her wondering why I’m not dishing out a prescription and letting her get on her way. The way we view pain and disease is very dependent on culture and our understanding of illness and its causes. The concept of rationalising pain and physical symptoms with underlying emotional problems is something that my middle-class English patients thrive on. They love to be asked about how their overall health may be affected by their external environment. ‘Hmmm, Mrs James, you seem to have had a lot of colds recently. Why do you think that might be?’ ‘Well, perhaps I have been overdoing it a bit at work recently and I am very worried about Samuel’s school entrance exams. Maybe I should go back to working part time. What do you think, Doctor?’

  I have no idea what Rina’s ideas are about her health and whether she ever contemplates any possible external cause for her all-over body pain. I’m not sure if it is a cultural barrier or a language one that I’m facing with Rina. Perhaps she does recognise that she is depressed but can’t express it to me for whatever reason. If I was working in Bradford or the East End of London, I’m sure there would be specialist services available for someone like Rina – a place with multilingual support and experts in problems faced by Bangladeshi women in the UK. Unfortunately, this town is small and mostly white. Our counsellors are excellent but I fear that they would face the same language and cultural barriers as me. I once started her on an antidepressant but despite careful explanation as to how they should be taken, she just took them once in a while when she had a pain and so, of course, they didn’t help.

  Rina’s daughter is with her today and is happy to interpret for me. The problem is that, although very bright and articulate, she is only 11 and I don’t feel it is fair to use her to help translate personal questions about her mother’s mental health. Officially, we should use professional interpreters but it is hard work and time consuming. Even if I can establish that Rina has stress and depression, I probably won’t change the things that are making her depressed and it is so much easier just to give a prescription for another painkiller and wave her on her way.

  Doctors do appreciate the importance of treating people holistically and recognising cultural differences but that appreciation doesn’t always help the individual patients in front of me. Sometimes I blame not being holistic on only having ten minutes per consultation, but I could have ten hours with Rina and I’m not sure whether the outcome would be any better. Yet another unsatisfactory consultation and a feeling of short-changing my patient.

  Dos and don’ts

  Doctors are fairly immune to seeing you naked. Not much will shock or embarrass us, but if we are going to be required to delve into your nether regions, it would be immensely appreciated if you had a bit of a freshen-up first. Men, if you have a problem with your bits, give them a quick wash before coming into my surgery. I personally haven’t had a foreskin for years. I find them an oddity at the best of times. I don’t want to have to peel back yours to discover a crusty layer of knob cheese. You will see me gag. Women tend to be a lot more considerate and, if requiring a vaginal examination, will make sure all is presentable. I did hear about one woman who, while running late for the doctor, gave herself a quick spray of what she thought was a vaginal deodorant. It wasn’t until she saw a puzzled-looking doctor remove a very sparkly-looking speculum from inside her that she realised she had doused herself with glitter spray by mistake

  Don’t ask me how I am. That’s my question. We both know that you are here to talk about you. I know you are being polite but one of these days I might just answer the question and spend your precious ten minutes ranting about my cat’s fungal infection and my annoyance at my neighbour’s choice of late-night music.

  Don’t ever ever ever say, ‘What’s up, Doc?’ It might seem momentarily amusing but it really isn’t. It is the equivalent of shouting, ‘I don’t belieeeve it’ to the actor from One Foot in the Grave, or shrieking, ‘Riiicky!’ to the corresponding EastEnders actor. We’ve heard it before and it just gets less and less funny. Some doctors hate being called ‘Doc’. I don’t really mind. In my football team there are three Bens but I’m the only doctor so I am affectionately calle
d ‘Doc’. ‘On the ’ead, Doc’ has a certain ring to it. At school I was distinguished from the other Bens by being called ‘Big Nose’, so ‘Doc’ is a significant improvement.

  Please don’t ask us medical questions when we’re not at work. I was at the barber’s and he asked me what I did for a living. I foolishly admitted that I was a doctor and he then proceeded to unbutton his shirt and ask me my opinion about a rash on his chest. We don’t want to answer medical questions on our day off and we certainly don’t want to examine you unless you are extremely attractive. I can promise you that this barber wasn’t! The awkward part of being asked medical questions outside of work is that I might need to ask embarrassing questions. For example, one of my wife’s friends asked me why she kept getting urine infections. When I started talking about the possible pH of her vagina and explaining how different sexual positions facilitate the passage of bacteria up the urethra, she looked rather disturbed. She blushed, made her excuses and has barely spoken to me since. My wife accused me of being inappropriate but at least her friend won’t ask me medical questions in the pub again. Some things are just best left for the consulting room.

  If you’re a smoker, just be honest about it. So many smokers come in with awful chest infections and, when I ask them if they smoke, they proudly state, ‘No, Doctor.’ When I then ask, ‘Did you used to smoke?’ They say, ‘I haven’t had a cigarette for two days.’ This doesn’t make you a non-smoker and certainly doesn’t merit any congratulations from me. The fact that you have felt so breathless and unwell that you haven’t managed the ten-minute walk to the corner shop to buy your cigs makes you disabled, not an ex-smoker.

  It is actually really refreshing when a smoker walks in and says, ‘Yes, Doctor, I smoke. I know that it’s bad for me but I like smoking and I don’t really want to stop.’ So many patients make up a lame excuse that they then recite to me: ‘I stopped for a few days and that, but then my sister Amy, she was really upset ’cause Kevin, her bloke, done the dirty on her again and I ’ad to comfort her and it was dead stressful and I ’ad to have a couple of cigs to calm me down…’

  Home births

  Sophie is 32 and about to have her first baby. She is not a patient but a friend. Typically of my generation of middle-class women, she focused on her herself and her career before considering starting a family. Up until now every aspect of her life has been very effectively managed. She is used to having complete control and we had joked that her wedding last year was run with ruthless efficiency like a military procedure. Sophie is delighted to be pregnant and, like every big event in her life, she has carefully researched everything there is to know about pregnancy and birth. The single most important conclusion she has made is that she doesn’t want her birth to have anything to do with the medical profession.

  ‘I’m not ill, you know. I’m having a baby. It is the most natural thing in the world. Why should I go to a bloody hospital?’

  Sophie had long since rejected Western medicine in favour of homoeopathy, acupuncture and herbal treatments. She only eats organic food and her near-daily yoga classes keep her fit. She had never really had to consider conventional medical treatments because she had always kept herself so sickeningly healthy. Sophie felt very strongly about having her baby at home with no medical intervention and she was ready to battle for her cause at any opportunity. We met up for a coffee and she was spoiling for a fight. Much to her disappointment, I am not particularly adverse to home births. Evidence suggests that if the pregnancy is uncomplicated, a birth at home is just as safe as a birth in hospital and it is certainly a much nicer environment. My personal reservation about births at home is the possibility of me as a GP having anything to do with them. Gone are the days when a GP would happily get out of bed at 3 a.m. to assist with a difficult home delivery. I have only ever delivered a couple of babies. That was some years ago and I had a very experienced midwife watching my every clumsy move. You really wouldn’t want me anywhere near the delivery of your child.

  Doctors see the births that go wrong. They are clearly the minority but even in this day and age, babies and – even very occasionally mothers – do still die during childbirth. When you see a problematic birth, it tends to stay with you. Given the choice personally, I would probably put up with unfriendly midwives and bad décor and have my baby in hospital. I would want the reassurance that a team of specialists was on hand should things go tits up. Of course, as a bloke I will never have to make the decision so my opinion is fairly irrelevant.

  Home birth advocates would say that delivering your baby at home leads to fewer complications as the mother is more relaxed and this reduces the rate of births that go to Caesarean section. Both of my friends who had opted for home births ended up going on to have a Caesarean after being transferred to hospital by ambulance. Rather than pushing towards home births, shouldn’t we try to put more effort into building birthing centres or making hospital a nicer environment to give birth in?

  My only other comment on home births is that they are something that I remain immensely dispassionate about. The birthing experience is clearly very important for the parents, but middle-class women complaining that hospitals are a bit sterile and unfriendly is not my biggest concern as a GP. Home births are almost solely a concern for the middle classes. As with homoeopathy, organic food and rejecting the MMR jab, they tend to be the choice of healthy, educated and well-adjusted parents. Whether their child is born at home or in hospital, the child will probably be welcomed into a warm, loving, supportive family.

  The births that I am concerned about are those from the young, isolated, council-estate mums who are often bringing their children into less savoury environments. I spend a lot of time trying to make sure that these mothers have the support they need and, with the help of social workers, midwives and health visitors, that the child will be safe from potential neglect and abuse. Sophie feels that a bad birth experience, and particularly a Caesarean, can affect the future development and personality of the child. I personally doubt that is true. I feel that far more important is the mother’s ability to make an early bond with the child and give that child a stable, nurtured and safe start in life. Postnatal depression is perhaps the biggest contributor to mothers struggling to bond with their children. This can affect women of all classes and ages, but poverty, isolation and being a teenage mum are, in my experience, the biggest risk factors. I personally would rather money was spent providing for these vulnerable mothers than on funding home births.

  Michael

  It was a drizzly Tuesday morning in November and Michael was my fourth patient complaining of a cough and sore throat. My initial reaction was that I was seeing yet another case of man flu. Young men make such a fuss when they have a bit of a cold. They demand mountains of sympathy and expect you to discuss with them for hours the merits of Lemsip vs Beechams.

  Unfortunately, Michael didn’t just have man flu. There was something not quite right. He had already had three courses of antibiotics for recent chest infections and was losing weight. On closer inspection, he also had a white furry tongue that was almost certainly oral thrush.

  Michael was 33 and a teacher at the local school. He was from Zimbabwe and had moved to England two years ago with his wife and baby daughter. His symptoms suggested a weakened immune system and I had to consider AIDS as a definite possibility. I discussed with Michael doing more blood tests. It is never easy bringing up the subject of HIV but it was important that I asked him directly about it and whether he felt he had ever put himself at risk. I talked to him about doing an HIV test and counselled him fully on what we would do if the result was positive.

  Sexual health clinics are much better than GPs at managing HIV testing and I suggested that he attended our local walk-in centre. Michael looked horrified. Teachers tend to avoid the clap clinic as there is always a good chance that they’ll be sitting in the waiting room surrounded by their teenage pupils. Michael denied that he had ever put himself at risk but agreed to talk
to his wife and come back the next day for me to do a blood test.

  Michael missed his appointment. I wrote a letter and phoned twice but he never got back to me. I had a dilemma. Michael could well be HIV-positive but didn’t want an HIV test. He was, of course, completely within his rights to make this decision, but what about his wife and daughter? They could well be HIV-positive, too, and if diagnosed early, could potentially live long healthy lives on antiretroviral medication. I doubted strongly that Michael had spoken to his wife about his suspected diagnosis. The whole family were my patients so I had a duty of care for them all; however, I couldn’t break Michael’s right to confidentiality.

  I was searching for a solution when one found me. Michael’s wife brought in their four-year-old daughter Cynthia to see me because of a lump on her neck. I had no idea if this lump was related to being HIV-positive or not, but it was an opportunity that I couldn’t miss. I talked with Michael’s wife about the many different causes for neck lumps in children, including AIDS, and discussed the option of a referral to the sexual health clinic for HIV testing. I wasn’t breaking Michael’s confidentiality but my actions did result in all three of them being tested. Unfortunately, the whole family tested HIV-positive with Michael and his daughter already having symptoms of AIDS.

  I didn’t officially break Michael’s confidentiality but in some ways I did break his trust. He hasn’t come back to see me since but instead saw one of the other GPs at the practice. Michael and his wife and daughter were now on antiretroviral drugs and doing well. I feel I can ethically defend my actions; however, I do wonder if I would handle things differently next time. What a relief it was when my next young male patient with a cough and sore throat genuinely just had man flu.

  Alternative medicine