I view alternative medicine a bit like I view prayer. I believe that both only work if you really have faith in them. They are also similar in the fact that neither can be explained by evidence or science, yet live on after thousands of years. My own personal belief is that both prayer and most alternative medicine practices only work via the placebo effect. However, as a doctor it is important that I put aside my personal reservations and accept that many of my patients believe in non-conventional forms of medicine. Trying to inflict my own scientific beliefs onto my patients just makes them feel defensive and alienated by modern medicine. I want my patients to feel that regardless of our differing views, they can always come and see me to discuss their health.
As a GP, patients often ask me what I think about specific alternative practices. It is important for me to tell them that they are not all the same. It would be rude to compare a chiropractor with a crystal therapist or a fully qualified herbalist with a faith healer. I am usually fairly non-committal on the subject and say, ‘If it works for you, then go for it.’ I am particularly keen not to put off my more difficult patients from trying alternative medicines, particularly if it means that they might be encouraged to not visit me quite so often.
One of the original founders of psychotherapy talks about the doctor being ‘a drug’. This is the idea that regardless of what we diagnose or what medicine we give, simply our spending time with a patient, listening to them and possibly reassuring them is in itself often an effective treatment for many ailments. This form of healing is perhaps being lost in the modern general practice of targets and ever shorter appointments. Regardless of whether they offer homoeopathy, acupuncture or Reiki healing, the alternative practitioners are filling that gap by giving the time and attention that GPs don’t have an opportunity to offer.
One gripe I have with alternative practitioners is that they are ultimately private. Somebody is making money out of your illness and having only ever worked for a free at point of access health service, I find that an uncomfortable concept. I am fortunate enough to have never had any problems with my back, but I am fairly sure that if I presented to a private chiropractor, he would examine me and diagnose me with various weaknesses and instabilities and then recommend a set of ten sessions for £50 a pop. I expect a lot of alternative practitioners do similar things. Doctors working in private practice are no better. I had a patient who returned from a skiing trip in Bulgaria. He had had an accident and injured his leg. The doctors did an X-ray to exclude a fracture, which is reasonable enough. They also did an ultrasound scan, a CT scan and prescribed five different medications. All this for a bad bruise! The doctors were playing on the patient’s fears of being unwell and fleeced him for a small fortune. Unfortunately, I think that many private doctors play this game and it is a real relief to me that I don’t have the temptation of earning more money by prescribing more drugs and ordering more tests.
Most of what I prescribe as a GP is based on evidence and I talked about this earlier in the book. The concept is that I can’t just give any medicine for any ailment. For me to use a medicine there has to have been a large non-biased trial that showed that this medicine worked better than a placebo. For some treatments such as homoeopathy these sorts of tests are fairly easy to carry out and most of the evidence would suggest that there is no difference between a homoeopathic treatment and a placebo. For other alternative treatments, conducting these sorts of trials is more difficult but it can be done. For those of you unfamiliar with Reiki, it consists of a specially trained Reiki ‘master’ laying his or her hands upon the patient and controlling the energy forces that pass through the body. Advocates of Reiki talk about the amazing feeling of a glowing radiance and heat that passes through them during a Reiki healing session. Apparently, an experiment took place where several actors watched a Reiki master perform and then they imitated his healing technique. When the actors impersonated the healer using realistic but completely made up mystical chants and movements, the patients were just as aware of the radiance and heat passing through their bodies and were unable to tell the difference between the work of the Reiki master and the actors.
Now I would be wrong to criticise a profession for healing via the placebo effect as I use placebos all the time for my patients. The important thing to remember is that placebos do work. As I said, I am fairly sure that anti-inflammatory gel is of no more benefit for chronic back pain than rubbing on a placebo gel. This would suggest that it is the process of rubbing the gel on and thinking that it is reducing the pain rather than any pharmacological properties of the gel itself that are working. However, whether you use a placebo gel or the real painkilling gel, the patient feels better than if they have no gel at all. This is how most alternative medicines work. The mind is an immensely powerful tool for healing and is used by conventional doctors and alternative practitioners alike. If we can convince our patients to have belief and faith in our treatments, the results can be astonishing.
My most dramatic witnessing of the healing power of the mind occurred during my time working in Mozambique. A middle-aged woman presented herself to the ward in absolute hysterics. She owed her village witch doctor money that she couldn’t afford to pay and he had put a curse on her. The woman was convinced that she would die shortly and was screaming and throwing herself onto the floor and beating the ground. We managed to keep her still for a few minutes to do some basic observations and I have never known someone to have a pulse and blood pressure so high. It was quite possible that she could die from a heart attack simply because of the immense stress her body was under.
The head of medicine was a German professor who was always particularly impatient with the local people’s spiritual beliefs and superstitions. ‘There is no such thing as witchcraft!’ he shouted at the woman as she writhed and screamed on the ground. The woman took no notice and carried on wailing as her blood pressure and heart rate continued to rise to increasingly dangerous levels. One of the local doctors took a very different approach. ‘I can break the spell,’ he told her authoritatively. He took some magical stones from his pocket (some gravel from the hospital courtyard) and started chanting and throwing his arms around. After several minutes, he dramatically threw the gravel to the feet of the hysterical woman and announced in a booming voice that she was cured. The woman collapsed into an exhausted heap and started to whimper. Her blood pressure and heart rate were normal within a few minutes and she happily headed home to her village. ‘If you look convincing enough, these people will believe anything,’ the doctor remarked to me after I had looked on in astonishment. He then calmly asked one of the nurses to sweep up the gravel and we carried on with the ward round.
A patient once told me that she had turned to homoeopathy as she didn’t feel that she was treated holistically by modern medicine. I felt a little offended by this. The different ways in which health and illness are perceived by different classes, cultures and ages are perhaps more evident to GPs than to anyone else. A good GP should, by definition, recognise the delicate balance between mind, body and spirit in the treatment of his or her patients. It’s not always easy to take all these multiple factors into consideration with our limited time and resources but most of us do try. We appreciate the importance of emotional factors in physical symptoms and that illness can affect patients, their families and their environments in a myriad of different ways. This patient who had turned her back on conventional medicine clearly felt let down by modern doctors. I personally won’t be prescribing any alternative treatments, but I do think that I could learn a lot from the techniques and holistic approaches of many complementary practitioners.
Thai bride
As I mentioned in ‘Who am I?’ I love being an observer and sometimes playing a part in the soap operas that are people’s lives. In real soap operas, the watcher can only shout at the telly when a character is clearly heading for a fall. As a GP, sometimes I have the opportunity to step in, but the problem is knowing whether it is the right thing t
o do. This was the problem I faced with John.
John had been my patient for a year or so. He was a nice enough bloke but struggled with poor social skills and he was also not particularly blessed in the good looks department. Perhaps unsurprisingly, he had reached his forties without ever having been in a serious relationship and so decided to go on a trip to Thailand to find a wife. I remember him coming to see me before his trip, nervously asking for advice on travel vaccines and malaria prophylaxis. Maybe I should have made the suggestion then that a two-week holiday to Bangkok was perhaps not the best way to find true love. However, I stayed quiet and a few months later John came to see me in order to register his new wife as a patient. Sung was 19. She was beautiful, elegant and also looked absolutely terrified. John looked like the cat who had got the cream. I can’t imagine anything more frightening than being plucked from your family, friends and country, to be put into a cold, grey, unfriendly town with a much older and slightly odd man who was now your husband. She also barely spoke a word of English. Perhaps it was true love but I doubted it.
John was present during my first consultation with Sung. I asked Sung a question and when she looked at me blankly, John offered to help translate. I was impressed that John had learnt Thai, only to find that instead of translating my question into Sung’s native language, he just repeated it in English but shouted in a slightly odd stereotype of a Chinese accent. It was like a Russ Abbot sketch from the 1980s.
After a few months, while her husband was at work, Sung started to learn English at a language school and took a part-time job in a burger bar with other students her age. It was not long after this that John came to see me with symptoms of painful discharge from his penis. I did a swab because I suspected chlamydia. Chlamydia can hang around undetected for a long time, but I didn’t think that John had been anywhere near a woman for years until Sung came along. John had also proudly told me that Sung was a virgin when they got married. It seemed fairly obvious to me that Sung was sleeping around, but what did I tell John? When the results came back from his swab, I explained that chlamydia was a sexually transmitted infection and advised that Sung came in to be tested and treated as well. Despite them both having a course of antibiotics, John came back with another sexually transmitted infection not long afterwards. I tried to hint gently that these infections were probably coming from outside of the marriage but John simply couldn’t accept that this could be possible. How much right did I have to interfere with this relationship? John was blinkered and in love. Sung was 19 and having fun with lads of her own age. I was watching this car crash unfold each week. If John were a friend, maybe I would have given him a shake and pointed out the obvious, but he wasn’t a friend, he was my patient.
A few months later, Sung left John for a 20-year-old boy who played bass in a band. John was devastated and ended up on antidepressants. ‘Why didn’t you tell me she was being unfaithful?’ he blubbed. What could I say? My job was to point out the facts and hope that John reached his own conclusions. Perhaps I should have made those facts a little clearer.
Dead people
I’ve seen loads of dead people but I’m still quite scared of corpses. As a hospital doctor, one of my jobs was to go and certify death. During a night on call, I would be covering ten or more wards and be up most of the night doing odd jobs and reviewing sick patients. I recall one night when, after having just got to bed at about 4 a.m., my pager went off. The nurse on one of the geriatric wards told me that one of the patients had died. It was an expected death so although there was no resuscitation and CPR necessary, a doctor needed to certify the death before the body could be taken to the morgue.
It was a cold dark night and I had to force myself out of my warm bed to make the long trudge from the on-call room to the hospital. ‘Room 12,’ the nurse said as I wandered on to the ward. Rubbing the sleep from my eyes, I stumbled into the darkened side room. To certify death, a doctor has to ensure the patient isn’t breathing, that his heart isn’t beating, that his pupils are fixed and dilated and that he doesn’t respond to pain. The pain response is usually elicited by rubbing your knuckles really hard onto the front of the person’s chest. It is call it a sternal rub. It hurts like hell and we also use it a lot on alive patients in A&E, as it wakes people from even the deepest drunken stupor. The room was dark and quiet and I was all alone with the body lying in the bed in front of me. Still half-asleep I decided to start with the pain response. As I pressed my knuckles hard onto the corpse’s chest, it jumped up, grabbed my hand and let out an ear-piercing scream. This was soon joined by an equally loud and terrified scream that was being emitted by me. The nurse then flew into the room and said, ‘Sorry, Doctor, did I say room 12? I meant room 10.’
Holistic earwax
Veronica Davis rarely came to see me as she favoured alternative medicine to the more conventional kind that I was attempting to practise. The very fact that she was in my consulting room that morning suggested that she must have been fairly desperate to have ventured in to see me.
‘Hello Ms Davis, how can I help you today?’
‘I don’t care what you say, I’m not seeing a surgeon. I won’t let those barbarians invade me with their implements of torture.’
‘I’m sorry, Ms Davis, but I’m not quite sure what the problem is.’
‘I’ve got a serious ear problem, but I swear to God I’ll die before you send me to one of those filthy disease-ridden hospitals. I know my rights. My body is my body and I’ll be the one who decides if it gets chopped open, thank you very much.’
‘First things first, let’s have a look in that ear, shall we? Hmmm. Seems it is a bit blocked up with some earwax.’
‘Does it need an operation?’
‘No, I think some olive oil drops should do the trick.’
Ms Davis had clearly been expecting to have to fight me and 20 others off her as we forced her into a waiting operating theatre to be sliced open by some bloodthirsty surgeons. I don’t have many friends who are surgeons and you won’t often find me first in the queue to defend them, but I do think they are perhaps misrepresented sometimes. The alternative medicine brigade needs to realise that surgeons don’t cut you open for fun. They would probably rather be playing rugby or getting very drunk and accusing each other of being gay. That is what they like doing best. They will only cut you open if they really have to. If you decide you don’t want to be operated on, they will be only too happy to have one less patient on their ever-growing waiting lists. Very few surgeons are good at the touchy-feely sensitive stuff, but then us touchy-feely GPs would be rubbish at fixing a broken pelvis or repairing a burst aorta. You should see the mess I make trying to carve a roast chicken! We each have our skills and if it were me that was in need of an operation, I would happily put up with a slightly insensitive posh rugby boy if I knew that he was a good surgeon and could put me back together again.
Veronica had spent hundreds of pounds on alternative treatments for her ear problem before she came to see me. Neither the homoeopath, cranial osteopath, herbalist, nor Reiki practitioner had actually looked in her ear. If they had, they would have seen a whole lot of hard brown wax that looked pretty painful. It annoys me that alternative practitioners call themselves holistic without actually knowing how the body works. Surely that basic knowledge is as important a part of treating someone holistically as looking after their emotional and spiritual needs. I decided not to give in to the overwhelming desire to be smug with Veronica but instead just felt relieved that the consultation was drawing to a close with a simple diagnosis and simple treatment.
‘But why has it happened?’
‘Excuse me?’
‘Why has the earwax formed? There must be a reason. Do you think it is because there has been an imbalance in my energies?’
‘Erm, no. It just happens sometimes. I get too much earwax sometimes, too. Bloody annoying.’
‘Well, perhaps, Dr Daniels you’re not facing up to some deep emotional issues that are being s
uppressed. Everything happens for a reason. You should look at your health more holistically.’
I’m all for trying to balance and integrate the physical, mental, emotional and spiritual aspects of disease, but this was earwax. Bloody earwax!
Obesity register
Jemma is 28 and has come to see me about an infected insect bite on her ankle. She is nice enough but not very confident and admits to feeling a bit nervous around doctors. We have a bit of a chat and I like to think that I put her at ease. Her bite needs some antibiotics and all is straightforward until my computer butts in. Flashing up on my screen is ‘WEIGH PATIENT AND CONSIDER INCLUSION ON OBESITY REGISTER.’ Yet another target in our target-based world. The computer wants me to weigh Jemma and if she is above a certain weight, I would be obliged to put her on a special register along with our other overweight patients. Hmm, how can I put this tactfully to Jemma?
‘Oh Jemma, before you go, I’ve noticed you’re a bit of a porker. Jump on the scales; mind not to break them now, cupcake. That’s it…16 stone. Bloody hell, you are a big girl! We’re going to have to put you on our special fatties list. That’s it, have a good cry. Maybe it will burn off a few calories. See you again soon for another weigh-in. Won’t that be fun?’
Okay, so I am a little more subtle than that, but I do object to having to put my overweight patients on an obesity register. Perhaps I’m wrong here, but I imagine that a young woman would not want a young slim male doctor, whom she doesn’t know, pointing out that she is overweight (something she is probably already aware of). Especially when she has come to see him about something completely unrelated.
Of course I recognise that obesity is a large problem with social and medical consequences. I sometimes have patients who come in to ask me specifically about their size and to seek advice and support about losing weight. When this happens, I’m happy to listen and try to offer some encouragement. I explain about eating less and exercising more, but generally the world is already oversaturated with information about losing weight. I don’t really have that much more to add other than a sympathetic ear and a few supportive words.
Confessions of a GP Page 12