Confessions of a GP

by Benjamin Daniels

  I saw a middle-aged man complaining of headaches. His headaches were fairly nondescript with no symptoms of weakness in his limbs or problems with his vision. He hadn’t banged his head and the only thing of note was that he was feeling a bit tired and stressed out at work. I gave him a really thorough examination and documented everything very clearly in the notes, but basically reassured him that there wasn’t likely to be a serious underlying cause of his headaches. A week later he was found collapsed at home and was found to have a brain tumour. His headaches were almost certainly related to this and I had missed it. However, during our consultation, I took him seriously and gave him a really thorough check-over. I also asked him to come back if his headaches weren’t resolving. He is recovering slowly in a specialist neurology hospital after some quite major brain surgery.

  The cockup and up shit creek

  Some time ago I saw a woman with some odd tightness in her chest. She was well in herself and only in her mid-fifties. She told me that she had the symptoms when she went into town shopping and wondered whether they might be due to anxiety. I asked her lots of questions about the pain to make sure it didn’t sound as if it was because of problems with her heart or lungs. I also gave her a thorough examination, but couldn’t find anything wrong. I had a long chat with her about relaxation techniques and breathing exercises and told her to come back if the pain got worse. Three days later she collapsed with a heart attack. Again I had missed the diagnosis, but sometimes heart problems can present oddly and perhaps many other doctors would have done the same as me. In hindsight perhaps I should have done a heart scan and ordered some blood tests but these might not have made a huge difference. My real error in this case was that my documentation in the notes was really poor. I didn’t write much about the pain she had or the examination I did. Legally, I hadn’t covered myself at all.

  As you can see, these three cases are all mistakes of sorts and could have landed me in trouble. As you can also see, the degree of the mistake doesn’t always correlate with the amount of harm that comes to the patient. I have learnt a lot from them and I am a better doctor as a result. The near miss with the blood transfusion was probably the most negligent on my behalf yet as by pure good fortune no one came to any harm, I got away with it completely. Had things turned out differently, I could have been struck off and, much more importantly, the patient could have died.

  Missing the brain tumour was the least negligent because I really did do a thorough well-documented history and examination. For the lay person reading this, you may feel that I should have sent the patient to have an urgent brain scan. Unfortunately, I don’t have access to brain scans. My only option would have been to have sent him straight to A&E. As with most GPs, I probably see about 200 people per year complaining of a non-complicated headache. If all GPs sent all of these patients to A&E, the system would collapse. The wife of the headache man is considering suing me. I’m a little anxious about this, but I know that I am completely covered because I’m fairly sure that if 100 GPs read my notes, most of them would have done the same thing as me. I felt dreadful when I found out that I had missed that brain tumour, but without X-ray vision, I don’t think I could have been a better doctor that day.

  Mistaking the chest pain for anxiety was similar to the headaches in that it was a difficult diagnosis to spot. However, if the patient had wanted to sue me she could well have been successful. I wrote so little in the notes from that consultation that if she had claimed in court that she had all the classic symptoms of a heart attack or angina, then I had nothing in writing to defend myself. Medico-legally if it isn’t written down, it hasn’t been done. Shortly after the heart attack, the patient came in with her husband to see me. They were angry and upset and wanted to know why I had missed the diagnosis. I made the excuse that it was sometimes difficult to spot heart-related chest pain, but ultimately I held my hands up and said sorry. The hospital cardiologist had fortunately told them that her presentation of heart pain had been very unusual and as he knew me from my days in the hospital, he backed me up by telling them that I was a very good doctor. As far as I know, my apology was enough and they are not planning any legal action.

  If I miss a diagnosis, the patient suffers regardless. But from a legal view point, irrespective of how excellent and thorough I was in the consultation, if I’ve not documented my findings, I may as well not have seen the patient at all. I see up to 40 patients per day so can’t remember each consultation. Court cases often come up years after the incident occurs and the medical notes are often the only thing the doctor has to defend their actions. If something goes wrong, the patient will probably think that they have a vivid recollection of the consultation, but often the details of the event can change as the memory is recalled time and time again. An example of this is when a patient says, ‘That Dr X told me I had a year to live’ or ‘The A&E doctor said I would never have children.’ First, doctors rarely commit to these sorts of bold statements and second, when I read the notes from those consultations, the documentation tends to be very different from the patient’s recollection.

  It is quite hard for a doctor to admit mistakes and I think what I’m trying to say here is that although I’m not the best doctor in the world, I’m mostly quite a good doctor. Mistakes happen to all of us. I try my best each day to avoid missing any serious health problems but I have made mistakes in the past and undoubtedly will make them in the future. My only other option would be to refer every headache I see for an urgent CT scan and every chest pain to A&E for a hospital admission. Perhaps in an ideal world I would do this but the NHS wouldn’t cope with the strain and it would also cause unnecessary anxiety to many well people.

  Some mistakes are genuinely because of negligence by poor doctors. Most mistakes are made by good doctors who perhaps missed a difficult diagnosis or didn’t write enough in the patient’s notes. I hope we don’t become like the USA where ambulances are chased by lawyers hoping to persuade unwell people that it could be their doctor who is to blame for their illness. On the other hand, were it my family member who was ill or dead because of a possible medical error, perhaps I would want some justice too.

  Dying

  Our frequent close proximity to death and dying is perhaps one of the features that sets doctors apart from people in other professions. For most people, death is fairly sanitised now. It is rarely seen in its gritty reality and many people of my generation will never have seen a corpse or even somebody very ill. The constant exposure to something that most people would find very shocking can’t help but take its toll on your personality and outlook on life. Of course, we don’t suddenly acquire these characteristics upon passing our final medical school exams. Death and dying become gradually normalised as we are processed through the system of medical school and our first hospital jobs as junior doctors. In our very first week at medical school, we were cutting up corpses in the dissecting room. This was partly to learn anatomy, but also an attempt to give us an early exposure to death and help us learn to distance ourselves from it emotionally. I know that I must have normalised dying in my head because, although I have seen hundreds of people die, I can only actually remember one or two of them. Perhaps I’m particularly callous or have an exceptionally bad memory, but as I’m sitting here now racking my brains, I can recall very few of the names or faces of patients whom I have watched breathe their last breath.

  Although I now feel very unsentimental towards death, the first patient that I watched die is etched very strongly in my memory. I can picture her face very clearly and I can even remember her name but I’ll call her Mrs W. She was an ordinary 60-year-old woman who had woken up as normal that morning. She had felt fine and had been getting herself ready for what she had expected to be a fairly average day. Somewhere between breakfast and getting ready to pop to the post office, her aorta burst. The aorta is the main artery that runs from the heart, so as you can imagine having it spring a leak is bad news. It was my first hospital attachment as a medi
cal student and I was hanging around A&E trying to learn something and not get in the way. As a third-year medical student, I was in a strange void between being a normal person and being a doctor. I’m fairly sure that no other nurse or doctor who was working that day will have any memory of Mrs W because it would have been just another day at work. But for me, it was all very new and shocking and I still remember the episode in distinct detail. I was seeing death in the way a non-medical person might see it and not from the perspective of the hardened doctor that I am now.

  When Mrs W’s aorta ruptured, she had a sudden pain in her abdomen spreading to her back and began to feel faint. She called an ambulance and after the casualty doctor felt her tummy and saw her blood pressure dropping, it became fairly clear that she had burst her aorta (known as a ruptured AAA – abdominal aortic aneurism). She needed an emergency operation and there were all sorts of people flapping around organising scans and getting the operating theatre ready. As a medical student, I had the advantage of not having my own role or job to do. I could just sit with the patient and take it all in.

  During the following ten minutes, several more doctors arrived, prodded her tummy and spoke among themselves. Despite being very unwell, Mrs X had been alert and conscious through the whole ordeal. Nobody had really had the chance to tell her what was going on, but from the commotion occurring around her it was obvious that things were serious. She lay in bed connected to drips and monitors, yet stayed calm and immensely dignified. Her husband and daughter were sitting on either side of the bed, each holding one of her hands. The consultant surgeon soon arrived on the scene. He was a big burly man and was already in his surgical blues as he barked instructions at the nurses and junior doctors. I felt a pang of fear just by being in his presence. He marched over to Mrs W, sat down at the side of the bed and took her hand.

  ‘I’m Mr Johnson and I’m going to be operating on you this morning. You have burst the main blood vessel that runs from your heart. If we don’t fix it, you’ll die. If we do an operation, there is a 50 per cent chance that you will survive.’

  The words on paper look unbelievably harsh but Mr Johnson spoke them with an amazing air of calm and gentleness. He refused to be distracted by the surrounding mayhem but instead focused all his attention on Mrs W and her family. Sitting and watching, I was overcome with an amazing sense of how her life lay so tightly in the balance. She could sit up and talk and see and hear, but hidden beneath her skin, she was slowly bleeding into her abdominal cavity and ultimately dying.

  ‘It is a major operation and we will need to replace the part of the burst vessel with a synthetic tube. After the operation, you may be in intensive care for some time. We’re going to wheel you into surgery and start operating straight away. Do you have any questions?’

  Mrs W and her family shook their heads. As the porter came to wheel her into surgery, she took back the hands of her daughter and husband. I assumed that she would say goodbye, tell them how much she loved them or at least leave them with some poignant words. Instead, she listed a series of instructions. ‘There’s some mushroom soup in the fridge that needs using up and your dad is running low on his athlete’s foot powder. I owe the window cleaner from last week and don’t forget to send a card to your auntie June on Tuesday, as it’s her birthday…’ The list of nonessential instructions continued right up until the anaesthetist put her to sleep. I wanted to shake her and say, ‘Don’t you realise what’s happening? This might be the last time you see your husband and daughter! Don’t you want to say goodbye?’ I guess we all deal with things differently and this was the way that Mrs W dealt with what must have been an overwhelming and bewildering experience.

  I changed into surgical blues and went into theatre. About halfway through the operation, Mrs W’s heart stopped. It was bizarre watching them do CPR on her chest when her abdomen was lying wide open. Her heart never restarted. The surgeons changed out of their surgical clothes, told her family the bad news and then carried on with their day. I imagine they barely gave her death another thought.

  I, on the other hand, was quite upset by Mrs W dying. It played on my mind for several weeks and I thought about her a lot. She was the first patient that I had watched die and although she was ultimately a stranger, I felt quite upset. I have never felt that way since about a patient dying. Sometimes I wish I could get that fresh and almost innocent compassion and emotion back. In some ways it would probably make me a more empathic and caring doctor, but at the same time if I felt like that about every patient who died, I would have had to give up the job years ago.

  Happy pills

  In one surgery I worked in, 1 in 10 of the adult patients was on antidepressants. That seems a huge number to me! I’m not sure if we were overprescribing them, or if our patients were a particularly miserable lot. I am certainly no expert in this subject, but depression is something that I see a huge amount of in general practice. The vast majority of cases are dealt with by us rather than psychiatrists and most GPs have had to become skilled in recognising the symptoms of depression and offering support.

  Depression used to be a subjective diagnosis based on the outlook of the doctor and the patient. The powers that be seem to find this a difficult concept so have found ways for us to measure depression. This allows us to fit the depressed patient into a neat box and follow a set protocol. The result is that we can then be measured and shown to be either achieving or failing to reach targets. I find this very irritating. Many people with depression don’t ever seek help. It takes a lot for a person to find the courage to come and see a doctor and tell him or her about some very difficult thoughts and feelings that they may be experiencing. It is a very personal consultation and usually requires the doctor to mostly listen and occasionally ask a few questions that may help illicit a few of the more subtle issues and personal aspects of the illness.

  I like to think that after having worked in psychiatry and now having been a GP for some time, I’m quite skilled in this area. Unfortunately, in order to reach targets and hence earn points and money, I now have to interrupt a potentially very sensitive and important consultation to fill in a questionnaire. The answers give me a number by which the computer can categorise the person’s feelings and decide whether they need an antidepressant or not. I find this slightly demeaning to both me and the patient.

  My other big issue with the way GPs treat depression is the automatic reflex we seem to have for giving out antidepressants. I am certainly not against antidepressants and feel that for many people they play a valuable role in helping improve lives, but are we overprescribing them? For me, there seem to be three common presentations of depression that we see day in and day out in general practice. The symptoms can be quite similar, but I feel that the underlying cause can be very different and that this is fundamental to how we treat it.

  Type 1. Grieving

  You don’t have to be a doctor to know that if something bad happens to us we feel sad. A bereavement or a relationship breakdown can give us all symptoms of depression. Feeling tearful, poor appetite and problems sleeping are all classic examples. Using my questionnaire, these symptoms would flag up a diagnosis of depression and suggest antidepressants, but is this really the right diagnosis? Isn’t a grief reaction a normal part of being a human? I’m not saying that these patients shouldn’t come to see their GP. We can offer support and a sympathetic ear. Maybe we could even refer them for counselling, but in the majority of cases, time and support from family and friends are enough to get people through these difficult times. Isn’t it okay to feel sad sometimes?

  Type 2. Classic clinical depression

  These people often spend much of their lives moving in and out of long bouts of depression. The condition severely disables the sufferer and those close to them and is a diagnosable ‘illness’. Often there is a strong family history of the disease and although there may be triggers for depressive bouts, sometimes there is no obvious cause and from the outside the sufferer has absolutely nothi
ng to be depressed about. There is a risk of suicide and these people often do benefit from medication. The antidepressants alter the way in which certain neurotransmitters work in the brain and, sometimes along with other types of support, can help people turn the corner and begin to feel better.

  Type 3. Low-grade misery

  This is probably what I see most of when working in an inner city. I spoke earlier in this book about SLS – shit life syndrome. This is the theory that people are suffering from symptoms of depression but rather than an imbalance in certain brain chemicals, they are simply living a really hard and often shitty life. This may seem like a harsh derogatory generalisation, but I defy anyone who works with single mums on the council estates of this country to deny that SLS exists. Yet again, my computer’s questionnaire labels these patients as depressed, but I generally find antidepressants fairly ineffective in these cases. For example, I saw a young single mum who had been feeling miserable for years. She wanted to try yet another happy pill and was demanding to know why none of the previous antidepressants had worked. Rather than just sign another prescription, I decided to try a new approach. We went through all the reasons that she felt miserable. These included being abused as a child, never knowing her father and having a difficult relationship with her mother. She had had abusive relationships with several men as an adult and and as a result was now alone with three children. She was unhappy with her appearance, had no confidence in herself and was struggling financially. She lived in a small, damp council flat in a particularly rough estate with lots of crime. Reflecting on all the shit things in her life didn’t exactly lift her mood but then we made a list of positive things for her to attempt. She is now doing a college course and claiming for child support from her children’s fathers. A small step, but more mood lifting than a little white pill.