Aggressive conduct disorder
This is an ethical dilemma that I faced and I have no idea if I did the right thing or not. I wonder what you will think. A mother came in to see me with her 12-year-old daughter and asked for her to be put on the pill. I said no and Mum was furious.
Basically, the daughter, whom I’ll call Amy, looked more like a 15-year-old than a 12-year-old. However, she wasn’t 15, she was 12! Her mother told me that she had ‘aggressive conduct disorder’. I had never heard of this but Mum explained to me that her condition resulted in her refusing to do anything that her mum told her to do, becoming very aggressive and basically doing anything that she wanted. She sounded like a stroppy 12-year-old with no boundaries to me. The difference between Amy and most moody 12-year-olds was that every evening Amy went to the local park with some older teenagers and drank alcohol, took drugs and had sex. She also refused to go to school. Mum told me that she physically couldn’t stop Amy from leaving the house. If she tried to do so, Amy would lash out at her and start hitting her mum and smashing up the house. Mum then showed me some of the bruises on her arms to prove it. Amy was bigger than her mum and there was no dad or partner around at home for support.
As far I was concerned, a 12-year-old having sex was child abuse and indicated a need to have social services and child protection services involved. I was amazed to hear that these services were already in place with social workers, the police and child psychiatrists all involved with her care and having regular child protection meetings. Despite this, there had been no change in Amy’s behaviour. Mum’s basic standpoint was that she couldn’t stop Amy from having sex but did at least want her to avoid the trauma of having an abortion or a baby. I just couldn’t believe that Mum appeared to be so accepting of her daughter’s behaviour.
Amy herself was in the room with us but sat silently in the chair staring at the floor. I tried to engage her and ask her a few questions. I even tried to speak to her without her mum present, but I got no response whatsoever. I am allowed to prescribe the pill to under-16s but I have to be convinced that they have the ability to understand all about the pill and make the decision as to whether they want to take it or not. As Amy refused to talk to me, I couldn’t be sure of this so I felt justified in not prescribing the pill for this reason.
Amy’s mum left, annoyed. ‘Don’t judge me,’ she said as she got up and left. ‘Do you not think I’ve tried everything I can to help and protect Amy? I love my daughter.’ It was too late. I had judged her. I feel that a parent must be able to physically prevent their 12-year-old daughter from having sex, getting drunk and taking drugs. Maybe my opinion will change if I ever have a teenage daughter. I’m not suggesting that Amy should have been taken into care and locked away, but shouldn’t there have been something more on offer from social services to give support for Mum and help her protect her vulnerable child? What was the future going to be for Amy? The advantage of being her GP was that I’d probably find out if I hung around for long enough. I just hoped she wouldn’t pitch up to see me next week pregnant.
Ed
Medics’ humour can be fairly brutal and one of our favourite games was stitching up our mates. Ed was a friend from medical school but when the rest of us qualified, he failed his exams and the poor bugger had to retake. Six months later, he did qualify and came and joined us as a hospital doctor. Ed was taking over my job on the ward and was extremely nervous about his first day. As I left on my last evening, I had the ward in fairly good shape ready for Ed to take over in the morning. However, we thought it might be entertaining to fish out a few embarrassing photos of Ed from medical school. Using the ward computer, we put a particularly unflattering photo of Ed on a notice. It stated: ‘THIS MAN CLAIMS TO BE A DOCTOR CALLED DR EDWARD BENNETT. HE IS A CONMAN. PLEASE REPORT HIM TO SECURITY IF SEEN ON THE PREMISES.’ We put the notices up on the ward that he was due to start on the next morning and then left for our new placements at different hospitals. Poor old Ed spent his entire first morning having to try to prove that he was really a doctor and eventually had to ask the dean of the medical school to confirm his identity.
Poor Ed was eventually allowed to start work and he survived his first year as a doctor. His next job was as a casualty doctor and, unfortunately, his first day was equally disastrous. We have a system where, at the beginning of August, we all swap jobs overnight. Often a doctor will be on call in one hospital one evening and then start work in a hospital in a different part of the country the next day. This is what happened to Ed. After finishing a shift at midnight, he woke up at 4 a.m. to drive 100 miles to a new hospital to start work in A&E. Ed didn’t know the area and was driving around town lost, trying to find the hospital. Unfortunately, the combination of being sleep-deprived and lost resulted in him crashing his car on a roundabout. He wasn’t badly hurt but the paramedics wanted to play things safe and he was wheeled into the A&E department where he had been due to start work, strapped to a spinal board and wearing a neck brace.
Being ill as a doctor is always a difficult experience, especially if you end up being admitted to the hospital in which you work. During my first year as a doctor, I was admitted for an operation on my ankle. It was very odd being on the other side and quite an eye-opener. My friends, of course, saw it as an excellent opportunity to stitch me up. They managed to find my drug card and thought that it would be hilarious to write me up for all sorts of unnecessary medications that would mostly have to be inserted up my backside. Still dopey from the anaesthetic, I had to fend off a particularly enthusiastic Filipino nurse who was determined to carry out all the doctors’ carefully written instructions.
Camouflage man
Camouflage man is frightening when you first meet him. He has a big bushy beard and wears head-to-toe army camouflage gear, complete with balaclava and army cap. He is homeless and carries all his belongings in a large holdall on his back that he secures to his body with a long chain that is wrapped around him several times and locked with a big padlock. Camouflage man has paranoid delusions that he is being followed and people are trying to attack him and steal from him. These thoughts are partly because of his mental illness and partly because life on the street is tough and he regularly gets beaten up and robbed. You would probably cross the road if you saw camouflage man walking towards you, but now that I know him I realise that he is much more afraid of you than you are of him. His real name is Nigel.
Nigel is mentally ill but because he doesn’t fit nicely into one neat category of mental illness, no one has really taken responsibility for him. Nigel has had schizophrenia since he was a teenager but because he is also an alcoholic and homeless, no one is very sure which team should be looking after him. Nigel won’t take any medication and won’t attend any psychiatric appointments. He often disappears for a few months at a time, but he always resurfaces and as his GP, I am perhaps the only healthcare professional with whom he regularly has contact.
He often tells me about his psychotic and frightening thoughts. They have been going on for years and are worse when he smokes cannabis. He sometimes becomes violent when he drinks and he has spent some time in prison. You might think that someone like Nigel should be in a psychiatric hospital and, 20 years ago, that is where he would have been. However, people with mental illness aren’t locked away indefinitely these days as they are treated in the community instead. Care in the community works well for some people with mental illness, but not for Nigel. He is a ‘revolving-door’ patient. He becomes quite mentally unwell and often then ends up being compulsorily detained by the police and brought into hospital. He is forcibly given a drug- and alcohol-detox along with antipsychotic medication. For a period of time, he remains relatively well, but he can’t be locked up for ever and eventually he is discharged and goes back to his old addictions and stops taking his medication.
My main worry with Nigel is that one day he might get very paranoid and kill somebody. It is very rare for somebody with mental illness to commit murder, but i
t does sometimes happen and when it does, the debate on how we should manage people like Nigel is reopened. The finger is pointed at GPs, psychiatrists and politicians and then everything blows over and not much changes. Today we can’t lock up Nigel because he isn’t harming himself or anyone else. I am scared that if he smokes enough dope, he might get sufficiently paranoid to harm someone, but my fears aren’t a good enough reason to lock him away. Nigel does have a designated psychiatric nurse, who is very nice but struggles to keep track of him. There are only so many times the nurse can wander the city centre looking for him. If she finds him, she buys him a coffee and tries to persuade him to stop smoking weed and to take his medication. Then she leaves and Nigel goes back to his chaotic paranoid existence. There are community support teams and services available to help people like Nigel, but when he is out of hospital he doesn’t really have much interest in using them.
Nigel will always have a difficult, chaotic life, but it would be nice to think that we had the services available to keep him and everyone else safe. At the moment we don’t. If he did take his medication regularly, he would probably stay fairly well. The problem is, like many people with mental illness, he just won’t take it voluntarily. One option is to consider paying people like Nigel to take their antipsychotic drugs. It is a controversial idea but every time Nigel is admitted to hospital it costs the NHS thousands of pounds. If Nigel were paid £20 per month to come and get his injection of antipsychotic medication, it would probably be enough incentive for him to take it and he would almost certainly remain well. This would save thousands of pounds in hospital admissions and also reduce the harm caused to Nigel and those around him every time he becomes unwell. Many are against this idea, feeling that it degrades people with mental health problems. There are many stable, well-supported people with schizophrenia and other types of mental illness who take their medication readily without the need for financial incentives. Unfortunately, there are also an awful lot of Nigels.
Memories
I see about 40 patients a day and have been a doctor for several years. As you can imagine, over the years I have seen many thousands of patients. For the duration of their time with me, each patient has my full and undivided attention. But once they leave the room, my recollection of them fades quickly and they are filed into a grey blurry part of my memory somewhere between the names for the small bones in the hand and the West Ham team of 1985.
I’m sure many patients forget me as rapidly as I forget them, but I’m still surprised by the impression I can sometimes make as a doctor. I once got stopped in the post office by an elderly lady who greeted me as if I was her long-lost son. ‘Dr Daniels! It is you, isn’t it? It’s me Rita, Rita Lloyd. You saw my husband Roger in A&E about four years ago.’ I had absolutely no memory of her at all. Even digging deep into my brain, I pulled out Tony Cottee and Frank McAvennie (1980s West Ham legends) but no Rita and Roger Lloyd. ‘You helped save my husband’s life!’ I was really racking my brain now. I should’ve recalled something. I endured many long and arduous shifts in A&E but it was rare that I ever helped save anyone’s life. ‘Roger had a tummy ache and everyone said it was just constipation but you examined him and said you thought there might be a more serious cause for the blockage. You sent him straight to the surgeons and they operated that night. He nearly died on the operating table but thankfully he pulled through.’ ‘Oh yes,’ I said. I now had the names of nine West Ham players and two hand bones (although one of those might actually have been a foot bone) but still had no memory of Roger and his tummy pain. ‘How is Roger doing now?’ I asked. ‘He died nine months later from the bowel cancer that was causing the blockage, but we are all so grateful for that extra time you helped to give us.’ She gave me a big hug, shed a tear and left me to carry on in the post office. It’s not often that I get a warm fuzzy feeling like that but it really was a vintage year for West Ham…and it’s nice to think that I occasionally make a difference as a doctor.
Fighting
Tommy has a proper West country ‘ooarr’ accent that never fails to entertain me. He’s not particularly blessed in the brains department and has a very high TTT score. TTT stands for tattoo to teeth. The rule is that if a patient comes in with more tattoos than teeth, they are probably going to have a fighting-related problem. This may seem like another unfair prejudice made by snobby middle-class doctors, but it is in fact a frighteningly accurate clinical sign.
‘’Allo, Doctor. I’ve come about my nose. It’s sniffing, see. I can’t sniffs on this side. And I can’t sniffs on the other side, neither.’ Tommy demonstrates with a long and unsuccessful attempt to breathe in through both nostrils in turn.
‘See, Doctor – I can’t sniffs nothing. I snores like a bear and I can’t even smells my own farts.’
You didn’t have to have a medical degree to spot the problem with Tommy’s nose. It was clearly big to start with, but had unmistakably been broken on several occasions and now pointed in several directions at the same time. Judging from his multiple tattoos and missing teeth, I imagine that Tommy’s nose has probably been punched out of shape, but it seems unfair to jump to conclusions.
‘So, Tommy, it looks like you’ve broken your nose. Was that a sporting injury, perhaps?’
Tommy gives me a big toothless smile.
‘No, Doctor. I broked it fighting. I broked it this way fighting in the pub and then my wife broked it the other way when we was rowing at home. Just the other day I think I might ’ave broked it again when I fell over pissed.’
I send Tommy off to the facial surgeons but warn him that they have quite a job on their hands.
I myself am pleased to say that I have never been hit. Although my nose is big, I am relieved that I have at least managed to keep it straight and I’m rather keen it remains that way. A recent report suggested that up to one-third of NHS staff have been physically assaulted at work. One of the reasons I have avoided violence during my years as a doctor is my natural tendency to exhibit cowardice at every possible opportunity. This was most clearly demonstrated when a fight broke out between two drunk patients one Friday night in the A&E department. When looking back at the CCTV footage with the police, several small nurses could be spotted bravely moving towards the action and attempting to break things up. Meanwhile, I could clearly be seen running away in the opposite direction towards the door.
I have been threatened on several occasions and it is easy to feel quite vulnerable when you are alone with an angry patient in a confined space such as an A&E cubicle or a GP surgery consultation room. People can get angry and aggressive when they are in pain or scared about their own health or the health of their loved one. Sometimes their aggression is part of an illness such as schizophrenia or dementia. Sometimes they are just drunken arseholes looking for a scrap. I have a simple rule. If someone is unnecessarily aggressive and abusive towards me, I won’t see them. On one occasion in A&E a man was needlessly abusive and threatening towards one of the nurses. He was a little drunk but that was no excuse. He was shouting and swearing in front of young children and elderly people in the waiting room and, towards the end of a long and tiring shift, I decided that I was not going to put up with that sort of behaviour and I refused to see him. This made him more angry and he ended up kicking off big time and getting arrested. I could have probably resolved the situation peacefully by placating him verbally, making him a cup of tea and letting him jump the queue to be seen. But why should I?
When I made the decision not to see that man, I was in a busy A&E department with plenty of porters and a couple of burly security guys on hand to help protect me from getting a beating. Had I been less well protected, my cowardly instinct would have kicked in and I’d have happily treated him immediately as long I knew that it was going to prevent me ending up with a nose like Tommy’s.
Class
After I call out my patient’s name on the tannoy, it takes approximately 30 seconds for them to walk from the waiting room to my consulting room. In t
hese 30 seconds I usually have a look at the patient’s address and before they have even knocked on my door, I have already made many sweeping judgements about their health. I’m not proud of this as these assumptions are based purely on the street they live on. I know the local area well and, as with most towns, there are some streets with nice posh houses and others with small impoverished council flats. Class shouldn’t play a part in how I treat my patients but it has such an effect on how people look after their own health, I can’t help but consider it. This might simply sound like my middle-class prejudice but I promise you it isn’t. Life expectancy for people in the lower social classes is significantly shorter than for those in the higher social classes and, in fact, even when you take out the risk factors of smoking, poor diet and obesity, simply being from a lower socioeconomic class independently increases the risk of having a heart attack.
From a personal perspective, I have worked in hugely different environments, from surgeries in inner city council estates to a surgery deep within the wealthy country lanes of the Home Counties. The difference in the sort of health problems seen is extraordinary. Issues such as smoking, teenage pregnancy and obesity are three of the biggest health problems that the UK faces today, but although they get a lot of publicity, it is very seldom pointed out that they are principally conditions of the lower social classes. Of course, there are a few posh people who are overweight and smoke and even the odd rebellious private-school girl who gets pregnant, but ultimately these medical burdens are more related to a person’s social environment than anything else. The onus is being put on to the NHS to solve these problems and, yes, we have a role to play, but ultimately if we could improve housing, education, attitudes and expectations, I think health would improve all on its own.
Confessions of a GP Page 17