Further Confessions of a GP

‘What now?’ was her next question.

Again, this was a hard one to answer. ‘We’ll get the palliative care nurses involved and will always make sure that you’re never in pain or distress with the symptoms. You might remain stable and fairly well for some time …’

‘But basically I’m going to die.’

I thought about trying to counter that remark with something upbeat and positive, but in reality Maggie was right. She was going to die and I couldn’t say anything that would change that fact. I stayed quiet, handed her a tissue and put my hand on her hand. We sat in silence for a few moments while she sobbed. After she left, I made myself a quick cup of tea, splashed some cold water on my face and pulled myself together enough to see my next patient.

Brian and Deidre

Every couple of months or so the surgery shuts for an afternoon and we have some sort of educational session. It’s an attempt to keep us up to date and make us better doctors. The most recent education afternoon was on the topic of sexual health. A lady with a colourful silk scarf and ethnic sandals was talking to us about the importance of sexual identity.

‘How often do you see your patients as sexual beings?’ she asked. ‘How often do you consider how the medications you prescribe might affect the sexuality of your patients?’ I had to admit that the answer to both of these questions was ‘never’. I knew that some medications could affect libido and erections, but I tended to avoid discussing it with patients if I could. This was all going to change from now on, though, I decided. The sex therapist lady was right. There was no point lowering a patient’s blood pressure if I was going to ruin his relationship because my drugs were inhibiting his erections.

The first chance to demonstrate my newfound sensitivity came the very next day. Brian had come in for a review of his blood pressure medication. I know it’s wrong to pigeonhole, but I always felt like Brian looked like the perfect stereotype of a bus driver: mid-50s, with mutton-chop sideburns and an ever-expanding beer belly. His faded white shirt always had large yellow sweat patches in his armpits and was open at the neck to reveal a big gold chain that matched his sovereign rings. Brian was accompanied by his wife Deidre, and although they always came to see me together, I had the impression that their relationship was often strained. With my new approach, perhaps I could help?

‘Brian, some men find that beta-blocker medication like the one you’re taking for your blood pressure can affect their ability to have erections. Do you ever find this to be a problem?’

‘Well, funny you should say that, Doctor. Me and the wife here have been struggling to manage in the bedroom department for some time. When we’re alone together I just can’t seem to get the little fella to stand to attention these days.’

Wow, I think to myself. What a breakthrough. The nice sex therapist lady was right. We do need to talk more about sex with our patients. Perhaps I can make a real difference to Brian and Deidre’s relationship. Perhaps the sexual frustration is the reason why they’re always bickering.

‘Mind you, I do still get erections though, Doctor,’ Brian said, interrupting my thought process.

‘This young lass got on the bus last Tuesday. It was a right warm day if you remember and, cor blimey Dr Daniels, you should have seen her! Gorgeous she was. Legs this long and a little top that didn’t leave much to the imagination if you catch my drift …’

Brian went on to explain in some detail each item of his young passenger’s clothing, and the relative part of her anatomy that was exposed as a result. ‘Rock solid I was, Doctor. Could barely keep the bus on the road! I could see her in my rear-view mirror and I had wood from the stop outside Boots on the high road all the way to the leisure centre past South Street. That’s five stops, and I got caught at the lights just before the bridge. I really don’t think it’s the blood pressure tablets that are the problem, Doctor. I think it might be Deidre. She’s not the woman she was. Just doesn’t really do it for me any more.’

Deidre had been sitting quietly up until now, but I could sense her rising fury. ‘Don’t you worry, Dr Daniels, erection or no erection, Brian doesn’t do a great deal for me either these days. In fact, he never really did. Even when we were young I always had a lot more fun on my own, if you know what I mean.’

Brian and Deidre went on to describe each other’s inadequacies in the bedroom department in some detail. To make things even more awkward, they didn’t speak directly to each other but instead spoke to me as if the other wasn’t present. I sank as deeply as I possibly could into my chair and cursed myself for turning what could have been a nice simple consultation into something so toe-curlingly awkward that I wished the ground would swallow me up. I tried to think of some useful interjections, but I was well out of my depth with this one, so instead I sat excruciatingly silent until Brian and Deidre decided that I had heard enough and left.

My brief attempt at viewing my patients as ‘sexual beings’ was well and truly over.

Maggie II

Maggie had come back to see me after seeing the cancer specialist again.

‘He was very nice, but he soon discharged me when I decided that I wasn’t going to have any chemotherapy.’

‘How are you coping?’

‘Everyone keeps telling me how brave I am. They tell me I’m a fighter and that I’m strong. I’m fucking dying and they just talk to me about staying positive. The problem is, Dr Daniels, I’m not that brave or strong or positive. Right now I’m scared. In fact, I’m thoroughly terrified. It’s as if I’m not allowed to admit it to anyone because I have to be so godforsaking brave the whole bloody time.’

‘It’s okay. You’re allowed to be scared.’

‘How about fucking terrified?’

‘Yup, that too.’

‘I’m all right when people are around or when I’m busy, but when everyone else is out and I’m alone in the house, I can’t stop myself from wondering about the end. How will it be? Will I be in pain? Will it be next week or still months away? Will I stop breathing first or will it be my heart that stops? Will I already be in a coma or will I feel myself dying? I need to have some power over this. Sometimes I wish I could piss off to Switzerland and end it all now. I just want to wrestle back control over this whole sodding thing.’

Regardless of the person with the cancer, the same clichés seem to recur time and time again. One of which is sufferers of the disease being universally thought of as ‘brave’. The public image is of ‘brave’ cancer sufferers heroically running marathons while defiantly sporting their chemotherapy-induced baldness. It’s as if the brave label arrives the moment you are diagnosed with cancer and you’re not allowed to be anything else. Reality TV personality Jade Goody morphed from being a national hate figure to being some sort of serene martyr the moment she was given her cancer diagnosis. In fact, such was the furore when she died that some people were calling for cervical cancer to be renamed ‘Jade Goody disease’. I thought I was going to have to start telling people that their smear revealed some abnormal Jade Goody cells on their cervix or that the Goody had spread to their liver. Jesus, as if breaking bad news isn’t hard enough already!

It wasn’t that Maggie was any less brave than anyone else. She was having a thoroughly normal reaction to the knowledge that she was going to die. We hadn’t really known each other well before her diagnosis, but she seemed to have acquired an immense trust in me since I spotted that she had cancer. To be fair, it wasn’t some sort of clever diagnosis worthy of House, but she clearly appreciated me sending her straight into hospital that first afternoon. There was no cure, but we were going to do everything we could to ‘keep her comfortable’. There’s another classic cancer cliché that Maggie hates.

Communication skills

Once a year our surgery sends out hundreds of anonymous patient satisfaction questionnaires. It always makes me feel a little under scrutiny, but overall I can’t dismiss the potential value of finding out what my patients really think about me. Some of the questions are about general matters, such as telephone access and how long it takes to get an appointment. Others are more directly targeted towards the patient’s interactions with the doctor, and contributors are specifically invited to comment on the experience of their most recent consultation.

When the collated results are emailed to me, I eagerly read them through. Being a good doctor isn’t just about being popular, but I can’t pretend that I wouldn’t feel thoroughly demoralised if all my patients reported in their questionnaires that they hated me!

This year, the first question asked whether the doctor helped them feel at ease. Phew, 85 per cent of my patients felt I had done this. The second question was whether the patient felt that their concerns had been listened to: 83 per cent scored me highly on this one. A further 88 per cent of the respondents were impressed with my ability to communicate with them. It was a relief that I was scoring well, but I was only reaching the average scores that most GPs achieve on these standardised surveys. Despite the regular pounding we get in the media, overall satisfaction in GP services remains consistently high.

The final question asked if the patients felt that their last consultation had helped lead to an improvement in their physical or mental health. On this I scored 40 per cent. Ouch! That meant for the majority of my patients, although they were put at ease, had their concerns listened to and were well communicated with, their actual health was no better off after seeing me than it was before.

This might seem like an epic failure, but actually it is a very accurate description of what a doctor does. The famous French writer Voltaire said that ‘the art of medicine consists in amusing the patient while nature cures the disease’. I would add that nature sometimes makes them worse too, but ultimately our role is often to offer a distraction while time and the miraculous natural healing abilities of the human body work their magic. Some of my patients are very aware of the limits of my therapeutic abilities, but others seem to feel that I should be performing miracles. Regardless of their expectations of my curative powers, every patient expects me to be nice to them.

It sounds obvious really, and of course it is, but a huge proportion of complaints against doctors aren’t about medical errors leading to ill health, but rather about doctors communicating poorly or not listening. One of my colleagues in A&E tells me that he always makes an effort to be ridiculously attentive to his patients however exhausted or frustrated he feels. Regardless of how rude, demanding and ungrateful the patient, he makes a huge show of bending over backwards to be gregariously charming. ‘Speaking to patients is like acting,’ he told me. ‘The only difference between me and a film star is that I’m too short, fat and bald for Hollywood.’ I try to follow his advice, but often my acting lets me down. It can be hard to be incessantly charming for an entire 12-hour night shift, but when I do manage it, my patients love me, regardless of how little I actually improve their health. This is why medicine is so often described by those in the profession as an art rather than as a science.

Having established the overwhelming importance of good communication skills when interacting with patients, it can be astonishing to witness some health-care professionals doing it so badly. Most catastrophic is when they have absolutely no idea how bad they are. Perhaps the oddest example I ever came across was as a student sitting in with a vascular surgeon. A nervous-looking gent in his 60s shuffled in with some smoking-related damage to the arteries in his legs. The very pompous surgeon asked him if he was still smoking. Defensively, the gent reassured the doctor that he had cut down from 20 cigarettes per day to just five. ‘Hmm,’ said the surgeon. ‘That’s hardly the greatest of achievements now is it? If I was a rapist who used to rape 20 women a day, but I had just recently cut down to raping just five women a day, I’d still be a horrible little rapist now wouldn’t I?’ The poor patient simply nodded aghast and I meanwhile had to pick my chin up off the floor. Perhaps it helped the patient in question give up those last five cigarettes, but even so, I’m not sure it could ever be recommended as a suitable technique for offering health promotion.

My personal worst moment of communication was about eight hours into a busy A&E shift some years ago. Corresponding to each patient sitting in the waiting room was a small set of paper notes headed with their name and the medical complaint that had brought them into the emergency department. Hour after hour, the routine was the same: I would pick up the top set of notes from the endless pile, walk into the noisy waiting room and shout out their name. For some reason, on this one occasion, instead of calling out the name, I shouted out the patient’s medical complaint instead.

‘SWOLLEN FACE,’ I bellowed at the top of my voice.

I was absolutely mortified as this was a terrible, if accidental, breach of patient confidentiality. Oddly enough, though, the patients didn’t seem to bat an eyelid and up stood a gentleman at the back of the waiting room with an impressively swollen face. He then proceeded to trudge unperturbed through into the treatment area. My terrible violation of his privacy had gone completely unnoticed, although I do wonder whether if I had shouted out ‘TWISTED TESTICLE’ or ‘FOREIGN OBJECT IN ANUS’ to a full waiting room, the fallout might have been rather more noticeable.

It’s not just doctors who can be so horrendously insensitive. I once heard of a young couple going to have the all-important 20-week ultrasound scan of their first pregnancy. The sonographer performing the scan apparently kept looking at the screen while ‘tut-tutting’ loudly and shaking her head. The understandably anxious parents-to-be asked what was wrong. However, the sonographer replied that she couldn’t possibly say, but that she would book them an appointment with the consultant for a few weeks’ time. The dad at this point, in his own words, ‘lost it a bit’ and demanded the sonographer tell them what she could see. Astonishingly, her response was, ‘Well, you know those funny people you sometimes see in the street? You know like those Oompa Loompa midgets in that Willy Wonka film. Well I think your baby might be one of those.’ The disgusted parents demanded to see the consultant straight away who quickly reassured them that the scan was in fact normal and also reassured them that the sonographer wouldn’t be doing any more baby scans!

Maggie III

Maggie phones me up quite often in the middle of the day when she finds herself alone and scared. I’m honoured that she confides in me, but I can’t deny that I find our conversations difficult. I can’t make everything fine with a prescription or a referral to a specialist. I spent so many years studying how to make people better that I still find it hard to accept that some patients are only going to get worse.

‘How are things?’

It always seems an awkward question to ask someone who is dying. It’s not like she’s going to say, ‘Brilliant thanks, Doc’, but I’m yet to find a more appropriate way of opening a conversation with her, so I stick with it.

‘Actually, Dr Daniels, I think I’ve found a bit of peace with it all. Don’t get me wrong; I’m not happy about dying from cancer. Far from it. If truth be told, I would love to have a few more years to wander about the place, but in the big scheme of things I can’t really complain about the life I’ve had. There have been ups and downs, but mostly ups, and I did always say that I never really planned to get old. In fact, I’d have made the most appalling cantankerous geriatric, so all in all it’s probably for the best that I won’t be around to see that through!’

‘Well, that’s one way to look at it.’

‘I’m worried about my husband Tony, though. He’s not really handling things very well. He just can’t really accept that I’m on my way out. He keeps looking up things on the internet trying to find miracle cures. Now believe me, I’d fucking love a miracle cure, but I’m no idiot. These quacks are just after our money and I know that my cancer can’t just vanish with a few vitamin pills and an Indian head massage. I just want to spend this last time I have with people I love around me. I don’t want to be chasing miracles that don’t exist.’

‘Have you told Tony how you feel?’

‘I can’t bear to crush his hope. He needs hope to deal with this. It is his focus and at the moment it’s the only thing driving him on. The latest one is this bloody ridiculous essential oils diet. I have to drink these oils he’s bought on the internet and then mix them with organic celery and carrot juice. It’s not exactly what I’d choose as my last supper, I can tell you. When he’s out I get my daughter to sneak me in some fried chicken and doughnuts!’

‘I think you need to tell Tony how you feel. You need to be really honest with him.’

‘My husband’s not one of those sorts of men, Dr Daniels. He doesn’t really like to talk about his feelings. I’m sure he’d just clam up.’

‘Funnily enough, my wife might say the same about me, Maggie, but here we are talking about some quite intimate, personal things. Sometimes you just have to try and see what happens.’

‘I’ll give it a go over the weekend and give you a ring on Monday to let you know how it goes.’

Maggie IV

‘Hello, I’m here to see Maggie.’

‘Come on in, Doctor. She’s just having a facial done, but go on through as the make-up girl is just finishing up.’

It seemed odd to think of Maggie having a facial. I always considered her a robust Yorkshire lass and had never associated her with beauty regimes. As I entered the room, Maggie was getting the last of her blusher applied. I’m no expert on such matters, but it looked a bit overdone to me. Her cheeks were excessively rosy and her lips a dazzling ruby red. The young girl applying it looked up and gave me a smile. ‘The family are coming to visit soon so we want her to look nice, don’t we?’ She added those final dabs of blusher with genuine pride, although I did rather wonder if there might be good reason why she only applied make-up to the deceased rather than to the living.

Despite the make-up girl’s best efforts, Maggie still had the yellow tinge all corpses seem to have. I’d come to complete the paperwork, and as the last doctor to see her alive I was supposed to do a final examination of her body. Maggie had been at the undertakers since Saturday afternoon and it was now Monday morning. If my examination revealed anything other than a diagnosis of death, something had gone very, very wrong.

I nodded at the undertaker to confirm that it was definitely Maggie lying on the metal trolley in front of me. I left my stethoscope in my bag, but stuck on some gloves and had a prod between her ribs on the left side of her chest to make sure she didn’t have a pacemaker fitted. I knew Maggie’s medical history well enough to know she didn’t have one, but I checked just in case. We are always told that cremating a body with a pacemaker still inside can blow up the crematorium. I imagine this is in fact a bit of an exaggeration and it’s more likely that the grieving relatives don’t really want to find the remnants of charred batteries while spreading the deceased’s ashes over her favourite rose bushes in the back garden.

I did mention to the undertaker that Maggie had had a silicone breast implant following her mastectomy some years before. There is no risk that the implants will blow up the crematorium, but they do leave a damaging sticky goo on the walls of the incinerator. Nowadays, most undertakers will remove them, which was an idea that tickled Maggie when she was alive. She told me she had suggested to her husband that he put her implant on the mantelpiece next to the urn containing her ashes, but apparently he hadn’t found it funny.

I was going to miss Maggie. She had an amazing spirit that shone through and she always made me smile however gloomy our discussions. For all the amazing medical breakthroughs of modern years, once she received her diagnosis, all we ended up offering her were steroids and morphine. Both are cheap old-fashioned drugs that we’ve been using for decades. In their defence, the morphine gave her a pain-free death and the steroids probably gave her an extra couple of weeks. Maggie had promised me that she would try to open up to her husband, talk about her feelings and say goodbye to him. In the end, her condition deteriorated very quickly and just two days after she made me that promise she was gone.

For those last few weeks I was Maggie’s confidant. I was someone outside the family to whom she could talk and on whom she could rely when she was in genuine need. It isn’t something ever taught at medical school. It can’t be measured or turned into a government target, but for those six weeks Maggie was my most important patient and although I was unable to cure her or prevent her death, nothing could make me feel more like a doctor than giving her my time.

When I’d heard the news of her death, I’d phoned her husband Tony to offer my condolences. I’d suggested that once the funeral was dealt with, he might want to pop in and have a chat. He didn’t take me up on the offer, but a couple of weeks later he did leave an envelope for me at the reception. It was a photograph of Maggie looking young and carefree. Her head was tilted back and she was laughing at something. It really did capture her spirit beautifully. On the back it just said, ‘Thank you for everything you’ve done for us, love Maggie and Tony.’

Can’t be too careful

Tracey’s entrance was never quiet. Buggy, shopping and three boisterous children piled into my room in a swirl of chaos.

‘’Allo again, Doc,’ Tracey chirped cheerily. ‘You must be sick of the sight of us, eh?’

‘Not at all,’ I fibbed back. ‘So what brings you in today?’

‘Well, it’s all of us really,’ and with that Tracey listed various transient minor ailments that seemed to be causing her and her brood great concern.

‘This one’s the worst,’ she said, pointing at her son Bradley who was jumping most energetically off my couch. ‘He’s really poorly. Not himself at all. He’s right off colour, he is. We was up the ’ospital all Saturday with him. ’Ad to call an ambulance and everything, but after nearly four hours waiting around in A&E they just said he had a virus and sent us home with paracetamol.’

Tracey spends a lot of time requesting medical attention. It seems that however many times either I or the other doctors offer reassurance, she needs more and will seek out medical help at the drop of a hat. I don’t begrudge Tracey her frequent attendances. Well, if I’m honest, at the time I often do, but in the cold light of day I can accept that she is trying to be the best mum she can be. She worries about her children like all parents do, and she doesn’t have the means to alleviate this anxiety without a trip to the doctor. For the last few years, I haven’t really paid much heed to Tracey’s frequent visits, but her name had now cropped up on our list of patients who attend A&E too frequently.

As we all know, the NHS has no spare money and one of the directives for saving funds is to persuade our patients to stop going to the hospital so often. For each attendance at the emergency department around £70 is charged to the NHS, and that cost doesn’t change much whether the treatment is simply some gentle reassurance, as in the case of Tracey, or if 10 doctors wrestle to save your life after getting knocked down by a bus. Our GP surgery gets paid £65 a year to look after Tracey however many times she comes in. The simple logic is, therefore, that for minor ailments it is much cheaper for Tracey to see us at the GP surgery than for her to go to A&E. It also frees up time for the emergency doctors to see patients needing genuine emergency care! That is why my bosses were telling me to make an ‘action plan’ with Tracey in an attempt to prevent her from visiting the hospital so often.