Confessions of a GP

I did finally manage to examine Olga’s bottom, only to find nothing unusual at all. In theory I should have done a rectal examination as well, but poor Olga had faced enough already and inserting my finger up her back passage without her really being able to understand my explanation of what I was doing seemed a bit unfair, bordering on abuse. I managed to book her in for an appointment another time with an interpreter present but she didn’t turn up, possibly having somewhat lost faith in me.

I recall another difficult rectal examination back when I was an A&E doctor. An elderly lady called Ethel had been brought in by her husband, Lionel, because of her having some tummy pains and bleeding from her anus. Ethel herself was quite demented and also very deaf. Lionel was a retired vicar and now caring for Ethel full time at home.

After taking a history from Lionel and feeling Ethel’s tummy, I needed to do a rectal examination. It was important to make sure that there wasn’t a blockage in the rectum causing her symptoms. ‘I'm going to need to examine your rectum, Ethel.’ ‘You what, love? I can't hear you.’ ‘I need to put a digit up your back passage, Ethel,’ I say again a bit louder and into her good ear. ‘What’s he saying, eh?’ ‘I’M GOING TO HAVE TO PUT A FINGER UP YOUR BOTTOM.’ This time I was shouting at the top of my lungs. It was only a set of curtains that separated us from the rest of the A&E department and, as you can imagine, curtains aren’t particularly soundproof. The entirety of the A&E department was now aware of Ethel’s impending rectal examination but, unfortunately, Ethel wasn’t. Her confusion was such that she couldn’t really comprehend what I was doing or why. Despite my best efforts to put her at ease, she was getting increasingly agitated. I put on a pair of gloves, moved her into as comfortable a position as possible and gently eased my right index finger into her anus. Suddenly, there was an almighty shriek. ‘Oooh, Lionel. Stop it, Lionel. You know I don’t like it that way. If you’ve got to put it in, at least put it in around the front.’ Poor Lionel was standing outside the cubicle in full view of all the patients and staff who were trying to hold back their giggles. He looked very embarrassed as he made his way back into the cubicle.

Julia

Julia was young, attractive and articulate.

‘I need you to section my boyfriend Andy. He’s completely mad and unreasonable and yesterday he smashed up my moped for no reason.’

I wasn’t expecting that one.

‘Your boyfriend doesn’t sound very nice but we aren’t going to be able to section him.’

‘But he’s mad! It wasn’t just any moped. It was my twenty-first birthday present. I drove it everywhere. It was my most precious possession! He knew that!’

I was tempted to explain that there wasn’t a special subclause in the Mental Health Act that allowed us to section people if the moped they smashed up was a very special birthday present. I held back and instead explained how a person would need to have a mental disorder and pose a risk of harming themselves or others before they could be sectioned.

‘He is a risk to me. He beats me up!’ Julia then proceeded to lift her shirt to reveal an impressive array of bruises on her torso.

‘Why don’t you leave him? There is a local domestic violence support group. Perhaps I could –’

Julia interrupted me. ‘He needs me. He says he would kill himself if I left him and I couldn’t have that on my conscience for the rest of my life. He needs help and all you’re telling me to do is leave him. He was abused as a child and so was his mum. His whole family is fucked up. I’m all he’s got.’

I wasn’t sure where to go from here. From the outside it seemed so straightforward. Leave, run away, start again. Julia had a lot going for her. She could have a whole new life. It clearly isn’t this straightforward as there are thousands of women like Julia who don’t leave or run away or start again. I would never really understand the complexities of Julia’s violent relationship but one thing was very clear. When she said that Andy had nobody else, what she was really saying was that she didn’t have anyone else. She was alone and, however difficult and abusive her relationship was, she clearly felt that it was all she had.

I was feeling guilty now. Initially, I hadn’t really been taking Julia seriously. I had thought that she wanted her boyfriend sectioned because they had had a tiff. It was now clear that things were more complex. Deep down Julia knew that I wasn’t going to section Andy but she was crying out for help and somehow it was me who was expected to provide this help. At medical school I had learnt about the role of mitochondrial antibodies in primary biliary cirrhosis and the parasympathetic nerve distribution to the salivary glands. It wasn’t the greatest preparation for dealing with a vulnerable desperate woman who got beaten up every day by the man who supposedly loved her. Regardless of my lack of training, at that moment I was all she had and I had to do my best.

‘If you leave him and he harms himself, that’s not your fault.’

‘Is that the best you can do? He needs help.’

Andy was a patient at another practice and I had never met him. I couldn’t really speculate what he needed but psychotherapy is usually our get-out clause when faced with a difficult psychological issue that is complex and not fixed with a tablet.

‘Maybe psychotherapy would help Andy?’

Julia looked hopeful until I explained that there was a two-year wait for psychotherapy in this town.

‘That’s really useful, thanks a lot.’

‘You have to leave him,’ I said again. I tried to say it with compassion but I really did feel it was her only option. Julia got up, left and slammed the door. I clearly hadn’t handled that very well. I had failed again. Would another doctor have handled that better? What would a counsellor have said, or a priest or even bloody Jeremy Kyle? I was not sure if Julia would come back to see me. If she did, maybe next time I’d just listen.

Good doctors

What makes a good doctor? I seem to remember being asked something like this during my medical school interview. The interview panel yawned through my contrived answer that mentioned some naïve nonsense about being caring and good at working in a team. As part of our target-based existence, the patient plays a large role in deciding if we are good doctors or not. The Labour government introduced patient satisfaction questionnaires as part of our performance targets.

During my training year I saw a middle-aged woman with stomach pains. I was very concerned and referred her urgently to the hospital because I thought she might have stomach cancer. She was seen and investigated within a week and turned out to simply have bad indigestion. When the snotty letter came back from the consultant, I was feeling a little red in the face. I had made an inappropriate expensive referral to the hospital and had caused unnecessary anxiety to the patient. I could just imagine the consultant grumbling into his endoscope as he cursed me for adding to his already busy day.

The patient and her husband, however, thought the sun shone out of my arse. ‘That wonderful Dr Daniels arranged for me to be seen so quickly.’ She bought me a very nice bottle of single malt to say thank you and told anyone who’d listen how fantastic I was. My poor medical judgement earned me a rather nice bottle of whisky and if my patient got to fill in one of the patient satisfaction questionnaires, I’d have been reported as the best doctor in the world.

Most medical practitioners have an idea whether they’re being good or bad doctors. On a Friday afternoon when I’m drained and tired, I know that I’m not giving my all. I try my best to remain professional but have to admit that I find it that bit harder to resist inappropriate requests for hospital referrals, sick notes and antibiotics. As GPs, we are supposed to be the ‘gatekeepers of the NHS’ but sometimes it can feel much easier to leave the gate permanently ajar rather than carefully defend the NHS hospital waiting lists by fending off the worried well. I’m very popular with my patients on a Friday afternoon because they are getting what they want, but I’m not always practising good medicine. Making the patient happy isn’t always the same as being a good doctor.

When I started as a GP I was told that it was easy to be a bad GP but hard to be a good one. A good doctor won’t prescribe antibiotics for a cold and won’t refer every patient with a headache for an expensive MRI scan. A good doctor should also be able to explain to the patient why he’s not agreeing to their demands, but sometimes, however hard you try, the patient leaves feeling dissatisfied and the doctor goes home feeling distinctly unpopular. It is a difficult balance to run on time but give each patient adequate individual attention, to allow patient choice but not give in to inappropriate demands, to keep referral rates low but make sure the patients get the expert input they need. I’m still not sure exactly what a good doctor is, but it is certainly more complex than earning a few smiley faces on a government questionnaire.

Connor

‘It’s my kids, Doctor. They’re little fuckers. I can’t control ’em no more. Something’s gotta be done about it. My youngest, Connor, was brought home by the police the other day.’

‘How old is Connor?’

‘He’s three.’

I rack my brains trying to think what a three-year-old could possibly do to get himself in trouble with the police.

‘They caught him putting rubbish through the neighbours’ letter boxes.’

‘Was he out on his own?’ I ask incredulously.

‘Oh no, Doctor, Bradley and Kylie was with him, but they was the ones telling him to do it.’

I skim through the notes to see that older siblings Bradley and Kylie are six and seven, respectively.

Mum Kerry is actually very likeable. She is a stereotypical council estate mum. Only 25, but already has three kids with three different men who are all now nowhere to be seen. Life is hard for her and she has very little support. She genuinely wants the best for her kids and really wants help.

Unfortunately for her, the entirety of my knowledge on child behaviour comes from having watched a couple of episodes of Supernanny on TV. I’ve never been the sternest of people and given the way my cat walks all over me, I’m probably not the best person to ask about discipline.

‘I think he’s got that DDHD condition. You know, where they’re little shits but it’s ’cause there’s something wrong with the chemicals in their brain and that.’

I’ve met lots of parents whose children have had a diagnosis of attention deficit hyperactivity disorder (ADHD). The parents love the label because it now excuses the bad behaviour. The kids run riot round my consulting room, rifling through my sharps bin and using my ophthalmoscope as a hammer. Mum and Dad do nothing to stop them and then say, ‘Sorry about the kids, Doc. It’s the ADHD – nothing we can do … brain chemicals and that.’

I don’t disbelieve that ADHD exists but perhaps it has been overdiagnosed in recent years. The main symptoms are lack of concentration, being easily distracted and not being good at listening. I could probably persuade myself that Connor has these symptoms, but I’m not sure that they are related to brain chemicals. I guess some children are more prone to developing these symptoms than others, but in most cases isn’t parenting more likely to be the most significant factor rather than a brain disease?

I’m not going to send Kerry’s kids to the child psychiatrist. The wait is long and I don’t want these children labelled as psychiatrically unwell. I’ve heard there is a specialist social worker locally who gives individual and group parenting skills classes. Kerry is perfect for her.

Kerry comes back a couple of weeks later to let me know how it went.

‘I really like my parenting support worker. She told me I mustn’t call ’em little fuckers no more but instead they are good children with some c.h.a.l.l.e.n.g.i.n.g behaviour.’

She goes on to tell me about how she is now rewarding good behaviour, setting consistent boundaries and using the naughty corner. Hold on a minute, I could have told her that. This parenting adviser must have watched the same episode of Supernanny that I saw.

Janine

Janine is nine years old and about 13 stone. She waddles into my room and then Mum waddles in after her. My room feels very small.

‘It’s her ankles, Doctor. They hurt when she runs at school. She needs a note to say that she can sit out games.’

‘Did you fall over or twist your ankle, Janine?’ I always try to engage with the child themselves if possible. Janine looks at the floor and then shakes her head. ‘How long have they been sore?’ Eyes still to the floor, this time I get a shrug.

‘Right, let’s have a look at these ankles then.’ I try to be engaging and smiley, stay positive and encouraging. I prod and poke her ankles and get her to move them around a bit. My examination is a bit of a show most of the time and today is no exception. One look at Janine walking into my room showed me that her ankles were basically normal. I try to make my prodding and poking look like it has purpose, but it is purely a performance for the benefit of Janine and her mum. I want them to think that I am taking them seriously, that I am genuinely looking for some ‘underlying ankle pathology’. As I prod away, I try to remember the names of some of the ankle ligaments … no joy there. Perhaps I’ll just try to remember which is the tibia and which is the fibula … no, just confusing myself now.

‘Right … Well, I can’t find any swelling or tenderness in those ankles … and she’s walking okay …’ This is the make or break moment … How am I going to put this tactfully? I am standing at the top of the diving board but do I have the bottle to make that jump? I could just write the note, prescribe some paracetamol syrup and climb quietly down the ladder. No, Daniels, come on, it’s your duty to say something. Right. Here goes. ‘Some children find that … erm err … that being a bit … erm …’ (Say it, Daniels, just say it)‘… erm overweight can make their joints hurt sometimes.’ I had done it. I had jumped!

Janine’s mum looks me straight in the eye. Her face looks like a pitbull slowly chewing a wasp. ‘It’s got nothing to do with her weight,’ she says angrily. ‘Janine’s cousin is as skinny as a rake and she has problems with her ankles, too. It’s hereditary.’

What can I say to that? My courageous leap got me nowhere. I belly-flopped painfully. Can I prove that Janine’s ankles hurt because she is fat? No. Is Janine’s mum going to accept that weight is an issue? No. I either argue on fruitlessly or accept that I am beaten and salvage the few scraps of the patient–doctor relationship that are still intact.

‘She can still do swimming!’ I shout as they waddle away, sick note and paracetamol prescription already tucked snugly into Mum’s handbag. It is a final attempt to redeem myself, but a poor one. I can picture Janine sitting in the changing rooms munching on some crisps while the rest of her class runs around outside. Beneath the many layers of abdominal fat, her pancreas would be slowly preparing itself for a lifetime of insulin resistance and the debilitating symptoms of diabetes that occur as a result. Meanwhile, her joints, straining under her weight, would be struggling to cope and the resulting damage would eventually develop into early onset arthritis.

Did I miss my chance to make a difference? Have I been a shit GP again? Are doctors slightly egotistical even to consider that a few well-placed words of advice from us can breach deeply entrenched lifestyle and dietary habits? ‘Hold on, kids, no more sugary drinks and turkey twizzlers for us. Dr Daniels thinks we are overweight and thank goodness he pointed it out or we would never have noticed. He’s given me a wonderful recipe for an organic celery and sunflower seed bake and we’re swimming the Channel at the weekend.’

Saving lives

A few years back I spent a stint working in a hospital in Mozambique. Each morning the American consultant would start the ward round with a prayer and then shout boldly and, with not the slightest hint of irony, ‘Come on team, let’s go save some lives!’ The rest of us would then cringe internally, roll our eyes at each other and then follow him round the morning’s array of sick and dying Africans. There are a surprising number of Western doctors filing around the wards of African hospitals. I’m not always sure of the motives but there we were: an American cardiologist, two British GPs and a French nurse. Between us, we had years of expensive medical training and lots of letters after our names. As we wandered through the wards, we didn’t really save many lives. The majority of our patients were dying of AIDS-related illnesses or malaria. There were no anti-AIDS drugs (antiretrovirals, ARVs) and even our malaria medication supply was low because of a robbery at the hospital pharmacy (an inside job).

Meanwhile, 30 miles outside of town, Rachel, a 22-year-old from Glasgow with no letters after her name, really was saving lives. Rachel had dropped out of her sociology degree and had been working in a call centre before deciding to come and do some voluntary work in Mozambique. She had raised some sponsorship from back home and was touring the rural villages with a troop of local women. All she had at her disposal was a basketful of free condoms and a few hundred subsidised mosquito nets. Accompanied by information and education in the form of songs and posters, her campaign was a raging success. She later e-mailed me to say that malaria deaths had reduced and that she was hoping to have an equally good result with HIV transmission rates.

At the same time, my learned colleagues and I made clever diagnoses on the ward and skilfully inserted chest drains and spinal needles. Occasionally, we did save a life and it was quite exciting when a patient got up and went home after being at death’s door. As we waved them off, we knew that ultimately they would be back. They couldn’t afford to pay for the full course of medication, and it was only a matter of time before they were unwell again and back in our hospital. We were briefly prolonging lives rather than saving them.

Regardless of the country it is practised in, most of hospital medicine is painting over the cracks rather than fixing the wall. Lives are saved by preventing illness rather than curing it. If you are 64 and admitted to hospital in the UK with a heart attack, it will be all blue lights and running around. After emergency heart scans, a dashing young doctor will probably give you a whack of clot-busting medicine into your veins and it could save your life. At age 16, this was just the kind of exciting medicine that I imagined my job would be. I have been that doctor and at times it is genuinely quite glamorous and exhilarating. Sometimes, it does make a real difference and lives are saved. The patient and family will thank you and you’ll feel pretty good for a bit.

Since I have been a GP, on balance I have probably saved far more lives than I did during my time as a hospital doctor. It is my job to try to prevent you from having a heart attack rather than save your life immediately after you’ve had one. It is far less glitzy and dramatic, but by helping patients control their blood pressure, give up smoking and reduce their cholesterol, I have probably helped prevent or at least delay many hundreds of heart attacks. This might sound like a pathetic attempt to try to elevate GPs and combat an inferiority complex put upon us by years of derogatory comments from our hospital colleagues, but I genuinely think it is true. In the same light, the pressure groups who pushed for the government bill for the smoking ban in public places or who pressed for the introduction of the compulsory wearing of seat belts will have saved more lives than all of us put together.

Public health doctors are those who rather than treating individual patients, look at the bigger picture of health trends across the country and the potential interventions that could help. The rest of the medical profession sneer at public health doctors even more than they do at GPs, but the conclusions of public health doctors influence big decisions made in Parliament and can save and improve many lives. The problem faced by public health campaigns in the UK is the tendency for people to react to being told what to do. In Mozambique, Rachel wasn’t faced with angry villagers demanding the ‘choice’ not to be given free condoms or complaining about the ‘nanny state’ forcing them to sleep under mosquito nets. Getting the balance in the UK is difficult. The opposition to wearing seat belts 30 years ago and the smoking ban more recently was huge. Our role as GPs is trying to tread the fine balance between giving useful advice and encouragement to make good lifestyle choices whilst not being too paternalistic and patronising.

Kirsty, the trannie

Kirsty had once been a married man with three children, but over the last five years she had spent many thousands of pounds having surgery to become a woman. She had her chin made less square, breast implants and, most importantly, her male organs surgically transformed into female organs. (In post-op trannie circles this is known as having your ‘chin, tits and bits’ done.) As well as the surgery, there was the electrolysis and oestrogen tablets, not to mention the huge amounts of money spent on boutique clothes, expensive make-up and a Gucci handbag that my wife would die for. The only problem was that Kirsty still looked overwhelmingly like a man. She was six foot two and had broad shoulders and stocky legs. Her 1980s perm and size-eleven feet squeezed into a pair of size-nine stilettos didn’t help. Kirsty looked like a rugby bloke who had been badly dressed up as a woman by his mates on a stag do.

‘How do I look, Dr Daniels?’ Kirsty asked as she flicked her hair and fluttered her fake eyelashes in the worst attempt to be flirty that I’ve ever seen. ‘I’ve had my boobs redone again. Do you want to have a look?’

‘No, no, that’s erm fine … I’m erm sure that they did a good job.’ Kirsty is such a regular at the surgery that she no longer feels the need to have a medical problem to present. She is quite happy to pitch up for a chat and a gossip. She always has a story to tell and is a nice break from the dreariness of afternoon surgery.

For those of you who are interested, the operation is called ‘male to female gender reassignment surgery’. There are various techniques but the most popular appears to be cutting off the testicles and inverting the penis. The penile and scrotal skin are combined and used to line the wall of the new vagina and to make the labia. The surgeon makes a clitoris using the part of the penis with the nerve and blood supply still intact. According to the surgeon’s website, this enables some patients to orgasm. I haven’t yet asked Kirsty about this but I’m sure she would happily tell me all about it given half a chance.

Despite the extrovert exterior, there was a real sadness about Kirsty. The sacrifices that she had made to change her gender were extraordinary. She gave up her marriage and children (only one of whom still talks to her). She lost her job and many of her friends and the pain she describes of the surgery and recovery period is unimaginable. Kirsty now lives slightly on the fringes of society. She is stared at in the street and struggles to find acceptance at every corner. It seems amazing to me that she would have put herself through this much to make the change.

Kirsty, however, has absolutely no regrets. She told me that five years earlier she felt that her only choices were to have the operation or commit suicide. In the nicest possible way, Kirsty is a bit of a drama queen but I genuinely think she means this and the doctors at the practice who knew her as a man agree that she was pretty close to ending her life back then.