Confessions of a GP (23 page)

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 these 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.

In most areas of our society, class is still extremely divisive. Our social class decides where we live, socialise, go on holiday and even where we buy our groceries. In many countries, private medicine ensures that class remains a divisive measure when it comes to the accessibility of healthcare. The NHS, however, means that the GP surgery is a bit of a melting pot for everyone. My waiting room can contain the posh ladies who lunch, sitting next to the homeless drug addicts who do crack. In theory, they should all get ten minutes of my time and have equal access to the NHS services available, but, of course, the reality is very different. Obviously, having private healthcare helps to oil the path to seeing the best doctors quickly, but even without paying, middle-class educated patients get a better deal. They ask more questions, are more demanding and are better able to access services available on the NHS. This has to go down as a failing on our part as doctors because we should be empowering our less-demanding and less-privileged patients with the information they need to get the best care available.

There are some wonderful GP surgeries in very poor parts of the country and they do a fantastic job; however, some of the surgeries in poorer areas are run down and unloved, with unmotivated and unhappy staff. The surgery on a council estate I know of is an example of this. It is very busy because there are a lot of social problems on the estate and, as I’ve mentioned, social deprivation breeds medical problems. The staff have been threatened and the surgery keeps getting broken into, which doesn’t help morale. Also there is the issue of money. I’ve talked previously about how GPs make money by hitting targets. This is a generalisation, but middle-class patients tend to be more active in managing and maintaining their own health than more socially deprived patients. This means that they are more compliant with medication and keeping appointments. Motivated healthy patients make it much easier for the GP to hit targets and, hence, earn money. The patients on council estates often have quite difficult, chaotic lives. If they miss their asthma review appointments or don’t take their blood pressure medication, then this directly influences how much the doctors earn.

The reduced earnings of the council estate practice and low morale mean that it can’t attract enthusiastic, dedicated new doctors. There is no shortage of GPs locally but the surgery on the council estate is currently being run by a series of locums. This is because one of the permanent doctors is on long-term sick leave with stress-related problems and, despite advertising, they can’t find a GP to fill the other vacant post. The locum doctors never get to know the patients and as a result are generally fairly apathetic and disinterested. It is the patients who lose out. Middleclass patients would often demand improvements or move to a new surgery, but the patients on the estate often don’t have the means to do this so put up with a poor service. It is yet another example of a two-tier health service. Nye Bevin must be turning in his grave.

Tingling ear syndrome

‘I’m sorry, Paula, but I have absolutely no idea why your right ear has been tingling a bit since this morning. I don’t think it is anything to worry about and it will probably go away on its own. Come back if it doesn’t.’

I spend quite a lot of my time telling my patients that I don’t really know what is wrong with them. This sometimes disappoints them terribly or at least makes them think that I’m a rubbish doctor, but the reality is that I see hundreds of patients with the odd ache or pain or tingle or discomfort and often I don’t really know what is causing it. This isn’t because I’m a rubbish doctor, it is just because we all get the odd funny ache or pain now and again and eventually it almost always goes away on its own. One of my colleagues tells his elderly patients that if they wake up one morning without any aches and pains, they have almost certainly died in the night! When I am faced with my patients’ mysterious aches and pains, I am often tempted to make something up and prescribe a placebo, but gone are the days where we could completely bullshit our patients and get away with it.

My brother is not medical and went to the doctor recently because one part of his arm was a bit red. His GP stroked his chin and then wisely stated that he thought my brother had a mild case of erythema. My brother was initially very impressed with this diagnosis. He didn’t know what the word meant but it sounded like a convincingly rare skin disease. He then went home and ‘Googled’ erythema only to find out that it means red skin. My brother had told his doctor that he had ‘an area of red skin’ and the doctor then cleverly diagnosed him with having ‘an area of red skin’. Using a Latin word to make ourselves sound intelligent does work briefly, but the internet now means that our jargon can be rapidly exposed as the bullshit it really is.

Most aches and pains that I see get better on their own with a bit of time. Coming to see me tends not to make a great deal of difference to this. You might think I’m talking myself out of a job but I’m not. If a 20-year-old woman has a bit of a tingly ear from time to time, then I’ll probably not know a cause or find a cure. However, a 60-year-old smoker with a tingly left arm might think his discomfort was equally trivial, but actually be having symptoms of a heart attack. This is where I come in. My job is to reassure the young person with a bit of a tingly ear but send the man with a tingly arm to hospital, as his heart might be about to stop.

If my healthy 20-year-old patient took her tingly ear and saw 100 doctors, healers or alternative therapists around the world, they would probably each come up with a different diagnosis. This is not because they are cleverer than me and know the real cause, but simply because they are being paid to give a diagnosis. If they can come up with a believable diagnosis, then they can sell a treatment. Telling someone that you don’t know what is wrong with them and that they’ll get better on their own is not a good way of making money if you work in a private health service. Fortunately for us, we have the NHS. GPs make money by jumping through hoops and reaching government targets, but not by making up diagnoses and then flogging you placebos.

Gary

I always found Gary to be slightly overbearing. He was a salesman of some sort and always shook my hand very firmly and maintained eye contact for a little too long. I was scared that one of these days he was going to talk me into buying a photocopier. This day he was a little more bashful.

‘I need your help, Dr Daniels. I had a little mishap at the Christmas party with one of the girls in the office. It was just a bit of drunken fun, but she’s just told me that she’s got chlamydia. I’ll be honest with you, Doctor, I’m fucking terrified. If my wife finds out, she’ll leave me. I’m already on my last chance. We’ve got two kids.’

‘Well, the best people to deal with this sort of thing are the doctors in the sexual health clinic. I could give you their telephone number.’

‘I’m not going to the clap clinic, Doctor. If somebody sees me there, I’m a dead man. I’ve had a look on the internet and I just need some of this antibiotic called azithromycin. One tablet does the job and we can just sort this out here and now.’

‘Well, it’s not ideal. Really, it would be better to test you. Have you had any symptoms? Burning when you pee? Milky discharge from your penis?’

‘I’ve had nothing like that but I’m not taking any chances and I’m not having you stick a swab down my little guy. I just need a prescription for the one-off antibiotic…and one for my wife.’

‘Have you told her?’

‘God, no! She’d leave me. Now this azithromycin stuff, would it dissolve in her tea? I was thinking about crumbling the tablet into a pasta sauce but was worried that the cooking process might damage it.’

‘Look, I can’t encourage you to be secretly drugging your wife with antibiotics. What if she has an allergic reaction? It’s my name on the prescription. I would have to take responsibility.’

‘Doctor, please work with me here. Man to man. My marriage is on the line. Why don’t you prescribe me a double dose and what I do with the pills is my responsibility. I don’t mind paying for them.’

‘Look, I feel really uncomfortable about this. I appreciate your predicament but I’m not prepared to prescribe you this medication knowing that you’re going to give some secretly to your wife.’

‘Do you really want to be responsible for the break-up of a family, Dr Daniels?’

‘To be fair, it wasn’t me who cheated on my wife.’

‘You’re not paid to judge me, Doctor. Look, I’ve an idea. Why don’t you call my wife in for a smear and while your down there, you can do a quick swab for chlamydia.’

‘Look, we can’t just test people and give them medicines without them knowing. We need to have consent.’

‘There must be something you can do. If you don’t prescribe me these antibiotics, I’ll get them off the internet and that’s even more dodgy. God knows what I could be poisoning her with.’

‘I’ve got an idea. Why don’t you get yourself tested? It’s only a urine test and then if you’re negative, you don’t have to worry.’

‘And if I’m positive?’

‘We’ll cross that bridge when we get to it.’

Thankfully, Gary tested negative and I never had to worry about a second attempt by him trying to talk me into secretly drugging his wife.

Beach medicine

Last year I was lucky enough to have been lying on a white sandy beach with calm, crystal clear, blue waters lapping on the shore. It was a picture of idyllic tranquillity until a woman dropped down dead a few yards away. Had it been an episode of
Baywatch
, I would have run over heroically and, with sweat glistening on my tanned bulging biceps, I would have brought her back to life with a few seconds of mouth to mouth. The rescued lady would have been 22 years old with large false breasts and gleaming white teeth. After spitting out a couple of gulps of sea water, she would have gazed into my eyes with her make-up still perfect and declared her undying love for me.

Unfortunately, this wasn’t an episode of
Baywatch
. The woman was a German tourist in her late seventies and was dead as dead could be. I did run over and try resuscitation and my wife bravely started mouth to mouth, which was impressive given that the German woman had vomited before collapsing. A crowd of onlookers developed and an ambulance was apparently on its way, but after 15 minutes of CPR, it became clear that this lady wasn’t coming back. The problem we had now was what to do? The ambulance was coming from the other side of the island and could be another hour. The sun wasn’t reflecting off my tanned rippling biceps because I don’t actually have any. Instead, it was beating down on my pasty white back and I could feel that I was beginning to burn.

I really wanted to call it a day. Not just because I was getting sunburnt but because this woman was dead. In a hospital I would have ‘called it’. This is where the team running the resuscitation makes a decision to stop. I am quite happy to make this decision in a hospital because I am surrounded by lots of other doctors and nurses and a hospital full of equipment. On this beach I had none of that. I didn’t have a heart monitor to tell me if there was any electrical activity coming from the heart. I didn’t have a blood glucose machine to tell me that she wasn’t a diabetic with a very low blood sugar and I didn’t have a team of other doctors to agree that it was the right decision. I did, however, have my common sense. It would take at least another 45 minutes for the ambulance to reach us and then another hour on bumpy roads to get her to a small, poorly equipped hospital with no intensive care department. The husband had told me that she had survived a heart attack earlier in the year and so it didn’t take a diagnostic genius to work out that she had probably just had a second one after returning from an overenergetic swim.

I decided not to go with my common sense and instead we carried on with the chest compressions and mouth to mouth. This was not because I thought that there was any chance of this woman surviving, but because her distraught-looking husband needed to feel that absolutely everything that could be done was being done. The other concern was a legal one. Once you start a treatment, it can be a thorny matter about deciding to stop. I wasn’t in the UK and from a litigious viewpoint, it was a much safer decision to carry on with the pointless CPR. I had a big crowd of onlookers now and they were every bit an audience as our performance was purely for show. The ambulancemen did eventually arrive but, to be honest, they were fairly useless. They didn’t have much equipment and they couldn’t intubate (put a tube into the lungs to help breathing). They didn’t even have a defibrillator (machine to give the heart an electric shock). Instead, they scooped her up on a stretcher, plodded along the beach to the ambulance and drove her to the hospital, continuing to resuscitate in much the same ineffectual way as me.