Confessions of a British Doctor

Tara

‘Doctor, you fucked up my medication again. That antidepressant you gave me was fucking useless and I need another sick note.’

Tara is taxing; we call them ‘heart-sink’ patients. When she walks into my consulting room my heart sinks to the floor and I often find myself hoping that it will stop altogether.

I try to view Tara with compassion. She is a vulnerable adult who grew up in an abusive, socially deprived family and she needs support and patience. The problem is that when running late on a Friday afternoon, my empathy is often overtaken by frustration and annoyance. I’m ashamed to admit it but rather than offer the time, patience and support Tara requires, I often find myself wishing I was somewhere else.

I sort out Tara’s medication and then ponder what to write on the sick note. Tara is 25 and has never worked. She doesn’t have a physical disability or a neat diagnosis to put on the dotted line. She isn’t depressed or psychotic, although she has seen a multitude of psychiatrists, psychologists and counsellors. The only firm diagnosis Tara has ever been given is ‘borderline personality disorder’.

I find the concept of personality disorders difficult, but my limited understanding is that someone with this diagnosis has a personality that doesn’t really fit in with the rest of society and they struggle to cope with all aspects of modern life. Most would agree that our personalities arise from a combination of nature and nurture, but in the case of Tara, growing up with an extreme lack of anything that could be called nurture is the principal problem. People with borderline personality disorders tend to act like stroppy teenagers. They often only see things in black and white and fly off the handle easily. They don’t have a particularly good idea of who they are and always seem to fall into stormy, damaging relationships. They have low self-esteem and often self-harm as a way of expressing their frustrations with life.

Stroppy teenagers grow up, but people with borderline personality disorders don’t. They struggle to cope with the adult world and require a huge amount of support and understanding from those around them. Despite being able to rationalise all this, I still find my consultations with Tara madly frustrating and I would love to prescribe her a twice daily kick up the arse. I am not proud that I feel like that about my most regular patient but I know that she also brings out similar feelings in the other doctors at the practice. Some smart-arse psychoanalyst would tell me that my ambivalence towards Tara is a reflection of my own feelings of failure in my inability to help her. I’m sure that is true but I can’t help but wish she didn’t come and see me quite so often.

I do occasionally have a ‘Conservative moment’ and feel righteous about why a physically fit 25-year-old has never worked and probably never will, but you only have to spend a few minutes with Tara to realise that her chaotic existence just wouldn’t cope with work. When she doesn’t like something, she either cuts herself or flies into a rage. She is a mess emotionally and no employer in their right mind would want her working for them. She has had input from all sorts of well-meaning and well-funded services over the years, but seeing a supportive social worker, health visitor, GP or psychiatrist for 15 minutes a week hasn’t managed to counteract the harm caused by 25 years of growing up in an abusive and damaging family.

Sometimes I worry that doctors write off patients with personality disorders too quickly. Some people go so far as to claim that it is a ‘made-up’ diagnosis that doctors put upon patients with mental health issues that are challenging and don’t fit tidily into any other diagnosis. There is no pill that cures a personality disorder so we label the person as a lost cause and withdraw all help and support. This seems a shame given that many of the chronic diseases we do treat can’t be cured. We don’t give up on our patients with diabetes because they can’t be cured. Instead, we do our best to control their symptoms as best we can and try to work with them to give them the best possible quality of life.

After a bit of reflection, I promise myself that I’ll be a bit nicer to Tara next time she visits. I’ll try to listen harder and be more supportive. I’ll give her more of my time and won’t rush her out the door. Maybe she’ll open up a little more to me? Maybe she won’t even notice? At least I will feel like a slightly nicer doctor for a few minutes.

Sex in the doctors clinic

According to a study in France, 1 in 10 male GPs questioned have had a relationship with a patient and 1 in 12 admitted to having actively tried to seduce a patient. One French doctor reportedly stated, ‘It is obvious that some patients like us and we are not made of wood.’ I have to say, I was quite surprised by the results of this study. When compared to the general population, I would say that my doctor friends are probably on the lower end of the scale when it comes to morals and good behaviour. Despite this, I can honestly say that I don’t think that any have had a relationship with a patient or even considered it. As medical students and junior doctors, we got up to all sorts of debauchery both sexual and otherwise, but somehow having sex with a patient never really figured. It is perhaps one of the few taboo subjects that remain among us. We will happily sit round in the pub competing to see who had made the worst medical error as a junior doctor, or recalling past drunken sexual adventures with the unfortunate student nurses who had fallen foul of our charms, but even admitting to finding a patient attractive just doesn’t happen.

When I started my medical career, my non-medical friends seemed to imagine that I would have all sorts of saucy moments with beautiful female patients. They were disappointed when I explained that as a hospital doctor, I rarely had a patient under 65. My days were spent looking at fungating leg ulcers and sputum samples, rather than pulling splinters out of the behinds of beautiful young women.

Since moving to general practice, I do have young female patients. There is also more of an intimacy that develops between doctor and patient. It is less about the proximity of the physical examination, but more about the openness and intimacy of the consultation. The patient is able to disclose their deepest, darkest feelings and fears, often revealing secrets that they wouldn’t divulge to their closest friends or family. It is part of the privilege of being a doctor and it is our job to listen and be supportive. Often the GP might be the only person in an individual’s life who does listen to them without judgement or criticism and it is this that can make us the object of attraction.

In my career as a doctor, I can think of three female patients who have made a pass at me. One was a lonely single mum, one was a lonely teenager and the third was a lonely foreign-exchange student. They all visited me regularly and offloaded their fears and worries. I sat and listened when no one else would; I nodded and made supportive noises; I was encouraging and made positive suggestions as I handed them tissues to mop up their tears. Vulnerable people can mistake this for affection. It is easy for a lonely person to forget that I’m being paid to listen to them. These three women fell for me because, unlike in a real relationship, the baggage was offloaded in one direction only. I didn’t get to talk about my regrets and fears. I wasn’t allowed to display my needy and vulnerable side. If my love-struck patients had to hear all my shit, I’m sure my desirability would have quickly dissipated.

I do care about my patients and I try my hardest to empathise, but ultimately my patients are not my friends or family members and once they leave my room, I move on to the next patient and problem. This may seem cold and callous, but if doctors got emotionally involved with all our patients and their unhappiness, our work would consume us and send us spiralling into depression ourselves. This does happen to some doctors. We call it ‘burn out’ and it doesn’t benefit doctor or patient.

The Hippocratic Oath states: In every house where I come, I will enter only for the good of my patients, keeping myself far from all intentional ill-doing and all seduction and especially from the pleasures of love with women or with men.

Many people, including at least 1 in 10 French doctors, probably feel that this is out of date and that consenting sex between two adults shouldn’t be frowned upon just because one happens to be the other’s doctor. I have to say that I agree with the Greek guy in this case. He clearly recognised the uniqueness of the doctor–patient bond and the vulnerability of the patient in this relationship. A sexual liaison that forms in this environment can never be equal, as the doctor will always hold a position of power and trust. In general, the medical profession’s governing body agrees with this and in the UK, quite rightly, doctors are still in a whole heap of the brown stuff if they have a relationship with a patient.

The elderly

My first patient of the morning is Mr A. He is 35 and has a sore ear. He only comes to the doctor about twice a year. I look inside and it is blocked with wax. During his ten-minute appointment I have explained the diagnosis, had a bit of a chat and sent him on his way with some ear drops. The medication is cheap, he gets better and I feel happy as a doctor that I have cured my patient. I am also running on time and know that I will get to the coffee before all the nice biscuits have been eaten by the receptionists.

My second patient of the morning is Mrs B. She is 87 and has come in with painful legs, a sore back, dizzy spells and some breathlessness. It takes her nearly half of her appointment time to shuffle in from the waiting room and take off her four cardigans. She is lonely and socially isolated and really wants to chat. She is a bit forgetful and not very good at giving me a clear story about what hurts when and where. She is already on a multitude of drugs, which she often forgets to take. After a long, disjointed consultation, she departs after 30 minutes without any of her symptoms really being treated and leaves me feeling like I’m not a very good doctor. She will be back next week with a new list of problems. My subsequent patients are annoyed because I am running late and by the time I get to coffee, I am left with a couple of broken, stale digestives.

One of the joys of being a GP is having a close and supportive relationship with elderly patients, but they really do take up the lion’s share of our workload. By definition, the ageing process means that as we get older, more and more things go irreversibly wrong until we finally die. This can be quite hard for both the doctor and the patient to accept. Of course, there are fantastic sprightly 90-year-olds who never visit the doctor and moping 20-years-olds who spend their lives in my waiting room. But generally speaking, the older you get, the more you see your doctor.

Treating elderly people with multiple complex medical and social problems is one of the more challenging areas of our work. The goal is to work as part of a team to maintain the person’s dignity and autonomy, while pacifying anxious relatives and navigating through the bureaucracy that is the NHS and social services. Elderly patients are often fantastically appreciative and working with them can be extremely rewarding. Having said all that, it is bloody hard work!

I worked once in a city practice in a young trendy part of town. There simply weren’t many elderly people who lived there. I saw more patients in less time and didn’t do any home visits. I had less disease targets to worry about because few of my young patients had chronic conditions such as heart disease and diabetes. I sat in a trendy coffee shop during my lunch hour, while my GP colleagues around the country traipsed round nursing homes and arranged home helps and hospital admissions. My job was certainly easier but also less rewarding and less interesting.

Dr Harold Shipman’s was Britain’s most prolific serial killer. He was a GP and over several years murdered his elderly patients with deadly overdoses of morphine. Many still talk of his crimes being motiveless. I don’t think they were. Most GPs could think of several frail, vulnerable elderly patients who take up a lot of their time. Shipman murdered his. One of the hardest parts of being a GP is taking care of elderly people wanting help for untreatable degenerative diseases. Most of us find that listening and offering some practical support and advice is the best we can do and actually very much appreciated. Shipman clearly viewed things differently and felt it was his right to murder his elderly frail patients. I imagine he enjoyed the power but I also think he was motivated by reducing his workload.

Bums

Intimate examinations can be awkward for both doctor and patient. Fortunately, a good explanation and reassurance from the doctor can make the whole procedure a lot less difficult. When the patient doesn’t speak very much English, the situation can be that bit more uncomfortable. This was the scenario I faced with Olga, a young Bulgarian woman who came to see me.

‘Pain in bottom, Doctor,’ she said in a very broad Eastern European accent.

I began to ask a few questions about what sort of pain it was. Was it related to going to the toilet? Was there any blood in the poo? These are all the normal questions that would usually give a doctor a fairly good idea of what the diagnosis might be. The problem was that each question was met with blank confusion. Olga had clearly found out how to say ‘pain in bottom’ but was unable to understand any word I said. Despite a brilliant attempt on my part to mime diarrhoea and constipation using a mixture of diagrams, sound effects and facial expressions, I was getting nowhere. Feeling completely useless, the only option I had left was to examine her. I motioned towards the couch and mouthed out the word ‘EXAMINATION’ very slowly and loudly. Olga seemed to understand, so I pulled round the curtain to give her some privacy as she undressed.

As those of you who have had the misfortune to have had your bottom examined by the doctor will know, we generally expect you to drop your trousers, jump up on the bed, pull your knees up to your chest and lie on your side facing away from the doctor. I usually have a blanket handy so the patient can remain covered until the examination itself takes place. Normally, the whole ordeal is quick and relatively painless – well, painless for me, anyway. Unfortunately, it would appear that things are done slightly differently in Bulgaria. I pulled back the curtain to find Olga naked from the waist down leaning over the couch with her bottom pointing to the ceiling. ‘No no, you need to be up on the bed!’ I cried. ‘ON THE BED,’ I repeated slowly and loudly. I pulled the curtain across again and after a few polite moments went back in. This time Olga was on all fours on top of the couch still with her bum pointing up in the air. After much gesticulating and loud slow explanations, I was still no closer to having Olga in a position in which I could examine her. I motioned for her to get off the bed and got on myself lying in the correct position. ‘LIKE THIS, YOU SEE.’ I was lying curled up on the bed while my half-naked patient was standing beside me still looking very puzzled. It was a moment that I was very glad wasn’t interrupted by a receptionist bringing in a cup of tea.

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 ER 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 ER and, as you can imagine, curtains aren’t particularly soundproof. The entirety of the ER 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 lock my boyfriend away in a mental hospital. 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 put him in a psychiatric hospital.’

‘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 involuntarily confine someone if the moped he 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 confined.

‘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.