The Complete Confessions of a GP

Average day

I sometimes think that people have an odd preconception of what makes up the typical day for a GP. These are the exact patients that I saw one morning, a wet Tuesday in November in a typical practice somewhere in the south of England. None of the consultations are outlandish or exciting enough to deserve their own chapter, but they are a very typical reflection of a GP’s average morning.

1 A seven-year-old boy having tummy aches. Mum was very worried, as her nephew had had a kidney transplant at a similar age. The tummy aches only occurred on mornings before school and after finally managing to keep Mum quiet for a few minutes, I asked the lad a few questions and he admitted that another boy was bullying him at school. Mum left the surgery and stormed straight up to the school.

2 A very nice woman in her thirties with six-month-old twins. She was finding it all a bit much and was very tearful. She did actually have symptoms of postnatal depression and was worried that it could be affecting her relationship with her children. We had a long chat about possible options, including counselling and antidepressants. She would be coming back to see me in a couple of days to let me know what she had decided to do and so I could see how she was getting on. I also wrote a letter to the health visitor to see what other support she could get.

3 A 60-year-old woman worried about the appearance of yellow lumps around her eyes. I explained they looked like cholesterol deposits. She told me that there was no point in her having a cholesterol test, as she refused to take any Western medicine and therefore wouldn’t take any cholesterol-lowering medication even if her cholesterol was high. She was also convinced that her diet couldn’t be any healthier than it already was. I told her about risks of having a stroke or a heart attack but I was happy that she was entitled to make her own informed choice not to have the test. I made sure I documented this carefully so she couldn’t come back and sue me at a later date.

4 A very nice woman in her fifties with breast cancer. She had chemotherapy and radiotherapy over the summer and thankfully her cancer seemed to be in remission. She told me that she lay in bed at night and every time she felt the slightest tingle in her fingers or an ache in her leg, she was convinced that it was the sign of her cancer coming back. We had a long chat and I tried to reassure her that her fears were normal and understandable. I put her in touch with a cancer support group.

5 A middle-aged woman with a slightly sore knee for two days, which was getting better. I went through the motions of examining her but everything looked normal. I couldn’t really work out what she was expecting me to do for her. She seemed happy enough with my reassurance.

6 An 80-year-old man who had had some diarrhoea over the weekend, which had since settled. He actually wanted to talk about the current legal wrangling he was having with his niece who was trying to evict him from his family home. I listened for about 15 minutes but was already running very late so had to cut him short and move on to the next patient.

7 A 30-year-old woman with a cold. She had come in specifically for antibiotics and she made this clear from the start. I examined her fully and then explained in much detail why antibiotics weren’t going to help her as she had a viral infection. She was very insistent that she wanted antibiotics as she had an important work presentation to do on Friday! She was not happy at all when I refused to prescribe her antibiotics.

8 A 40-year-old man involved in a mild car accident over the weekend. He had some very mild muscle aches in his neck but nothing that needed to be seen by a doctor. He was only here for insurance purposes in case he decided to make a claim at a later date. I was slightly annoyed that he had used up an urgent slot for this. This is an example of one of the few instances where I feel we should charge patients to be seen.

9 A fairly straightforward tennis elbow. However, the man was a self-employed mechanic so when I advised him to rest his arm, he gave me a resigned smile and said, ‘I’d love to, mate, but who’s going to run my garage?’ I referred him to a physio and advised painkillers.

10 A three-month-old baby with a cold. Very cute. She was absolutely fine and smiled throughout my examination. A smiling baby always helps lift my spirits, especially halfway through a busy morning.

11 A very anxious woman who was convinced she had had an allergic reaction to her latest blood pressure medication. She had a history of lots of unusual medication allergies. Perhaps they were genuine allergies or perhaps there was a degree of hysteria. She was far too frightening for me to argue with so I stopped the medication and agreed to try yet another one.

12 A woman in her late sixties with a cough and breathlessness. She thought she had a chest infection but on closer inspection it looked to be actually due to a build-up of fluid in her lungs because of problems with her heart. I spent some time explaining the likely diagnosis and started her on some new medications and also ordered various tests.

13 A patient didn’t turn up – frustrating, as many patients phoned this morning wanting an appointment but were told that there were none available. I have to admit that it was a relief for me in some ways. I was running late by now so I had the chance to catch up a little bit.

14 A very odd case. A 38-year-old woman came in to see me. She was seven weeks pregnant and had been trying to get pregnant for years. Previously, she had been seen in the infertility clinic and had had two miscarriages. She told me that she wanted an abortion because she had felt so unwell since becoming pregnant and couldn’t cope with the symptoms. It was also a bad time for her to be pregnant. She had just been to the hospital for a scan which showed a normal pregnancy so far. She was flying next Thursday, so wanted the abortion before then. I’m sure there was something she wasn’t telling me. My suspicion was that the pregnancy was the result of an affair but I’m just guessing. I referred her to the specialist clinic and I know that they do a long and detailed assessment prior to considering an abortion.

15 A 17-year-old girl seen with her mum. She had a long history of being seen by lots of specialists. Mum was convinced that her daughter had ‘never been well due to a weak immune system’, although all tests have been normal. She was being schooled at home. All a bit weird and I wasn’t keen on being dragged in too deeply as I was not her normal doctor. I looked through the notes and saw that despite having apparently ‘never been well’, she did manage to get herself pregnant last year and have an abortion and was also recently seen in A&E after getting into a drunken fight outside a pub. Hmmm. They just wanted a repeat prescription of her normal medication, so that was easy enough.

16 An 80-year-old man who arrived 20 minutes late and couldn’t remember why he’d come to see me. He lived alone and drove everywhere. I suggested that we assessed his memory but he refused. I also suggested that if his memory was poor, maybe he should stop driving until he had an assessment from the DVLA. He refused this as well. I decided to contact the DVLA myself. It was a break in confidentiality and his driving might have been fine, but if he killed someone in an accident … I wrote the letter.

I finished the morning surgery late and grabbed a sandwich before rushing off to do a couple of visits:

Visit 1. A 78-year-old man who had had a mini stroke the night before. He had had 11 previous mini strokes and was on all the right medication to control his blood pressure, keep his cholesterol low and thin his blood, etc. He had recovered fully since the previous night and my visit wasn’t really necessary medically, but his wife was anxious and I spent 20 minutes reassuring her that she was doing all the right things and she thanked me repeatedly for coming out to see them.

Visit 2. A 57-year-old man who couldn’t get out of bed that morning. He was previously fairly well. Initially, I thought he was being a bit precious but then I noticed that the whites of his eyes were a bit yellow (jaundice) and on examining his abdomen, found he had a big liver. Unfortunately, my gut instinct was that he probably had cancer. He asked me what I thought was wrong and I said that I thought there were all sorts of possible causes and I wouldn’t like to commit until he had had a scan. Once back at the surgery, I make a referral to get him seen urgently by the bowel and liver specialist. Should I have said I thought he had cancer? I wouldn’t want to worry him unnecessarily if he just had gallstones or something completely benign.

So there we are. That was my morning. There were also a few extra phone calls and prescriptions to sign. The nurse popped in inbetween patients to ask me a few questions and I had to dictate some letters and sign some forms. I had a quick cup of tea and got myself ready for the afternoon surgery.

That was exactly what I did that morning. I have no idea if that fits your expectation of an average GP’s morning but there it is and probably fairly typical for most GPs. It was, perhaps, unusual in its absence of drug-abuse problems and sick-note requests, but that was probably mostly because the practice was in quite a middle-class area. Fortunately for me, I found the morning interesting, challenging and rewarding. It was a typical morning, but would still be completely different from yesterday and tomorrow.

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 surgery

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 ‘Carry on Doctor’ 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 young Barbara Windsor lookalikes.

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 dissolved.

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 fella 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 bodyagrees 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 GP.

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.

I recently read that Harold Shipman’s murders were 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.