The Complete Confessions of a GP

Meningitis

Every six months or so, a newspaper will print an article with a headline something like: ‘GP MENINGITIS BLUNDER – My GP diagnosed my child as having a cold, ten hours later she was in intensive care with meningitis.’ This is the sort of story that terrifies every parent and every doctor. For GPs who are also parents, it is a double-fear whammy.

Meningitis is a frightening condition for GPs because it tends to affect children and young people and if we miss it, the patient can be dead within hours. The difficult truth behind the scaremongering headlines is that any child who is seen by their GP in the first few hours of meningitis will probably be sent home with some paracetamol having been told that they have a viral infection. Early meningitis symptoms are generally a fever, feeling a bit lethargic and not being very well. We see bucket loads of children like this every week. The symptoms of a rash and neck stiffness that give away the diagnosis are only seen much later on, by which time the child is already quite sick.

I know an excellent and experienced GP who sent home a child who then went on to develop meningitis. It is a horrible diagnosis to miss but only rarely is it a ‘blunder’. The only thing we GPs can really do for the thousands of snotty feverish children we see every day is educate the parents as to what danger signs to look out for and when to bring them back to see us.

I’ve only seen meningitis a handful of times and thank goodness never as a GP. The first time I saw it was the most memorable. I was working in casualty and a dad carried his four-year-old child into the waiting room. I took one glance at the child and went straight to the drugs cupboard, whacked some penicillin into his vein and called the paediatric registrar instantly. Despite the fact that I had never seen meningitis before, the diagnosis was obvious. The child looked really bloody sick. He was floppy and completely disinterested in anything around him. This was not a clever diagnosis. No doctor in the world would have sent this child home. Several hours earlier when the child was just a bit hot and bothered but still happily watching Disney videos and playing with his brother, the diagnosis would have been much more tricky. If I’d seen the child at this stage, I could easily have sent him home and become the next day’s ‘blunder doctor’ newspaper headline.

I am always happy to see children and babies in my surgery and will do my best to fit them into a full surgery if Mum or Dad is worried. In fact, seeing kids is one of my favourite parts of being a GP. The main difference between children and adults is that kids are very rarely unwell. The truth is since I’ve been a GP, I’ve probably seen well over a thousand children and babies, but I am yet to see one that was unwell enough for me to be really worried. Meningitis is really scary but also pretty rare. I understand that this might not be that reassuring if it is your own child that is hot and miserable and that is why I’m always happy to see kids and to reassure parents. As a parent myself, I do realise that it is hugely anxiety-provoking to have this small person for whom you are solely responsible and whom you love overwhelmingly and unconditionally. We doctors are equally anxious when our kids are unwell and I once heard of a GP rushing her infant to see an ear, nose and throat specialist as she was convinced her child had a nasal tumour. She was understandably very embarrassed when the specialist then removed an impressively big but definitely benign bogey from her child’s nostril.

A few kids need a good check-over before I’ve reassured myself that they can go home, but the vast majority are obviously fine as soon as they walk through the door. This may seem a bold statement to make when I’ve previously talked about how easy it is to miss meningitis early on. However, these borderline kids are the minority of children we see. If a child skips into my consulting room and gives me a smile, they haven’t got meningitis. I can’t say that they won’t develop meningitis in 12 hours’ time but then I couldn’t say that any well child wouldn’t develop meningitis in 12 hours’ time. Unfortunately, that is the nature of the disease. In the same way that it took me about one second to decide that the child with meningitis was really sick, it takes me about one second to decide that 99 per cent of the children I see are completely fine.

When I say that the vast majority of the children I see are ‘fine’, I don’t mean that they are not unwell. What I mean is that they don’t have meningitis or any life-threatening condition that needs hospital admission right then. They also almost certainly don’t need antibiotics as they invariably have a viral infection. It’s important that I don’t use the word ‘fine’ to Mum and Dad as they have been up half the night with a miserable crying infant. These children are ill but not ill in a way that I can do anything about. It is just part of being a child.

Kids get ill because they haven’t been exposed to lots of the bugs that we have. They are going to be snotty for much of their early years and often spend the vast majority of their first couple of winters going from one viral infection to another. Children need to build up their immune systems and, unfortunately, the only way they can do this is to be unwell. I often think that new parents are a bit unprepared for this part of parenthood. Children will have recurrent ear infections, coughs that last for weeks, sore throats that are really sore and funny spotty rashes that don’t quite look like anything in my dermatology textbook. All these things are just part of being a kid and staying up all night comforting them is part of being a parent. It’s not much fun at the time but it’s normal. I would love to be able to give an instant cure for these childhood illnesses but, unfortunately, I can’t. My job is simply to listen to the parents, do a quick examination, offer encouragement and reassurance and make sure that Mum and Dad come back if they are worried. A generation or two ago when big extended families lived together, this reassurance was given by Grandmother or Auntie, but nowadays parents can be quite isolated, hence it is often the GP that fills this role.

Soothing anxious parents is definitely one of the hardest parts of my job. Many are very happy with some sensible reassurance. Others are looking for antibiotics and won’t be happy unless they leave with them. We all want the best for our child and seeing them unwell is hard to bear. I think some parents feel that they are letting their child down if their snotty and coughing infant doesn’t get antibiotics. In direct contrast, as I strive to be a good doctor, I am trying to hold back from giving antibiotics. It can be a difficult battle that can go either way.

To try to swing the encounter in my favour, I have developed a battle plan. The first thing that I do is try to empathise and say how the child definitely does have a very bad infection – be it a cough or ear infection or sore throat, etc. I sympathise about how hard it is for the whole family when a child is up all night coughing and crying, etc. Vital is me then telling the parents what a great job they are doing with regular paracetamol and lots of cuddles. My aim is to make them feel that I am on their side and that I realise how exhausted they are with no sleep and a miserable child. Then I explain why antibiotics aren’t appropriate to treat viruses, but still offer them as an option. If I’ve done my job well, they say no, but feel that it is their decision. Finally, I make sure that they will come back and see me if they are concerned and tell them about the worrying symptoms of meningitis to look out for.

If I’ve succeeded, they don’t come back, as the parent feels more confident and the natural course of these viruses is that the child gets better. Ideally, they also feel a bit more confident about managing the child at home next time they are poorly. When these consultations go well, they are great. When they go badly, they are a disaster and usually either end up with the child getting an inappropriate prescription for antibiotics or an anxious parent getting very upset and dragging their child to A&E.

Uzma

It’s 6.30 p.m. and my last patient has just walked in. I’m running on time and I’m due to meet a few friends for a drink after work. Working in offices, they have been in the pub for ages and have a pint waiting for me. If I can just get through this last patient quickly, whizz through some paperwork, I’ll be in the pub by seven.

Uzma comes in. ‘I need the repeat of my pill, Doctor.’

Happy days! Contraceptive pill checks are a boring part of general practice but quick and easy. I do a speedy blood pressure reading, ask if there are any problems, which invariably there aren’t, and then the patient is out of the door within a few minutes.

Just as I’m generating the prescription, Uzma seems to be welling up. I’m torn now. I am a nice sympathetic doctor. Honest! It’s just that I’m tired and drained and I can practically taste my pint. I really don’t fancy spending the next half-hour listening to a weeping 16-year-old. I contemplate pretending not to have noticed, but it’s too late. The tears have arrived. They are unmistakable, especially as they are now dripping on to my blood pressure machine. I sink into my seat and prepare myself for a long evening.

‘So Uzma, you seem a bit upset?’ Not exactly reading between the lines, given her quiet sobs have now turned into loud wailing.

‘I can’t go home tonight, Doctor; they all hate me. Everyone hates me.’ More wailing and tears. ‘They blame me for everything and always take my brother’s side.’ Wail wail. ‘My parents don’t understand me. We’ve had a massive fight. There’s no way I’m going home tonight. No way!’

Uzma’s parents are from Pakistan. Perhaps they are forcing her into an arranged marriage or trying to make her drop out of school? I saw a Tonight special with Trevor McDonald on this sort of thing. Perhaps I can really help this young woman. I’ll need to get social services and the police involved tonight and find her a place of safety.

‘Uzma, are your parents very strict with you? Are they trying to make you do things you don’t want to do? Do they hit you?’

‘Hit me? God no.’ Uzma looks at me like I’m an absolute idiot. ‘They all just hate me ’cause they’re losers. My sister Nadia, yeah. Oh my God, she’s such a bitch. Only because she’s jealous ’cause she’s got a big arse and no boys fancy her and my mum is always moaning at me about doing my homework and she never says nothing to my brother. He does whatever the fuck he likes.’ Like the tears, the words are now unstoppable. There are no breaks for punctuation, but only the odd pause to wipe her tears and blow her nose before the next torrent of adolescent anguish is released.

My interest is diminished again. There aren’t going to be forced marriages or honour killings. This is just an ordinary 16-year-old having a hissy fit after a row with her parents. Uzma’s mum and dad seem fairly liberal all in all. They probably wouldn’t be too happy if they knew she was shagging Darren who works in the garage but then that’s not a cultural thing, nobody would want their daughter shagging Darren from the garage.

Uzma is still crying her eyes out and is refusing to go home. What the hell am I going to do now? I need some help with this one. I’m rubbish at comforting crying teenagers. Why on earth has this girl come to see me about all this? Surely there must be far better qualified people to deal with this than me. Someone trained in understanding the emotional turmoil of adolescence, someone who finds it rewarding to address teenage angst on a regular basis. Someone with endless patience and empathy and someone who wasn’t supposed to be in the pub 20 minutes ago! As she sobs, I do a quick Google search for teenage counsellors in the town. I get a few numbers and phone them but just reach answerphones. They’re all in the bloody pub, lucky buggers.

Just as I’m wondering how I’ll ever get home, Uzma’s phone rings. It is one of those annoying ringtones that is extra loud and the start of an R&B track that I don’t recognise because I’m over 20. The tears stop almost instantaneously and she answers the phone, ‘’Old on a minute, Doc. Wassup, Letisha … Is it? … Is it? … Oh my days! … Are you chattin’ for real! … I’m just with the doctor and that … I’ll be right there.’

The anguish suddenly vanishes. ‘Sorry, Doc, I’ve got to go. My friend Letisha just got dumped. I’ve got to go round and find out what’s going on.’

Before I can say a word, Uzma is gone. Speechless, I sit in silence pondering the mysterious world of the 16-year-old.

Africa

During a holiday in East Africa, I visited some old friends from medical school who were working in a small rural hospital in Kenya. Rob and Sally had been GPs in the Midlands until they decided to sell their house, quit their jobs and commit to three years in Kenya setting up and running a rural hospital.

Rob proudly showed us round. They had been in Kenya for two years and had achieved an enormous amount for the local community. Thanks to their tireless work, there is now an organised maternity unit and a well-equipped medical ward. Rob has also set up an AIDS clinic with free testing and, most importantly, free access to AIDS medication. It is the only one of its kind in the whole region. Rob and Sally have also pushed hard for education and disease prevention and have spearheaded a campaign to encourage mosquito nets. As a result, they have significantly reduced malaria deaths.

Not only had Rob and Sally been working hard treating patients, they have also been single-handedly planning and managing the changes and improvements to the hospital mostly with funds they have raised themselves. My targets in England for the year might be to get a few patients to lose some weight or cut my diazepam prescribing. Rob and Sally’s targets were to build a maternity ward and prevent 100 local children from dying of malaria.

Rob asked me to help out with the HIV clinic for the day. There was no appointment system. The patients arrived en masse in the morning and sat patiently outside my room all day until the last one was seen at about 6 p.m. Not a single person complained about waiting and each one thanked me with genuine gratitude and warmth when the consultation finished. It truly was a humbling experience.

My most memorable patient was Cynthia. She had set off from a neighbouring village the night before and, despite being weak with advanced AIDS and TB, she walked the entire 12 miles and spent the night sleeping in the doorway of the hospital along with many other of the morning’s patients. She didn’t speak any English so a nurse was translating for me. Cynthia was 24 but looked much older. Her two children had both died aged around 18 months and, although never given a diagnosis, they almost certainly died from AIDS-related illnesses. Cynthia’s husband, from whom she contracted HIV, left her once she could no longer work and he realised that she wouldn’t be able to produce any healthy children for him. Cynthia was alone and her only means of income was digging in the fields. She was still getting up each day and attempting to work, but her AIDS was advanced and she was too weak to dig. The medications for her AIDS and TB were free and were helping, but what she really needed was something decent to eat. ‘Where are you going to get your next meal?’ I asked via the interpreter. She shrugged her shoulders and then after a long silence looked me in the eye and asked me a question in her native tongue. Waiting for the translation, I assumed that Cynthia would be asking for some money or food. To my surprise, what she actually asked me for was a job. Even in her weak state, Cynthia clearly still felt that she should earn her way and hadn’t even considered a hand-out. One of the previous patients had given me six eggs to say thank you for the mosquito net I gave him, so I gave them to Cynthia and she left with at least some basic sustenance to help her muster the energy for her long walk home.

As an idealistic sixth-former applying for medical school, I imagined spending many long years working in the poorest and neediest parts of the world. The reality is that apart from my brief experience in Kenya, my only other time practising medicine abroad was three short months in a hospital in Mozambique soon after I qualified. The reality of working in an African hospital was really hard. The facilities were limited, the bureaucracy made me want to tear out my hair and the extent of the corruption was terrifying. The experience was incredible and although it was some years ago, I think of that time often and it helps put both my work and life back in the UK into perspective. I’m a more experienced doctor now and could potentially be much more help back in that hospital in Mozambique, but the question is: do I have the motivation to go back?

Rob is a GP with a similar amount of experience to me. The week before we arrived in Mozambique, a woman came to the hospital in the middle of the night in labour with an arm presentation. This means that the baby’s arm had been born but the rest of the baby was still inside the womb and basically stuck. Rob, like me, had spent a few weeks on an obstetrics attachment as a medical student but that was pretty much the sum of his experience of delivering babies. Suddenly, as the only doctor around and ten hours from the next nearest hospital, Rob had to do something. The woman needed a Caesarean section, but there simply weren’t the facilities at hand. He tried desperately to push the arm back in and deliver the baby but to no avail and the baby died. The mum was extremely weak from loss of blood and exhaustion. The baby needed to be taken out or the mum would die too. Rob cut off the baby’s arm and managed to deliver the remainder of the dead baby.

Rob saved that woman’s life and I have the utmost respect for him. If he had decided to stay in England, that woman would have undoubtedly died. Throughout this book I’ve moaned a bit about the fact that I went to medical school to save lives and make a difference but instead I keep lonely old ladies company and dish out sick notes to the work shy. I haven’t ruled out the possibility of returning to Africa to practise some genuine ‘life-saving’ medicine, but right now I’m not sure that I have the emotional strength to hack the arm off a dead baby at three in the morning.

Evidence

I was being dragged round town on a Sunday morning and, despite the fact that I really fancied a coffee and some cake, my wife wanted us to try out one of the new trendy juice bars that had sprung up. The man behind the counter had a silly pointy goatee and a ponytail. I asked him what an acai berry was given that it was going to make up one-fifth of my five berry smoothie. ‘It’s hand picked from the shores of the Amazon, man.’ (I doubted this.) ‘It’s got 100 times the vitamin C of an orange so a real natural high. You’ll be feeling great all morning and it’ll keep those colds at bay.’ He looked really pleased with himself as he handed me my smoothie and I wondered what other nonsensical medical advice he gave out to his customers. ‘Eat a papaya and cure your verruca.’ ‘Eat some raspberries and your friends will like you more.’ I was desperate to tell Mr Goatee Man that there was no evidence to suggest that eating excess vitamin C was of any benefit in keeping colds away and that it wouldn’t give me a ‘boost’, why would it? Added to this was the fact that if I received any more than 200mg of vitamin C, I’d simply shit and piss out the excess so might as well stick to an orange, which was much tastier and cheaper. My wife knows me too well and gave me a look that meant stay quiet and don’t embarrass her in public. I took my smoothie and sat down. Irritatingly, it was really nice and made me feel quite revitalised.

Mr Goatee Man and his smoothie are part of a growing trend of advertising and marketing of ‘healthy products’ with huge claims about medical benefits without any evidence to back them up. This might seem like a typical rant from a closed-minded doctor, but I genuinely have nothing against my patients taking many herbal remedies and dietary supplements. Many of our medicines originate from plants so perhaps some of them may have genuine medical properties. Saint John’s wort, for example, is shown in clinical trials to be effective in the treatment of depression. What I object to is health food companies playing on people’s fears and anxieties with regard to their health by making unproven medical claims to sell their excessively expensive products.

Doctors work by the rules of something called ‘evidence-based medicine’. The principle of this is that if I want to prescribe you something, it should be of proven benefit. In the past doctors gave out all sorts of tonics and pills based on guesswork and trial and error. I’m sure some of these medications were effective and helpful, but many would have been no better than a placebo. Nowadays we are supposed to apply some evidence to everything we prescribe. If you come to see me with high blood pressure, I can think of 10–20 different pills I can start you on. As the patient you need to put your faith in me giving you the most effective pill for your condition. I can make a decision based on my own experiences over the years after having tried a few different pills on a few different patients. Or I can make my decision founded on a trial of over 10,000 people with high blood pressure that looked with minimal bias at which drug or combination of drugs seemed to reduce blood pressure most effectively and with the fewest side effects. These studies are by no means perfect and as an individual you may not respond in the same way that the majority of people did in the study. However, isn’t that a more accurate way of deciding your medication than by me choosing which tablet I most like the name of, or which medicine has the prettiest drug rep who takes me out for lunch most often?