Confessions of a GP (11 page)

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?

Soon after my smoothie, I was stopped in a shopping mall by a guy selling eucalyptus cream for diabetics.

‘How does this work?’ I ask.

‘Well, mate, you know diabetics, yeah? They have bad circulation to their feet and get foot ulcers.’ (I can’t fault him so far.) ‘Well, when you rub this cream into the foot, it improves the blood flow to the skin.’

‘Rubbing anything into your feet increases the blood flow.’

‘Well, the eucalyptus cream increases oxygen production in the soft tissues.’

‘How does it do that?’

‘Free radicals and that.’

‘Have you got any evidence to show that this works any better than, say, rubbing lard into your feet?’

Mr Eucalyptus Cream Man shows me the back of his jar of cream. It says, ‘Formulated specifically with diabetics in mind.’

‘That’s not really evidence, is it?’

‘Is it you who is diabetic?’

‘No.’

‘Someone in your family?’

‘No.’

‘Are you going to buy some of this cream, then?’

‘Absolutely no.’

‘Well, piss off and stop wasting my time. I’m trying to make a living here.’

Really, I’m just as guilty as Mr Eucalyptus Cream Man. Mr Dudd came to see me recently with a bad back. His back aches because, like him, it is 90 years old. The vertebrae are crumbling and his spine has no flexibility any more. He has tried codeine but this makes him constipated and drowsy and I’m reluctant to prescribe him anti-inflammatory tablets because these could give him a stomach ulcer and damage his kidneys. I decide to give him an anti-inflammatory gel to rub on to his back. There isn’t really any evidence that this is more effective for back pain than rubbing lard onto his back. I still prescribe it because I don’t want to say, ‘Sorry, Mr Dudd, your spine is as crumbly as stilton and there is bugger all I can do for you.’ Instead, he goes home and every morning Magda his Polish care assistant comes and gently rubs the ‘magic’ gel into his lower back. Mr Dudd thinks it is wonderful. ‘Thank you, Doctor. That gel really helps.’ That’s the thing about medicines that are shown to be no better than a placebo: they still work because placebos work. As long as the placebo is cheap and doesn’t cause any harm, I’m all for them. I am marginally better than Mr Eucalyptus Cream Man because his cream cost £25 and he was targeting vulnerable old people with diabetes who are worried about getting foot ulcers. My ibuprofen gel cost £1.25 and I made an old man very happy (with a bit of help from an attractive Polish care assistant). Interestingly, the cost of the painkilling gels varies between £1.25 and £12.75 depending on the brand, yet all are probably no more effective for back pain than lard, which costs 19p if you buy the no-frills version in Tesco.

Sticking to evidence-based medicine can be very frustrating. For years I had enjoyed advising my patients to drink lots of cranberry juice when they have a urine infection. They always loved this advice. It helped stop the bugs from sticking to the wall of the bladder I used to say. I don’t know where I got this information from but it sounded good and someone clever must have told me it at some point. I guess it was just one of those urban myths that we all buy into sometimes. Patients always love a risk-free natural remedy, especially when advised by the doctor. Unfortunately, a big study recently showed that although drinking cranberry juice can help prevent urine infections, it can’t actually rid you of the bacteria once you have an infection. Bugger, sticking to evidence-based medicine can be very boring sometimes.

Carolina

Carolina was 15 and, unlike the vast majority of teenagers who come to see me, she actually spoke to me in normal words and sentences rather than in grunts and shrugs. I had seen her on several occasions with minor problems, but this time she came in wanting to talk about going on the pill. She didn’t have a boyfriend but some of her friends were having sex. She didn’t feel ready to have sex yet but wanted to make sure that if anything unexpected did happen that she would be protected. She understood all about sexually transmitted infections and knew how important it was to use condoms. She had also looked up online all about the pill and how it worked. I suggested that she spoke to her mum about this but Carolina told me that her mum was a strict Catholic and she couldn’t talk to her about sex. We had a long chat and she decided that she was going to take the prescription for the pill away with her and then have a think about things before potentially cashing it in for the tablets themselves. I remember thinking to myself that if I ever have a teenage daughter, I hope she can talk as openly and honestly about sex as Carolina.

A month later I got an angry phone call: ‘Dr Daniels, it is Carolina’s mother here. I was just wondering if you could tell me the age of consent in this country.’

‘It’s, erm, 16.’

‘In that case, why have I found a prescription for the contraceptive pill under the bed of my 15-year-old daughter? It’s got your signature on it.’

It was an awkward moment. My first reaction was to ask what she was thinking looking under her daughter’s bed. Surely that must be the first rule of having a teenager. Don’t look under their beds, as you’ll only find something you don’t want to know about! Carolina’s mum was furious. It was a shame, really, as she came to see me fairly often herself and we actually got on quite well. She was one of those really grateful patients who always thanked me profusely even when I hadn’t really done much. She was Polish and I romanticise that in Poland they have an old-fashioned respect and admiration for their doctors long since vanished in the UK. The problem was that alongside the old-fashioned value of respecting doctors was the old-fashioned value of expecting your teenage daughter to keep her virginity until her wedding night.

The rules on prescribing the pill to minors are fairly clear. Girls under 16 can go on the pill without their parents’ permission. They must have capacity, which basically means that they are able to understand the decision they are making and the pros and cons. As the doctor, I am supposed to encourage the girl to speak to her parents but if I think she will have sex anyway it is recommended that the doctor prescribe her the pill. This was contested in 1983 by a Catholic mother called Victoria Gillick. She didn’t want her underage daughters being given the pill without her permission. She lost the case. Interestingly, although under-16s can make their own decisions about treatments that they want, they can’t refuse treatment. For example, if a 15-year-old has appendicitis and needs to be operated on but she or he declines surgery, the parents can overrule the decision.

For me, prescribing the pill for 15-year-olds is something that I do fairly frequently. Some people feel that as a GP prescribing the pill, I’m encouraging underage sex. As far as I’m concerned, teenagers are influenced by friends, music, TV and magazines. They’re not influenced by slightly geeky 30-year-old doctors with bad hair and Marks and Spencer’s trousers. She might later regret having her first sexual experience too young, but she’ll be more damaged by having an abortion or a baby. The decisions are much harder if the girl is 14 or 13 or if the boyfriend is much older. It is such a grey area. If Carolina had a boyfriend who was 16 or 17, I guess that would be okay. What if he was 20 or 25? When do I break confidentiality and call the police or social services? These sorts of issues are difficult to judge but faced by GPs every day. I imagine that doctors who have strong religious convictions or those who have teenage daughters themselves may view the whole issue very differently from me.

Back to Carolina’s angry mum. I was a bit stuck. I wanted to tell her how sensible her daughter was and that the very fact that the prescription hadn’t been cashed in demonstrated her maturity. The problem was that I owed Carolina her confidentiality and couldn’t really say anything to mum at all other than to explain that I was within the law to prescribe her daughter the pill. I did sympathise with Carolina’s mum. Although I remember feeling very grown up at 15, it is pretty young really. I wasn’t having sex at 15 but that wasn’t by choice. My combination of bad skin, unfashionable clothes and a disabling tendency to blush and then stammer awkward nonsense whenever within about 15 yards of a girl, meant that I didn’t lose my virginity until my late teens. Perhaps my opinions will change in the future, but at the moment I sort of feel that at around that age teenagers will want to be having sex. They will probably make mistakes and have experiences they regret, but if my teenage-girl patients can get into their twenties without getting pregnant or becoming riddled with venereal disease, then I’m probably doing a good job.

Lee

Lee was 36 and was just out of prison. He had been due to be my last patient of the morning but his appointment was at 12.20 and he turned up at 1.30, just as I was about to leave the surgery to do a visit and grab some lunch. I was in the office and could hear him getting slightly aggressive with the receptionist as she explained that I wouldn’t see him. It was only fair that I went out and gave her some support.

‘Are you the doctor? Will you just see me quickly? I need something to calm me down.’

‘No, you’re over an hour late so you’ll have to rebook in to see me or one of the other doctors this afternoon.’

‘Well, can you just give me something to help me sleep?’

I’m not a big fan of prescribing sleeping tablets such as diazepam. I try to avoid prescribing them myself, but looking through Lee’s medication list on the computer, I saw that he had a repeat prescription of diazepam still on his screen from before he went into prison. The computer showed he had been prescribed diazepam regularly for years and so I agreed to let him have a prescription for a week’s worth now with the plan to start cutting them down at his next appointment. I quickly printed and signed his prescription for diazepam and booked him an appointment for later that afternoon.

That was my one and only consultation with Lee. It took place in the reception area of the surgery and I dished him out a few pills to get him out of my hair so I could get on with my day. Lee didn’t attend his afternoon appointment and by the next morning he was dead, having taken an overdose the night before. I read and reread the automatic and very impersonal fax that is generated for every A&E presentation:

Dear
Doctor Daniels
,

Your patient was admitted at
03.45
with a presentation of
overdose
. He was discharged with a diagnosis of
death.

I felt like shit now. Had Lee overdosed on the medication I prescribed him? I hadn’t seen Lee because I was hungry and tired from a long morning surgery and didn’t want to get held up. Was that a good excuse? If I had seen him properly and listened, maybe I wouldn’t have given him the prescription at all. Perhaps he would have told me a few of his worries, felt a bit better and not topped himself. Had I missed a rare chance to make a real difference? I had an unpleasant morning stewing over Lee’s death, imagining explaining myself to the judge.

‘So Dr Daniels, the deceased came to see you feeling vulnerable and desperate. He had a history of violence and depression. You were his only source of help and what did you do next?’

‘I gave him a week’s worth of sleeping pills and told him to bugger off, your honour.’

It didn’t look good, did it?

Suicide is a difficult case for GPs to deal with. We see depression and self-harm by the truckload but not many patients actually successfully kill themselves. When I was an A&E doctor, the cubicles were full of teenage girls who had taken eight paracetamol after a row with a boyfriend or parent. There were a lot more cries for help than genuine suicide attempts and most of the ‘overdoses’ were generally dismissed by A&E doctors as time-wasters. When I was working in psychiatry we saw the next step up. These were genuinely depressed people who took big overdoses and really wanted to die at the time. They only very rarely succeeded in causing themselves any real harm and still ended up in an A&E cubicle with the casualty doctors equally reluctant to have to treat them. Only one of my patients successfully committed suicide during my time in psychiatry. He was a nice young lad of 19 who was just recovering from his first episode of schizophrenia. He had just returned from a gap year travelling round Asia and was looking forward to starting university when he became really psychotic and unwell. He was hearing voices and getting very paranoid. He had to be sectioned and admitted to the ward but he started to improve with medication. I was really pleased with his progress and happy that he was ready to be discharged home. He was realising his potential future of daily medication, psychotic relapses and social stigma. He got into his mum’s car, took off his seat belt and drove very fast into a wall. It made me appreciate that, actually, if you really do want to die it isn’t that difficult.