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 couldnt 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. Im sure there was something she wasnt telling me. My suspicion was that the pregnancy was the result of an affair but Im 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 wasnt 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 couldnt remember why hed 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 wasnt 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 couldnt 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 wouldnt 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 wouldnt 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 GPs 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. Im 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 Taras medication and then ponder what to write on the sick note. Tara is 25 and has never worked. She doesnt have a physical disability or a neat diagnosis to put on the dotted line. She isnt 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 doesnt 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 dont 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 dont. 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. Im sure that is true but I cant help but wish she didnt 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 wouldnt cope with work. When she doesnt 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 hasnt 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 dont 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 cant be cured. We dont give up on our patients with diabetes because they cant 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 Ill be a bit nicer to Tara next time she visits. Ill try to listen harder and be more supportive. Ill give her more of my time and wont rush her out the door. Maybe shell open up a little more to me? Maybe she wont 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 dont 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 doesnt 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 wouldnt 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 individuals 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 Im 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 didnt get to talk about my regrets and fears. I wasnt allowed to display my needy and vulnerable side. If my love-struck patients had to hear all my shit, Im 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 doesnt 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 shouldnt be frowned upon just because one happens to be the others doctor. I have to say that I agree with the Greek fella in this case. He clearly recognised the uniqueness of the doctorpatient 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 professions 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 Im 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 lions 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.