Unfortunately for her, the entirety of my knowledge on child behaviour comes from having watched a couple of episodes of Supernanny on TV. Ive never been the sternest of people and given the way my cat walks all over me, Im probably not the best person to ask about discipline.
I think hes got that DDHD condition. You know, where theyre little shits but its cause theres something wrong with the chemicals in their brain and that.
Ive met lots of parents whose children have had a diagnosis of attention deficit hyperactivity disorder (ADHD). The parents love the label because it now excuses the bad behaviour. The kids run riot round my consulting room, rifling through my sharps bin and using my ophthalmoscope as a hammer. Mum and Dad do nothing to stop them and then say, Sorry about the kids, Doc. Its the ADHD nothing we can do brain chemicals and that.
I dont disbelieve that ADHD exists but perhaps it has been overdiagnosed in recent years. The main symptoms are lack of concentration, being easily distracted and not being good at listening. I could probably persuade myself that Connor has these symptoms, but Im not sure that they are related to brain chemicals. I guess some children are more prone to developing these symptoms than others, but in most cases isnt parenting more likely to be the most significant factor rather than a brain disease?
Im not going to send Kerrys kids to the child psychiatrist. The wait is long and I dont want these children labelled as psychiatrically unwell. Ive heard there is a specialist social worker locally who gives individual and group parenting skills classes. Kerry is perfect for her.
Kerry comes back a couple of weeks later to let me know how it went.
I really like my parenting support worker. She told me I mustnt call em little fuckers no more but instead they are good children with some c.h.a.l.l.e.n.g.i.n.g behaviour.
She goes on to tell me about how she is now rewarding good behaviour, setting consistent boundaries and using the naughty corner. Hold on a minute, I could have told her that. This parenting adviser must have watched the same episode of Supernanny that I saw.
Janine
Janine is nine years old and about 13 stone. She waddles into my room and then Mum waddles in after her. My room feels very small.
Its her ankles, Doctor. They hurt when she runs at school. She needs a note to say that she can sit out games.
Did you fall over or twist your ankle, Janine? I always try to engage with the child themselves if possible. Janine looks at the floor and then shakes her head. How long have they been sore? Eyes still to the floor, this time I get a shrug.
Right, lets have a look at these ankles then. I try to be engaging and smiley, stay positive and encouraging. I prod and poke her ankles and get her to move them around a bit. My examination is a bit of a show most of the time and today is no exception. One look at Janine walking into my room showed me that her ankles were basically normal. I try to make my prodding and poking look like it has purpose, but it is purely a performance for the benefit of Janine and her mum. I want them to think that I am taking them seriously, that I am genuinely looking for some underlying ankle pathology. As I prod away, I try to remember the names of some of the ankle ligaments no joy there. Perhaps Ill just try to remember which is the tibia and which is the fibula no, just confusing myself now.
Right Well, I cant find any swelling or tenderness in those ankles and shes walking okay This is the make or break moment How am I going to put this tactfully? I am standing at the top of the diving board but do I have the bottle to make that jump? I could just write the note, prescribe some paracetamol syrup and climb quietly down the ladder. No, Daniels, come on, its your duty to say something. Right. Here goes. Some children find that erm err that being a bit erm (Say it, Daniels, just say it) erm overweight can make their joints hurt sometimes. I had done it. I had jumped!
Janines mum looks me straight in the eye. Her face looks like a pitbull slowly chewing a wasp. Its got nothing to do with her weight, she says angrily. Janines cousin is as skinny as a rake and she has problems with her ankles, too. Its hereditary.
What can I say to that? My courageous leap got me nowhere. I belly-flopped painfully. Can I prove that Janines ankles hurt because she is fat? No. Is Janines mum going to accept that weight is an issue? No. I either argue on fruitlessly or accept that I am beaten and salvage the few scraps of the patientdoctor relationship that are still intact.
She can still do swimming! I shout as they waddle away, sick note and paracetamol prescription already tucked snugly into Mums handbag. It is a final attempt to redeem myself, but a poor one. I can picture Janine sitting in the changing rooms munching on some crisps while the rest of her class runs around outside. Beneath the many layers of abdominal fat, her pancreas would be slowly preparing itself for a lifetime of insulin resistance and the debilitating symptoms of diabetes that occur as a result. Meanwhile, her joints, straining under her weight, would be struggling to cope and the resulting damage would eventually develop into early onset arthritis.
Did I miss my chance to make a difference? Have I been a shit GP again? Are doctors slightly egotistical even to consider that a few well-placed words of advice from us can breach deeply entrenched lifestyle and dietary habits? Hold on, kids, no more sugary drinks and turkey twizzlers for us. Dr Daniels thinks we are overweight and thank goodness he pointed it out or we would never have noticed. Hes given me a wonderful recipe for an organic celery and sunflower seed bake and were swimming the Channel at the weekend.
Saving lives
A few years back I spent a stint working in a hospital in Mozambique. Each morning the American consultant would start the ward round with a prayer and then shout boldly and, with not the slightest hint of irony, Come on team, lets go save some lives! The rest of us would then cringe internally, roll our eyes at each other and then follow him round the mornings array of sick and dying Africans. There are a surprising number of Western doctors filing around the wards of African hospitals. Im not always sure of the motives but there we were: an American cardiologist, two British GPs and a French nurse. Between us, we had years of expensive medical training and lots of letters after our names. As we wandered through the wards, we didnt really save many lives. The majority of our patients were dying of AIDS-related illnesses or malaria. There were no anti-AIDS drugs (antiretrovirals, ARVs) and even our malaria medication supply was low because of a robbery at the hospital pharmacy (an inside job).
Meanwhile, 30 miles outside of town, Rachel, a 22-year-old from Glasgow with no letters after her name, really was saving lives. Rachel had dropped out of her sociology degree and had been working in a call centre before deciding to come and do some voluntary work in Mozambique. She had raised some sponsorship from back home and was touring the rural villages with a troop of local women. All she had at her disposal was a basketful of free condoms and a few hundred subsidised mosquito nets. Accompanied by information and education in the form of songs and posters, her campaign was a raging success. She later e-mailed me to say that malaria deaths had reduced and that she was hoping to have an equally good result with HIV transmission rates.
At the same time, my learned colleagues and I made clever diagnoses on the ward and skilfully inserted chest drains and spinal needles. Occasionally, we did save a life and it was quite exciting when a patient got up and went home after being at deaths door. As we waved them off, we knew that ultimately they would be back. They couldnt afford to pay for the full course of medication, and it was only a matter of time before they were unwell again and back in our hospital. We were briefly prolonging lives rather than saving them.
Regardless of the country it is practised in, most of hospital medicine is painting over the cracks rather than fixing the wall. Lives are saved by preventing illness rather than curing it. If you are 64 and admitted to hospital in the UK with a heart attack, it will be all blue lights and running around. After emergency heart scans, a dashing young doctor will probably give you a whack of clot-busting medicine into your veins and it could save your life. At age 16, this was just the kind of exciting medicine that I imagined my job would be. I have been that doctor and at times it is genuinely quite glamorous and exhilarating. Sometimes, it does make a real difference and lives are saved. The patient and family will thank you and youll feel pretty good for a bit.
Since I have been a GP, on balance I have probably saved far more lives than I did during my time as a hospital doctor. It is my job to try to prevent you from having a heart attack rather than save your life immediately after youve had one. It is far less glitzy and dramatic, but by helping patients control their blood pressure, give up smoking and reduce their cholesterol, I have probably helped prevent or at least delay many hundreds of heart attacks. This might sound like a pathetic attempt to try to elevate GPs and combat an inferiority complex put upon us by years of derogatory comments from our hospital colleagues, but I genuinely think it is true. In the same light, the pressure groups who pushed for the government bill for the smoking ban in public places or who pressed for the introduction of the compulsory wearing of seat belts will have saved more lives than all of us put together.
Public health doctors are those who rather than treating individual patients, look at the bigger picture of health trends across the country and the potential interventions that could help. The rest of the medical profession sneer at public health doctors even more than they do at GPs, but the conclusions of public health doctors influence big decisions made in Parliament and can save and improve many lives. The problem faced by public health campaigns in the UK is the tendency for people to react to being told what to do. In Mozambique, Rachel wasnt faced with angry villagers demanding the choice not to be given free condoms or complaining about the nanny state forcing them to sleep under mosquito nets. Getting the balance in the UK is difficult. The opposition to wearing seat belts 30 years ago and the smoking ban more recently was huge. Our role as GPs is trying to tread the fine balance between giving useful advice and encouragement to make good lifestyle choices whilst not being too paternalistic and patronising.
Kirsty, the trannie
Kirsty had once been a married man with three children, but over the last five years she had spent many thousands of pounds having surgery to become a woman. She had her chin made less square, breast implants and, most importantly, her male organs surgically transformed into female organs. (In post-op trannie circles this is known as having your chin, tits and bits done.) As well as the surgery, there was the electrolysis and oestrogen tablets, not to mention the huge amounts of money spent on boutique clothes, expensive make-up and a Gucci handbag that my wife would die for. The only problem was that Kirsty still looked overwhelmingly like a man. She was six foot two and had broad shoulders and stocky legs. Her 1980s perm and size-eleven feet squeezed into a pair of size-nine stilettos didnt help. Kirsty looked like a rugby bloke who had been badly dressed up as a woman by his mates on a stag do.
How do I look, Dr Daniels? Kirsty asked as she flicked her hair and fluttered her fake eyelashes in the worst attempt to be flirty that Ive ever seen. Ive had my boobs redone again. Do you want to have a look?
No, no, thats erm fine Im erm sure that they did a good job. Kirsty is such a regular at the surgery that she no longer feels the need to have a medical problem to present. She is quite happy to pitch up for a chat and a gossip. She always has a story to tell and is a nice break from the dreariness of afternoon surgery.
For those of you who are interested, the operation is called male to female gender reassignment surgery. There are various techniques but the most popular appears to be cutting off the testicles and inverting the penis. The penile and scrotal skin are combined and used to line the wall of the new vagina and to make the labia. The surgeon makes a clitoris using the part of the penis with the nerve and blood supply still intact. According to the surgeons website, this enables some patients to orgasm. I havent yet asked Kirsty about this but Im sure she would happily tell me all about it given half a chance.
Despite the extrovert exterior, there was a real sadness about Kirsty. The sacrifices that she had made to change her gender were extraordinary. She gave up her marriage and children (only one of whom still talks to her). She lost her job and many of her friends and the pain she describes of the surgery and recovery period is unimaginable. Kirsty now lives slightly on the fringes of society. She is stared at in the street and struggles to find acceptance at every corner. It seems amazing to me that she would have put herself through this much to make the change.
Kirsty, however, has absolutely no regrets. She told me that five years earlier she felt that her only choices were to have the operation or commit suicide. In the nicest possible way, Kirsty is a bit of a drama queen but I genuinely think she means this and the doctors at the practice who knew her as a man agree that she was pretty close to ending her life back then.
Empathy is defined as an identification with and understanding of anothers situation, feelings and motives. I like Kirsty but I cant really empathise with her, as I just find it so hard to imagine what it would be like to be so unhappy with the gender I was born with. Kirsty is quite astute and I think that she has spotted this in me. As she left, she said, Its fucking hard being me, you know. You should try being a trannie for a day.
I did once lose a bet at medical school and had to spend an evening out dressed as Smurfette. Im not sure it really corresponds to empathising with the emotional and physical turmoil experienced by a transsexual; however, being painted completely blue and wearing a dress and blonde pigtails, it did take me a hell of a long time to get served at the bar.
Its my boobs, Doc
Stacy was in her late thirties but the years of smoking and sunbeds made her look much older. She stormed in and sat down with the look of someone who wasnt going to leave until she got what she wanted. Its my boobs, Doc. I must have had a slightly puzzled look on my face, so in order to enlighten me she lifted her top to reveal her large and extremely distorted breasts. They looked like two oval-shaped melons surrounded by a layer of puckered skin and had two nipples drooping off the ends. They were pointing at awkward angles and looked completely disconnected from the rest of her body.