‘We’re time twins!’ Kenny shouted enthusiastically.
‘Yes, we are,’ I replied smiling, unable not to be caught up in Kenny’s infectious drug-induced gusto.
‘I tell you another thing we’ve got in common, Dr Ben. As a boy I always dreamed of being a doctor. I wanted to do something good with my life. I really wanted to help people and make them better. I also liked the idea of driving a nice car and flirting with lots of sexy nurses.’ He gave me a wink. ‘Although I think I might have left it a little late now,’ he added ruefully.
‘It’s never too late to flirt with the nurses, Kenny, but I’d give our charge nurse Barry a wide birth. He’s a grumpy old bugger.’
‘Yeah, I spotted him on my way in. Perhaps a career in medicine isn’t for me after all.’
Maybe it was just too much emotion caused by lack of sleep, but I couldn’t help but feel a connection with Kenny. Sharing a date of birth is fairly insignificant really, in the big scheme of things, but at four in the morning during our peculiar substance-enhanced encounter, it seemed to hold some meaning.
I imagined us both as small babies, beginning our lives on that same day. We would have started off similarly enough as two equally innocent infant boys, new and full of potential. Our first steps and first words would have coincided and at some point during our childhoods we both decided that we wanted to be doctors. What had ebbed away at Kenny’s potential while mine was being steadfastly encouraged?
After giving Kenny a quick check over, I wandered out to the nurses’ station where Barry the charge nurse was slumped in his chair looking unshakably miserable. I told him about the connection I’d made with my time twin and reflected on why and how our lives had taken such different paths.
‘He’s just a smack head who happens to share your birthday. Stop being a sentimental twat and get some work done. Most importantly, get him discharged before he comes down off whatever he’s taken and starts kicking off.’
As I finished writing up his notes, the prison officer walked Kenny out of the department to his waiting van. ‘My carriage awaits!’ he exclaimed giving me a regal wave with his non-cuffed hand. ‘See ya later, Big Nose Benny.’
‘Nice meeting you, Crackhead Kenny.’
Maggie I
‘It’s my leg, Doctor. It doesn’t really do what I want it to do. It’s as if it’s not really part of me any more.’ Maggie tried to crack a smile but I could see she was really scared.
‘Right, let’s have a look then.’
Maggie was quite right. Her left leg wasn’t doing what it was supposed to be doing. She could sort of move it, but her coordination was shot and she had resorted to walking with a stick.
‘I’m walking like an old lady, but I’m only 56. It just came on over the weekend and it’s getting worse.’
Maggie was clearly looking for some reassurance, but the truth was that I was worried too.
‘We need to get this looked into,’ I said, stating the obvious.
I’d met Maggie a few times, but usually only when she was accompanying her husband for his blood pressure appointments.
‘Any medical problems in the past?’ I asked as I scanned through her notes.
‘No, I’m fit as a flea. Well, I had breast cancer in 2003, but that’s long gone. It can’t be anything to do with that.’
I looked up from my computer screen and she held my gaze. I was trying to find words that might be both reassuring and honest, but before I could even open my mouth, Maggie was crying.
‘The breast cancer’s all gone,’ she blubbed, trying to convince herself more than convince me. ‘They discharged me from the clinic five years ago.’
‘It may well be nothing to do with the breast cancer, but let’s just get some tests done.’
Maggie clearly needed to see a specialist and have a scan. She didn’t really need to be admitted to hospital that morning, but then it wasn’t appropriate to make her wait two weeks for an outpatient appointment either. When stuck with this sort of quandary, I generally default to the ‘What would I want if it was me?’ option. This turned the decision into a bit of a no-brainer and I phoned the medical consultant on call who agreed that she should go straight up to the hospital.
Sometimes it’s really satisfying to get a diagnosis right, but I took no pleasure in having my suspicions confirmed this time. Maggie’s leg symptoms were due to her breast cancer returning. It had already spread extensively and it was lesions in the brain that were causing her leg symptoms. After being told the result of the scan she was discharged with some steroids.
Maggie had still been in a state of shock when they’d given her the diagnosis in hospital, so she made an appointment with me to go over a few things. First of all she wanted to know how the cancer had lain dormant for all those years before coming back. I would like to have been able to answer that question, but the truth was I just didn’t know. It wasn’t something she’d done wrong; it was just one of those awful facts about cancer. Sometimes we think we have beaten it, yet somehow this horrible disease has a dirty habit of reappearing. Maggie hadn’t even noticed a breast lump, but by the time she had her scan there were cancerous lesions in her liver, bones and brain. The cancer specialist offered her some chemotherapy that might temporarily shrink the tumours, but he made it very clear that he could offer her no cure.
‘What now?’ was her next question.
Again, this was a hard one to answer. ‘We’ll get the palliative care nurses involved and will always make sure that you’re never in pain or distress with the symptoms. You might remain stable and fairly well for some time …’
‘But basically I’m going to die.’
I thought about trying to counter that remark with something upbeat and positive, but in reality Maggie was right. She was going to die and I couldn’t say anything that would change that fact. I stayed quiet, handed her a tissue and put my hand on her hand. We sat in silence for a few moments while she sobbed. After she left, I made myself a quick cup of tea, splashed some cold water on my face and pulled myself together enough to see my next patient.
Brian and Deidre
Every couple of months or so the surgery shuts for an afternoon and we have some sort of educational session. It’s an attempt to keep us up to date and make us better doctors. The most recent education afternoon was on the topic of sexual health. A lady with a colourful silk scarf and ethnic sandals was talking to us about the importance of sexual identity.
‘How often do you see your patients as sexual beings?’ she asked. ‘How often do you consider how the medications you prescribe might affect the sexuality of your patients?’ I had to admit that the answer to both of these questions was ‘never’. I knew that some medications could affect libido and erections, but I tended to avoid discussing it with patients if I could. This was all going to change from now on, though, I decided. The sex therapist lady was right. There was no point lowering a patient’s blood pressure if I was going to ruin his relationship because my drugs were inhibiting his erections.
The first chance to demonstrate my newfound sensitivity came the very next day. Brian had come in for a review of his blood pressure medication. I know it’s wrong to pigeonhole, but I always felt like Brian looked like the perfect stereotype of a bus driver: mid-50s, with mutton-chop sideburns and an ever-expanding beer belly. His faded white shirt always had large yellow sweat patches in his armpits and was open at the neck to reveal a big gold chain that matched his sovereign rings. Brian was accompanied by his wife Deidre, and although they always came to see me together, I had the impression that their relationship was often strained. With my new approach, perhaps I could help?
‘Brian, some men find that beta-blocker medication like the one you’re taking for your blood pressure can affect their ability to have erections. Do you ever find this to be a problem?’
‘Well, funny you should say that, Doctor. Me and the wife here have been struggling to manage in the bedroom department for some time. When w
e’re alone together I just can’t seem to get the little fella to stand to attention these days.’
Wow, I think to myself. What a breakthrough. The nice sex therapist lady was right. We do need to talk more about sex with our patients. Perhaps I can make a real difference to Brian and Deidre’s relationship. Perhaps the sexual frustration is the reason why they’re always bickering.
‘Mind you, I do still get erections though, Doctor,’ Brian said, interrupting my thought process.
‘This young lass got on the bus last Tuesday. It was a right warm day if you remember and, cor blimey Dr Daniels, you should have seen her! Gorgeous she was. Legs this long and a little top that didn’t leave much to the imagination if you catch my drift …’
Brian went on to explain in some detail each item of his young passenger’s clothing, and the relative part of her anatomy that was exposed as a result. ‘Rock solid I was, Doctor. Could barely keep the bus on the road! I could see her in my rear-view mirror and I had wood from the stop outside Boots on the high road all the way to the leisure centre past South Street. That’s five stops, and I got caught at the lights just before the bridge. I really don’t think it’s the blood pressure tablets that are the problem, Doctor. I think it might be Deidre. She’s not the woman she was. Just doesn’t really do it for me any more.’
Deidre had been sitting quietly up until now, but I could sense her rising fury. ‘Don’t you worry, Dr Daniels, erection or no erection, Brian doesn’t do a great deal for me either these days. In fact, he never really did. Even when we were young I always had a lot more fun on my own, if you know what I mean.’
Brian and Deidre went on to describe each other’s inadequacies in the bedroom department in some detail. To make things even more awkward, they didn’t speak directly to each other but instead spoke to me as if the other wasn’t present. I sank as deeply as I possibly could into my chair and cursed myself for turning what could have been a nice simple consultation into something so toe-curlingly awkward that I wished the ground would swallow me up. I tried to think of some useful interjections, but I was well out of my depth with this one, so instead I sat excruciatingly silent until Brian and Deidre decided that I had heard enough and left.
My brief attempt at viewing my patients as ‘sexual beings’ was well and truly over.
Maggie II
Maggie had come back to see me after seeing the cancer specialist again.
‘He was very nice, but he soon discharged me when I decided that I wasn’t going to have any chemotherapy.’
‘How are you coping?’
‘Everyone keeps telling me how brave I am. They tell me I’m a fighter and that I’m strong. I’m fucking dying and they just talk to me about staying positive. The problem is, Dr Daniels, I’m not that brave or strong or positive. Right now I’m scared. In fact, I’m thoroughly terrified. It’s as if I’m not allowed to admit it to anyone because I have to be so godforsaking brave the whole bloody time.’
‘It’s okay. You’re allowed to be scared.’
‘How about fucking terrified?’
‘Yup, that too.’
‘I’m all right when people are around or when I’m busy, but when everyone else is out and I’m alone in the house, I can’t stop myself from wondering about the end. How will it be? Will I be in pain? Will it be next week or still months away? Will I stop breathing first or will it be my heart that stops? Will I already be in a coma or will I feel myself dying? I need to have some power over this. Sometimes I wish I could piss off to Switzerland and end it all now. I just want to wrestle back control over this whole sodding thing.’
Regardless of the person with the cancer, the same clichés seem to recur time and time again. One of which is sufferers of the disease being universally thought of as ‘brave’. The public image is of ‘brave’ cancer sufferers heroically running marathons while defiantly sporting their chemotherapy-induced baldness. It’s as if the brave label arrives the moment you are diagnosed with cancer and you’re not allowed to be anything else. Reality TV personality Jade Goody morphed from being a national hate figure to being some sort of serene martyr the moment she was given her cancer diagnosis. In fact, such was the furore when she died that some people were calling for cervical cancer to be renamed ‘Jade Goody disease’. I thought I was going to have to start telling people that their smear revealed some abnormal Jade Goody cells on their cervix or that the Goody had spread to their liver. Jesus, as if breaking bad news isn’t hard enough already!
It wasn’t that Maggie was any less brave than anyone else. She was having a thoroughly normal reaction to the knowledge that she was going to die. We hadn’t really known each other well before her diagnosis, but she seemed to have acquired an immense trust in me since I spotted that she had cancer. To be fair, it wasn’t some sort of clever diagnosis worthy of House, but she clearly appreciated me sending her straight into hospital that first afternoon. There was no cure, but we were going to do everything we could to ‘keep her comfortable’. There’s another classic cancer cliché that Maggie hates.
Communication skills
Once a year our surgery sends out hundreds of anonymous patient satisfaction questionnaires. It always makes me feel a little under scrutiny, but overall I can’t dismiss the potential value of finding out what my patients really think about me. Some of the questions are about general matters, such as telephone access and how long it takes to get an appointment. Others are more directly targeted towards the patient’s interactions with the doctor, and contributors are specifically invited to comment on the experience of their most recent consultation.
When the collated results are emailed to me, I eagerly read them through. Being a good doctor isn’t just about being popular, but I can’t pretend that I wouldn’t feel thoroughly demoralised if all my patients reported in their questionnaires that they hated me!
This year, the first question asked whether the doctor helped them feel at ease. Phew, 85 per cent of my patients felt I had done this. The second question was whether the patient felt that their concerns had been listened to: 83 per cent scored me highly on this one. A further 88 per cent of the respondents were impressed with my ability to communicate with them. It was a relief that I was scoring well, but I was only reaching the average scores that most GPs achieve on these standardised surveys. Despite the regular pounding we get in the media, overall satisfaction in GP services remains consistently high.
The final question asked if the patients felt that their last consultation had helped lead to an improvement in their physical or mental health. On this I scored 40 per cent. Ouch! That meant for the majority of my patients, although they were put at ease, had their concerns listened to and were well communicated with, their actual health was no better off after seeing me than it was before.
This might seem like an epic failure, but actually it is a very accurate description of what a doctor does. The famous French writer Voltaire said that ‘the art of medicine consists in amusing the patient while nature cures the disease’. I would add that nature sometimes makes them worse too, but ultimately our role is often to offer a distraction while time and the miraculous natural healing abilities of the human body work their magic. Some of my patients are very aware of the limits of my therapeutic abilities, but others seem to feel that I should be performing miracles. Regardless of their expectations of my curative powers, every patient expects me to be nice to them.
It sounds obvious really, and of course it is, but a huge proportion of complaints against doctors aren’t about medical errors leading to ill health, but rather about doctors communicating poorly or not listening. One of my colleagues in A&E tells me that he always makes an effort to be ridiculously attentive to his patients however exhausted or frustrated he feels. Regardless of how rude, demanding and ungrateful the patient, he makes a huge show of bending over backwards to be gregariously charming. ‘Speaking to patients is like acting,’ he told me. ‘The only difference between me and a film star is that I’m
too short, fat and bald for Hollywood.’ I try to follow his advice, but often my acting lets me down. It can be hard to be incessantly charming for an entire 12-hour night shift, but when I do manage it, my patients love me, regardless of how little I actually improve their health. This is why medicine is so often described by those in the profession as an art rather than as a science.
Having established the overwhelming importance of good communication skills when interacting with patients, it can be astonishing to witness some health-care professionals doing it so badly. Most catastrophic is when they have absolutely no idea how bad they are. Perhaps the oddest example I ever came across was as a student sitting in with a vascular surgeon. A nervous-looking gent in his 60s shuffled in with some smoking-related damage to the arteries in his legs. The very pompous surgeon asked him if he was still smoking. Defensively, the gent reassured the doctor that he had cut down from 20 cigarettes per day to just five. ‘Hmm,’ said the surgeon. ‘That’s hardly the greatest of achievements now is it? If I was a rapist who used to rape 20 women a day, but I had just recently cut down to raping just five women a day, I’d still be a horrible little rapist now wouldn’t I?’ The poor patient simply nodded aghast and I meanwhile had to pick my chin up off the floor. Perhaps it helped the patient in question give up those last five cigarettes, but even so, I’m not sure it could ever be recommended as a suitable technique for offering health promotion.
My personal worst moment of communication was about eight hours into a busy A&E shift some years ago. Corresponding to each patient sitting in the waiting room was a small set of paper notes headed with their name and the medical complaint that had brought them into the emergency department. Hour after hour, the routine was the same: I would pick up the top set of notes from the endless pile, walk into the noisy waiting room and shout out their name. For some reason, on this one occasion, instead of calling out the name, I shouted out the patient’s medical complaint instead.
Further Confessions of a GP (The Confessions Series) Page 2
