My first job after qualifying was as a junior surgical doctor and I had a particularly frightening consultant. His ward rounds were terrifying and when he demanded a patient’s blood results, I was expected to know them. If I didn’t have them to hand I was on the end of a bollocking that could be heard from the other side of the hospital. My response to this was to do blood tests on all my patients every day to make sure that I had every possible result to hand. Not only were my poor patients often unnecessarily stabbed with a needle each morning, but I must have personally cost the NHS a small fortune. How much? I have no idea. To this day I don’t know the cost of a standard blood test, but I should, shouldn’t I? I’m not suggesting that doctors shouldn’t order blood tests any more, but clearly knowing the financial value alongside the clinical value of what we do is important.
One of my patients got the shock of his life recently when he discovered the actual cost of the injections he is having for his rheumatoid arthritis. He has one per week and they cost £178.75 each. That’s twice his weekly rent. He wanted to know if he should add them to his house insurance, as when he has four syringes of the stuff sitting in his fridge, they are more valuable than anything else he owns. Of course I don’t begrudge him these injections. I am extremely proud that the NHS provides them for him. They have allowed him to continue working and kept him off benefits. They make a massive difference to his quality of life, but I’m glad he knows their financial value as it means that he treats them with the respect they deserve. He understands how precious each vial is and ensures that they don’t get smashed or accidentally thrown out with the mouldy vegetables when his fridge gets a clean.
The government is planning to send us all a breakdown of exactly what our tax is spent on. Should we be sent something similar about how much we cost in terms of our health care? I don’t want anyone to be made to feel guilty about using the NHS, but how many of my patients who miss a hospital appointment realise that each failed attendance costs around £120. Or that it costs £59.48 for the asthma inhaler that keeps getting left on the bus and £244 for the ambulance needed to get to A&E after drinking to oblivion on a Saturday night. I don’t advocate anything other than a free health service at the point of delivery, but just knowing the financial value of what is provided is a good thing for patients and doctors alike, isn’t it?
Danni I
One of the most striking things about Danni was how unattractive she was. I couldn’t quite believe that men paid money to have sex with her. This can’t help but sound incredibly mean, but it really was my gut reaction when she first told me her profession. Danni was 25 years old, but so slight and slim she had the body of a 13-year-old. Her face, however, looked older than her years and was dominated by bulging dark eyes with large bags underneath and sharp protruding cheekbones. Her lips were thin and the angles of her mouth were cracked with sore-looking red lines. The medical term is angular cheilitis and I remember learning at medical school about various causes. In Danni’s case the cause was basically malnutrition. The only things that went in her mouth were Coca-Cola, cigarettes, a crack pipe and her clients’ penises.
I was curious to know how much she charged. I knew she spent almost every penny she earned on crack, but I wondered whether she got paid directly by her pimp in drugs, or got to walk away with a bit of cash in her pocket. I nearly asked her, but deep down I knew that I couldn’t really justify this question as part of my medical consultation. She had a childlike respect for authority and if I’d asked the question she would have answered without hesitation. Much as I was tempted it wasn’t fair for me to feed my voyeuristic intrigue. I also didn’t want her to get the wrong idea as to why I might be asking about prices for her services.
I could tell Danni was nervous because she was incessantly putting Chapstick on her lips. Taking off the lid, twisting the bottom and smearing her lips every few seconds. I’m fairly sure she didn’t even realise she was doing it and the Chapstick was probably a substitute for the cigarette with which she could normally occupy her hands.
‘I’m sorry, Dr Daniels, but I’m a bit mucky down below. I think I might have picked something up again.’ She looked genuinely apologetic, as if she’d really let me down.
‘I thought you promised me you were always going to use protection from now on.’
‘Yeah, I meant to, but it’s getting harder and harder to find decent punters. The Eastern European girls have driven the prices down and I can only get work now if I go bare back. It’s the recession.’
Normally it was just plumbers and carpenters who complained to me about EU labour migration and the double-dip recession. I hadn’t realised it was affecting the oldest profession as well.
‘But it’s dangerous, Danni. You could catch HIV.’
Danni looked up at me like I had just told her off; I had rarely felt so paternal towards a patient.
‘He was one of my regulars, so I thought it would be okay.’
The idea that a client who regularly used prostitutes would be less likely to have an STI seemed an odd concept but I wasn’t going to take her up on it.
‘He’s the dad of my two kids,’ she added nonchalantly.
‘The dad of your two kids is still one of your clients? Do you still charge him?’
‘Well, he pays the other girls so I don’t see why he shouldn’t pay me.’
After a few years in this job I thought nothing could surprise me, but Danni had left me absolutely speechless.
‘He’s not looking after your kids, is he?’
‘No, they’re still with the foster family. The social worker says that if I stay clean for six months I’ll be allowed supervised contact.’
‘That’s great and how’s that going? Staying clean I mean.’
Danni’s hesitation said it all and we both knew she was no closer to kicking her habit.
I ended the awkward silence by asking her to get up on the couch so I could examine her. The discharge looked and smelled like gonorrhoea, but I sent off some swabs to be sure. Some of the medical advances made over the last 150 years have been incredible, but go back to Victorian Britain and you would have found a doctor like me examining prostitutes for gonorrhoea in much the same way. Medics can now look at MRI scans on their iPhones and blast away tumours with lasers, but we can’t seem to stop those same old-fashioned gonorrhoea bacteria being passed to and fro in precisely the same way they always have done. In Victorian times doctors prescribed prostitutes with compulsory doses of mercury and arsenic for gonorrhoea. At least Danni had come to see me voluntarily and I could give her antibiotics rather than poison. There have been reports of antibiotic-resistant strains of gonorrhoea, but thankfully our local variety generally still responds to penicillin.
‘I am sorry, Doctor,’ Danni repeated.
‘Don’t be sorry, Danni. I just want you to look after yourself.’
‘I will, I promise.’
The NHS, the envy of the world?
The NHS is the envy of the world … although apparently it’s not the envy of many Polish people living in the UK. Such is their dissatisfaction with our health-care system, many of my Polish patients go home to seek medical care and two Polish doctors have set up their own private clinic in London, which is apparently thriving. I could quote data showing how good our health care outcomes are in comparison to other nations, but for most people, personal experiences outweigh any statistical evidence that I can offer.
One of my young Polish patients asked me why doctors in the NHS only prescribe paracetamol. The answer is, of course, that we don’t. I prescribed him paracetamol for his slightly sore knee and explained that it would get better on its own. He told me that in Poland he would have got an X-ray and seen an orthopaedic surgeon. I also prescribed him paracetamol for his viral sore throat. In Poland his doctor would have apparently performed a chest X-ray and given antibiotics. I have prescribed him only simple painkillers for his ailments because they are benign and due to the amazing self-healing power of the
human body they will get better all on their own. He is a fit 28-year-old who doesn’t need extensive medical investigations for his minor health complaints, but were a privately run health clinic to be set up in our local town, I suspect he would happily part with £70 to see a non-NHS GP. I’ve not seen many private doctors prescribe a cheap drug like paracetamol when they can prescribe numerous more expensive ones. It would also be lucrative for a private practitioner to order as many expensive investigations as possible. These should be done quickly, as once the patient gets better, he may not be quite so willing to part with his credit card details.
Going against the grain, I do have one Polish patient who isn’t quite so critical of the NHS. She is only 23 years old and has been working here as a waitress. She came to see me one afternoon with a lump on her arm. It was hard and craggy and felt like it was attached to the bone. I placed her urgently on the cancer referral pathway and within 10 days she had seen a specialist, who unfortunately agreed with my diagnosis. She had a rare aggressive bone cancer called an osteosarcoma and it needed urgent treatment. She was sent to the Royal National Orthopaedic Hospital in London where she received top-notch cancer treatment and the sort of specialist surgery that only a few places in the world can offer. She is now back at work with only a small scar on her forearm to remind her of her recent brush with death. She went back home to Warsaw last month to take her notes and scans to a Polish doctor for his opinion. He told her that the management for her condition in Poland would have been to amputate her arm above the elbow.
Those most ill tend not to be the ones who complain loudly about the NHS. A person who has been hit by a bus or is being treated for cancer tends to sing praises for the treatment they receive. The private clinics steer well clear of those who are seriously unwell as there is no money to be made from them. I can’t imagine a team of private doctors offering to set up an independent A&E department. The private sector prefer to cherry pick the fortunate majority, who are basically fairly well but are often disgruntled with the NHS. The private health-care system in the USA is extremely lucrative for the same reason. They also make their huge profits by targeting their services to well people. For example, they have scared the population into believing that they all need yearly colonoscopies to screen for bowel cancer. Each colonoscopy test costs on average $1,185, while here in the UK we test poo for signs of bowel cancer instead which costs around £10. Studies suggest that both techniques have similar levels of effectiveness as a screening tool, but the American insurance companies can’t make any money out of a £10 poo test. Of course, the real crime in the USA is that people with bowel cancer but no health insurance die, unable to afford a colonoscopy or the potentially life-saving treatment they need. Thank goodness for the NHS.
Much as I love the principles of the NHS, I don’t live in a bubble and I would be the first to admit that it can be a bit rubbish sometimes, as can some of the people who work within it. We need to constantly root out our failings and strive to improve it from within. Sometimes this feels like an impossible task and when the NHS is on the receiving end of a constant barrage of abuse from the media, it can be tempting to look to the private sector as a way out. A private health clinic recently asked me if I’d consider leaving the NHS to become a private GP. I said no, and for two reasons. The first was that if patients are really sick, there is nothing better than our local NHS services. Secondly, I became a doctor to provide sick people with what they need, rather than offer well people what they want.
Don’t look down
‘Don’t look down, Ben,’ I was saying to myself over and over in my head. My throat was tightening and beads of sweat were forming on my forehead. No, I wasn’t walking a tightrope across the Grand Canyon – it was much harder than that. I was trying to maintain eye contact with a patient and avoid looking down at her ridiculously enormous breasts.
Well into her late 40s, every other part of Julie’s body was moving in a southerly direction, but somehow her breasts were defying Newton’s laws and appeared perfectly suspended by an invisible force that was maintaining them at an exact right angle to her body. I was rather hoping that Julie was completely unaware of the tricky battle going on in my head, but I suspect not. She was wearing a particularly skimpy top given the cold spell of weather we’d been having and just when I seemed to be successfully maintaining uninterrupted eye contact, she would push her chest out and wriggle in her seat, throwing me completely off my game.
I had met Julie once or twice before, but had no previous recollection of her breasts. I would like to point out that I don’t generally remember my patients on the basis of their bra size, but such was the oddity of the bosoms that I was trying desperately to ignore that I couldn’t believe they would have previously passed me by unnoticed. I had watched enough episodes of Celebrity Big Brother to be able to at least hazard a guess that they were fake, but such was my desperation not to be caught staring that I couldn’t be 100 per cent sure that they were in fact due to prosthetics rather than genetics.
After the normal small talk about the weather, Julie told me why she was there.
‘I just need another sick note, Doctor.’
Scanning through her medical notes, I could see that Julie only ever really attended the surgery for sick notes. Every six months or so she would see a doctor and be signed off work for depression. She had always declined counselling or antidepressants, but when on her last visit I’d asked her to fill in a depression questionnaire, she scored maximum points and so the sick note was extended. Surely this time I couldn’t sign her off work quite so readily. She had almost certainly had a boob job since her last visit and this was throwing me into an ethics minefield. Can you really be too depressed to work yet voluntarily endure the pain and stress of major cosmetic surgery? What about the money? Are you allowed to claim benefits if you have a spare £6,000 for a new set of breasts? Most importantly for me, how was I going to broach this sensitive subject? Such was my inert sense of awkwardness, I could barely bring myself to even glance at Julie’s breasts, let alone declare them as a topic of conversation. Imagine the embarrassment I would face if I cited her false breasts as evidence that she couldn’t be depressed and they turned out to be real! I decided I would have to approach the subject from a different angle.
‘So, how is your depression at the moment, Julie?’
‘Actually, not that bad, Doctor. I’m feeling happier than I have done for a long time.’
Great, I thought to myself. No sick note for you, and I wouldn’t have to mention the two white elephants in the room. This was turning out to be considerably less stressful than I had feared.
‘I was depressed before, so my Gary bought me these new boobs for my birthday and it’s worked a treat. My Gary always knows how to cheer me up and they’ve put a big smile on his face too! What do you reckon of them?’ Julie asked, proudly pushing her chest in my direction.
‘Well, erm … I hadn’t really erm … noticed …’
‘Oh get away, Dr Daniels, you’ve barely taken your eyes off them since I walked through the door,’ she said, smiling broadly.
I was now staring at my computer screen intently pretending to be checking something important, while secretly wishing the ground would swallow me whole.
‘Well … erm Julie, so … erm … getting back to the reason for your visit here today. Surely you don’t really need a sick note any more now that you’re no longer depressed?’
‘Thing is, Doctor, I am much happier now, but my Gary’s a cheeky little rascal and he ordered a cup size or two too big. Let me tell you these things weigh an absolute ton and my back is bloody killing me. So if you could just cross out depression on the sick note and replace it with back pain that would be grand.’
Mrs Patrick
Mrs Patrick was my nemesis. As already mentioned, she was the very first patient I had seen at this surgery and I can still remember her venomous distrust in me the first time we met. Her misgivings about me had not diminished
, but nor had they prevented her from visiting me at least once per week for the past nine months. Such was the frequency of her visits that some days I spent considerably more time with her than I did my own wife.
‘Just a few problems today, Doctor,’ she uttered as she pulled out a lengthy list of her ailments neatly jotted in blue biro on a scrap of paper.
The production of a ‘list’ always causes my heart to sink a little, but when the list belonged to Mrs Patrick, I usually completely lost the will to live. It was a Thursday morning and I had last seen Mrs Patrick on the preceding Monday afternoon. How could she have developed a brand new list of medical ailments in less than 72 hours?
‘Well, first of all I’m getting terrible headaches.’
Mrs Patrick declared this complaint as if it was the first time it had ever been mentioned to a doctor. She had in fact been suffering from headaches since before I was born. It was first documented in her notes in 1974 and I wondered just how many GPs, neurologists and pain specialists had heard about her headaches over the past 40 years. As technology developed so did Mrs Patrick’s headache investigation. When the CT scanner was invented, her doctor referred her for a CT scan. When the MRI scanner was devised, she was diligently sent for an MRI scan. I could just picture her disappointment as each new ground-breaking investigation reported her brain as being completely normal. Over the last four decades numerous new headache medications had come onto the market. A succession of doctors had endeavoured to embrace these latest pharmacological discoveries for her benefit, but without exception each pioneering medication had offered no relief. Continuing this trend, my latest desperate attempt at curing her headaches had fared no better: ‘Those tablets you gave me made my headaches about a million times worse,’ she snarled at me as if I had prescribed them in a deliberate attempt to cause her distress.
Further Confessions of a GP (The Confessions Series) Page 8
