These prospective medical students had already passed a stringent shortlisting process, which involved having high academic grades and passing an aptitude test. They had all written enthusiastic personal statements and had glowing references. Now it was the turn of we three doctors to make the final decision as to whether they were good enough to one day become doctors.
This is a pretty tough call to make based on spending 15 minutes or so with a nervous 17-year-old and although there is a subjective element to the decision-making process, we had set questions and a marking scheme in order to try to make everything as fair as possible. Medicine was once an extremely male-dominated profession, but now 70 per cent of students at our local medical school are female. This is fairly common throughout the country and it will be fascinating to see how the dynamics of medicine change over the next decade or so as the profession becomes increasingly female dominated.
Until I started interviewing, I couldn’t work out why so many more young women were being selected over men, but as I saw more and more applicants, the reason became increasingly obvious. The girls were just so much better than the boys in the interviews. They were articulate and enthusiastic with a range of interests and could conduct themselves really well. With the odd exception, the boys couldn’t. Such was the contrast that I was amazed that the percentage of male students getting in was as high as 30 per cent.
My two fellow interviewers were both female doctors and seemed undeterred by the huge mismatch in how the genders were performing. As we accepted more and more girls and rejected more and more boys I felt sure that at least one boy would do well and get offered a place. The next lad to walk in instantly reminded me of myself at his age. His shiny Marks & Spencer suit was as ill-fitting and unfashionable as the one I’d worn at my medical school interview. He was skinny and awkward and just looked so much younger and less worldly than the girls we had seen before him. His references and predicted grades were excellent and I was determined I was going to do my best to give him a really good shot. Unfortunately, despite being thoroughly likeable, he was stumbling through the questions and was scoring as badly as the other boys.
We were halfway through the interview. The next set question was to ask what he had achieved during that summer. The marking scheme gave points for voluntary work and anything that indicated a breadth of extra-curricular interests. The last girl who’d been in had told us about her charity work at a local hospice and how she had passed her grade-eight violin exam with distinction; the girl before told us of the fantastic sense of achievement she had felt on completion of her Duke of Edinburgh gold award. The young lad sitting in front of us looked completely flummoxed by the question and as far as I was concerned, rightly so. When I was 17, I spent the entirety of my summer holidays playing Tomb Raider on my PlayStation, getting stoned and masturbating. Charity work and music exams had been the last thing on my mind. If I could state my greatest achievements of that summer it was learning to skin up and having a moderately successful fumble in the dark with a girl I met at a music festival. By the uncomfortable dithering from the young lad in front of us, I got the impression that his summer had been equally unproductive.
‘Did you go away anywhere, perhaps?’ I prompted in an attempt to end the awkward silence.
‘Oh yes, I went to Glastonbury with my mates.’
‘Great, did you have a good time?’
‘Yeah, it was the best,’ he said, breaking into a big smile.
And with that I scored him maximum points on my marking sheet. As far as I was concerned, there was no reason why spending a summer practising the violin or orienteering on Dartmoor would make anyone a better doctor than going to a music festival.
After that he relaxed a bit, and as the interview went on he showed himself to be charming, intelligent and equipped with the kind of qualities we were looking for. Even my fellow interviewers were won over and we decided to offer him a place.
Taking benefits away from addicts
Crackhead Kenny had come back to see me. He bashfully apologised for storming out on me last time he was in; I told him that I accepted his apology, and I meant it. There’s no room in this job for holding grudges and I was pleased that Kenny had decided to stick with me as his GP rather than move to another practice in an attempt to find a doctor who would prescribe him what I had refused.
Kenny was here to ask me for a sick note and it was a timely request as that very morning it had been reported that the government was threatening to stop heroin addicts from being able to claim incapacity benefit. About a hundred of my patients are heroin users and they are all signed off work. The government spokesman pointed out that it was unfair that hardworking taxpayers were paying for the addictions of others. This may well be true, but is an attempt to force heroin users such as Kenny into gainful employment really a viable option?
We recently advertised for an admin assistant at our surgery. It is a low paid, unskilled, part-time position that requires no previous experience and no great physical exertion. Such is the nature of the times, we had more than 60 applicants, most of whom were greatly overqualified for the post. None of the applicants were intravenous heroin users, but if any were we wouldn’t have shortlisted them. If we wouldn’t consider employing a heroin user, who does the government think will? With the exception of the odd ailing rock star, I am yet to hear of a gainfully employed injecting heroin addict.
Heroin is an awful, all-consuming drug that destroys the personality of the person behind the habit. The next fix becomes more important to the user than food, shelter and, most sad of all, the people who care about them most. It is not a lifestyle that can easily coexist with a nine-to-five job. As Kenny sits in front of me, I don’t even consider not signing his sick note. There is no way in the world that he could hold down a job in his current state. The government is very welcome to switch Kenny and addicts like him from incapacity benefit to jobseeker’s allowance, but it would simply be an expensive and time-consuming PR exercise.
If the government chooses to take it one step further and remove all drug users’ benefits, the result would be an almighty hurrah from some, but it would simply mean a large number of the most vulnerable members of our society being made homeless and pushed further into crime, prostitution and begging as they looked for alternative ways to feed their habits. The extra burden placed on the criminal justice system would almost certainly end up costing far more than the relatively meagre hand-outs that heroin users currently receive in the form of incapacity benefit. It is much too simplistic to think that if we took Kenny’s benefits away from him, he would be forced to stop taking drugs, find a job and instantly become a more positive and worthwhile contributor to society.
Our local drug and rehab services are very good, but although most of my patients who use heroin are actively enrolled within substance misuse services, very few will successfully turn their lives around. Treating heroin addicts punitively with prison sentences doesn’t seem to work either, so it would appear to me better to try to work out why people fall into heroin addiction in the first place. Most of us experiment with drugs to some level or another in our youth, but even during my own sustained and enthusiastic period of adolescent experimentation, I never got anywhere near a place where injecting a syringe full of heroin into my arm jumped out as being a good idea.
Kenny had a 10-minute appointment with me that day and it took less than one minute to fill in a sick note. I decided that it might be an opportunity to ask him how he became an addict. The story Kenny told me was a familiar one. As with many of my patients who use heroin, he seemed to take those extra few steps into harder drugs and full-scale addiction after a fairly miserable start in life. Heroin is often an escape from the grim realities of life, and among my patients child abuse and growing up in care seem to pop up time and time again as the most damaging experiences addicts are trying to escape from.
As a doctor, I try not to get carried away with the emotion and morality of what I see
because it interferes with the practical aspects of the job. Many of my patients have self-inflicted injuries and illnesses and whether they are due to heroin, alcohol, smoking or falling off ponies, offering my indignation benefits no one. In my eyes politicians have no option but to take the same approach. I am dealing with addiction on an individual basis while they have to consider it on a more national scale, but ultimately the realities are the same.
Heroin dependence exists and is hugely detrimental to everyone. Vitriolic sound bites about the cost to taxpayers might make favourable headlines in the right-wing media, but they don’t make the problem go away. There will always be some people who fall prey to heroin. Whether we view this as the fault of society or the individual is meaningless. As far as I’m concerned, the real issue is trying to prevent vulnerable people like Kenny from plunging into addiction in the first place rather than seeking to blame them once they have.
Stuck in the middle
It was rare to see Tilly with both of her parents. They had split up the previous year and, although they were still being forced to live together due to the negative equity on their house, the break-up was less than amicable.
Tilly was sitting between them and she didn’t look well. She was thin and pale, and her parents were clearly sufficiently worried to try to put their differences aside for long enough to come together to see me.
‘Well, Dr Daniels, Tilly’s not been well since he took her camping that time. I told him not to take her but he didn’t take any notice.’
‘Well that’s nonsense, Dr Daniels – it was nothing to do with the camping. If her mum didn’t let her eat so much junk food she might look a little healthier.’
‘Hold on,’ I interrupted. ‘Can I just ask what symptoms Tilly actually has?’
‘She’s tired all of the time, Doctor, and she just wants to sit on the sofa and drink orange squash.’
Tilly didn’t look like the lively six-year-old child I had once known.
‘Any family history of anything?’ I asked
‘Drinking on his side,’ Tilly’s mum jumped in, pointing an accusatory finger at Tilly’s dad. ‘Practically all of them are pickled by the time they reach 40.’ She started miming a swaying drunk downing a bottle of wine added with her own ‘glug glug’ noises
‘Well at least my family have a bit of fun once in a while. The only thing that runs in your family is misery and bitterness. If you cut your mum open she’d bleed lemon juice she’s so sour—’
‘How about diabetes?’ I interrupted
They both looked at me with concern.
‘Does diabetes run in either of your families?’
For the first time Tilly’s mum and dad actually looked at each other. ‘No,’ they both said shaking their heads in unison.
I’d just tested Tilly’s urine and it was full of glucose.
‘I think Tilly might have diabetes, which is why she’s been feeling so unwell.’
I went through the diagnosis of diabetes with Tilly and her parents. It was scraping the surface really as there was so much new information for them to take in. I couldn’t really begin to tell them everything they needed to know, but perhaps for the first time in a while they were a family again, and Tilly’s mum and dad were able to put their differences aside in their shared love for their daughter.
Danni III
This time Danni had been beaten up. It wasn’t the first time this had happened, but today she seemed really shaken up by it.
‘I actually thought he was going to kill me, Dr Daniels. He had his hands around my neck and was throttling me like this.’ She mimed herself being strangled and I could see in her face how terrified she must have been.
‘Did you speak to the police?’
‘Well, I gave a statement, but they didn’t seem that bothered. He wasn’t a regular and I was so off my tits at the time I couldn’t really remember what he looked like to give a decent description.’
‘Why did he attack you?’
‘He paid for one thing and then wanted something extra thrown in for free. Got pissed off when I said no. Thing is, Dr Daniels, it doesn’t really have to be much of an excuse for some of these blokes. I see how they look at me, as if I’m not really human. The things they say can hurt even more than the punches sometimes.’
‘Well, I’ll document the injuries in case it does go to court.’
‘Okay, Doctor, but that’s not actually why I’m here.’
‘Oh?’
‘Well, this last beating really scared me. I genuinely thought that was it. As he was strangling me all I could think about was my kids.’
Danni paused for a bit and then looked me in the eye.
‘That moment was rock bottom for me and when I realised I wasn’t going to die, I thought, right, Danni, you’ve got a second chance here. A real chance to prove everyone wrong and show that you can get your life back on track.’
‘Fantastic, Danni! I’m really pleased you’re making a positive out of this.’
‘That’s where you come in, Doctor. You’ve always been kind to me and I need you to help me get my kids back.’
‘I’m not sure it’s that simple, Danni. It’s not me who makes that sort of decision.’
‘I know it won’t be easy, Doctor. The social workers never listen to me, but they’ll listen to you. If you can tell them that I’m coming off the game and off the smack then we can stop them putting my kids up for adoption.’
I had never met Danni’s children, but I had read her notes. They had been with her for a few years before being taken into care and from what I could gather being taken away from Danni was the best thing that had ever happened to them. They were thriving with a new foster family who were hoping to adopt them. They were settled in a new school and flourishing in an environment of security and stability that Danni could never offer them.
‘To be fair, Danni, how many times have you promised that you’re coming off the drugs before? You can see why the social workers might be dubious.’
‘It’s different this time. I love those kids. They’re mine. They had no right to take them away. Why won’t anyone believe me when I tell them that I love them?’
‘But it’s not enough just to love them, Danni.’
Danni was silent and I regretted my words.
‘So you think I’m a shit mum as well?’
‘It’s not that, I know you love your children, but kids need more than just to be loved. They need to grow up feeling safe and secure. They need routine and adults they can always rely on. I’m not saying that you won’t be able to offer them that one day, but I’m not sure you could right now.’
Danni looked really hurt. Filling up with tears she looked at me with venom.
‘I thought you were different, Dr Daniels, but you’re just like them. Judging me and making decisions about my life you’ve got no right to make.’
With that Danni was gone.
Danni was my patient and my duty of care was with her, but I couldn’t support her trying to take her children back. How I could I write a letter suggesting that they should leave their settled and happy life and be thrown back into the chaos that was Danni’s? Those children had a golden opportunity to break free from the cycle of misery that had engulfed Danni and I couldn’t endanger that. Maybe Danni could break free too. Maybe this time was different and she would turn her life around. Perhaps I’d got things completely wrong and Danni could become a fantastic mother? It was a risk I was going to have to take and although Danni feels let down by me right now, I hope that someday she’ll agree it was the right decision.
Funny X-ray
It was another chaotic morning in A&E and my first patient was being wheeled into the department on a specially reinforced trolley. Like other 999 services, our local paramedics had invested in some reinforced equipment in order to cater for the ever-increasing size and weight of the local population. The woman being wheeled in was huge, and we needed to transfer her from the special strong-and-wid
e trolley to a strong-and-wide hospital bed.
The paramedics told me that the woman had collapsed at home, and by the exhausted looks on their faces I could imagine it had been quite an effort to get her up off the floor. How they managed it I don’t know, but they certainly deserved the cup of tea that was waiting for them in the staff room. There wasn’t much more the paramedic crew could tell me about their patient, so I tried to ask her a few questions. Unfortunately she was confused and drowsy and only mumbled a few nonsensical remarks, so I soon gave up.
There are numerous reasons why a patient might be admitted confused and if there is no background history to help point us in the right direction, the obvious next step is to examine the patient. Sometimes examination findings alone can give us all the clues we need, but when a patient is as large as the lady in front of me was, most of the clues potentially gained from the physical examination are hidden under layers of fat. I tried to listen to her lungs, but as I endeavoured to find somewhere on her back to lay my stethoscope, I was met with so many rolls of fat that it was tricky to find a flat surface on which to place it. I tried in vain to listen to lung sounds, but the lungs were separated from my stethoscope by so many inches of fatty tissue that the sound couldn’t be transmitted and I heard nothing. Examining the abdomen was no easier. As I pressed my hand on to her tummy, I knew that there was no way that I would be able to glean any useful information about the organs buried deep below. I could just about feel a pulse in her wrist and so I knew she had a heartbeat but unfortunately, again, I couldn’t hear it. The ECG machine, blood pressure monitor and oxygen probe were struggling as much as I was, and after 10 minutes I realised that I was absolutely none the wiser as to why this lady was unwell.
Further Confessions of a GP (The Confessions Series) Page 10
