But risk is never that simple. In some parts of the UK, horse riding is riskier because people aren’t used to horses, and either whizz by too fast or throw missiles at you for amusement. In leafier areas, horse-riders are given a generously wide berth and ecstasy takers are more likely to be stoned. Taking ecstasy is also riskier in the sense that it’s illegal, and it’s much harder to get arrested for horse-riding (unless you ride bareskin). And ecstasy use may see you hung out to dry in the Daily Mail, a punishment seldom seen for trotting an old Exmoor round the block, even if it’s just as risky.
Prof. Nutt got a bit of a roasting for his comparison, not for its accuracy but its possible effect. A government advisor saying ecstasy has the same risk as trotting isn’t likely to get more people in the saddle, but it might encourage drug taking. ‘Get your disco biscuits here. Safe as horses.’
At least with horse riding, you know roughly what you’re letting yourself in for. You can reduce the risks by choosing your animal wisely, putting the saddle on properly, adjusting the stirrups, wearing a hard hat and a bright jacket, and steering clear of busy roads. And you can turn back or get off if it starts to bucket down. But once you’ve swallowed an anonymous tablet of who knows what, you’ve no idea what you’ve let yourself in for and no way of escape. And if you take a queer turn, you may not be surrounded by people who have your best interests at heart.
On paper, ecstasy is no more risky than driving 230 miles in a car, riding 6 miles on a motorbike, travelling 6,000 miles by train or mud-wrestling two fat Labradors. But nothing makes you feel more alive, in love and in the moment than a damp snout at both ends.
Where do I find my ‘I’ve had enough’ button?
When you’re balancing pleasure and pain, there comes a time when the two cross over and you need to bail out. Some lucky people have an automatic ‘I’ve had enough’ button (IHEB) buried deep in the forebrain that tells them when to stop drinking and go home before they make a complete arse of themselves or wake up with terminal head throb. They’ll often suddenly disappear from parties or the pub, and manage to hail a taxi home without being sick in it.
If you haven’t yet evolved an IHEB, or yours is stuck on manual, you need someone to tell you when to stop and to hide your car keys. This won’t be any of your button-less mates, who’ll all be docking in the snug, but a switched-on friend who’s looking out for you. If everyone with an auto IHEB buddied up with everyone without, the UK would be a far pleasanter place to drink in.
2
Doctors’ quirks
Doctors are human and creatures of habit, so although medicine is supposed to be based on science, you can still get very variable opinions and experiences from visiting different doctors with the same problem (or even the same doctor on different days). Half-full doctors save lives, half-empty ones merely delay death. I love the quirkiness of doctoring, but far too much of it is done in an anxious rush. Doctors need to slow down, like everyone else, and medicine needs to rediscover its humanity. As a wise old consultant once told me: ‘Always take time to smell the patients.’
Do doctors take the same advice and drugs they dish out to patients?
Not always. I know plenty of doctors who are overweight, drink too much alcohol, cycle without a helmet, eat bacon sandwiches, have no idea what their cholesterol level or blood pressure is and refuse to have a flu jab. We do this because we know that if you’ve got a good job in a country that disposes of its shit properly, you’re likely to live to eighty unless you’re unlucky. And we’re prepared to accept a few risks in return for pleasure and freedom.
The drugs and advice we dish sound mighty impressive when you apply them to the whole population, but the benefits to an individual person seem far more marginal. And some of the things that are bad for you in excess (sun, alcohol, wrestling with Labradors) are good for you in moderation. The trick with risk is to suss out the pros and cons of whatever you fancy, and enjoy it without guilt. But if shit happens, accept it, turn it into a good story and move on.
Some risks and benefits are very hard to predict. An Asian medical student went to a concert in London, a few months after the July bombings, wearing a backpack. He was stopped and searched, and found to be carrying a packed lunch and a couple of spliffs. This could have meant the end of his career but he was an exemplary student and the General Medical Council decided to give him counselling and regular drug testing instead. So now he goes around telling everyone how fabulous the GMC is, which is almost unheard of.
Are doctors full of spin?
Yes, but then so is everyone. There are endless ways that you can frame information to nudge people in one direction or the other. Some patients respond to numbers, some to humour, some to metaphor and some to the sight of the doctor rolling up his sleeve. Medicine is part science, part performance art and part getting you out of the door as quickly as possible at 6pm on a Friday.
Say you’ve got high cholesterol. Here are a dirty dozen bits of advice you might get, depending on who you see. Some are possibly more ‘right’ than others, but who’s to say what’s the best option for a ten-minute consultation in a small, muggy room that reeks of stale coffee and the remains of the previous patient? You decide …
1. ‘If you take this drug every day for five years your risk of death will be reduced by a whopping 40%. And even if you live, no-one wants to go through a heart attack or a stroke. Open wide!’
2. ‘If thirty-three people like you take this drug every day for five years, one death will be prevented and I don’t know whether it will be yours. But it seems unlikely. Shall I draw a picture?’
3. ‘If 100 people like you are given no treatment for five years, 92 will live and 8 will die. Whether you’re one of the 92 or one of the 8 is anybody’s guess. Then, if 100 people like you take this drug every day for five years, 95 will live and 5 will die. Again, I’ve no idea if you’re in the lucky 95 or the unlucky 5. Did you get all that? Maybe I’d better open the window.’
4. ‘I don’t really believe in all this cholesterol bollocks. Just bugger off and enjoy yourself. A dog, a job and a knob. That’s all you need.’
5. ‘We could all do with lowering our cholesterol but you’re already on ten tablets and God knows how they’re reacting with each other. Go away and eat lots of vegetables.’
6. ‘You must take this drug for the rest of your life or you might die prematurely or suffer chronic ill-health. We’ll start you on the cheapest. By the way, you have gorgeous eyes.’
7. ‘Did you see the ‘goal’ on Saturday? It was so far over the line, I though Neil Warnock’s head was going to explode. I bet he’s got high cholesterol. So have you, by the way, but we’ve run out of time to talk about it. Why don’t you make an appointment with the nurse? She specialises in body fat.’
8. ‘Please take this tablet every day for life. I will earn more money if your cholesterol goes down, and private school fees are increasing 8%, year on year. Could you lend me a fiver?’
9. ‘I’m not going to advise you one way or another about your cholesterol. You need to evaluate the risks and benefits for yourself and make your own choice. Here are twenty-seven guidelines. You have precisely three minutes. Do you mind if I open the window?’
10. ‘If you swallowed 1,825 tablets at a rate of 1 a day for five years and at a prescription cost of £400, your absolute risk of death would fall by 0.03%. The statistically significant side effects are muscle damage, headache, abdominal pain, nausea, vomiting, hair loss, anaemia, dizziness, depression, nerve damage, hepatitis, jaundice, pancreatitis and hypersensitivity syndrome. Still want some? Shall we try homeopathy instead? Or perhaps you’d prefer to write a poem?’
11. ‘Look at these pretty little tablets, aren’t they sweet? Little peachy dollops of doctor love, all for you. Please swallow them, just for me. You are my favourite patient, after all. You can sit on my knee and call me daddy if you like.’
12. ‘Come outside and look at this. I’ve made a
snake out of all the tablets you’ll be gulping down over the next decade and it goes twice around the surgery, up the herbaceous border and back. And guess where I got all these pills? From the cupboard under the sink of all those patients who died without opening the packets.’
Why do some GPs buzz you and some fetch you?
How doctors summon you is a good indication of how they’re going to treat you. Ever since the invention of electricity, buzzing has been the norm for doctors who considered it too secretarial to fetch and carry patients from the waiting room. Early intercoms were not known for their voice quality, and patients were left to guess if they were being called, based on a rough crackle and a few syllables of Dalek.
Modern intercoms go through the telephone network and are of much better sound quality, the only drawback being that if you inadvertently consult with the receiver off the hook, the whole waiting room gets to hear about Mrs Taylor’s warty growth.
Many practices use technology to avoid human contact. Some have a big machine that you plug your date of birth into when you arrive, and you’re summoned automatically without having to trouble the receptionists (who are far too busy helping the anxious and confused key their dates of birth into the new machine).
Other practices have a not-so-subtle electronic display that flashes up inappropriate digital adverts (‘Has your doctor got dirty fingernails? Contact Bennett’s solicitors, no win no fee’). And when you’re summoned, your name crawls across the screen, like an announcement for the next station, but in lurid LED red. So now everyone knows you’ve thrown a swine-flu sickie.
To preserve confidentiality, patients can be given an anonymous number, which goes down a treat in the clap clinic (‘Morning Vicar.’ ‘Shhhh – today I’m 157 on the men’s side’). Or you can try a more personal touch. One local GP practice gives patients tokens with numbered Beatrix Potter characters on. When there’s a buzz, you compare numbers and discover you’re behind Appley Dappley but in front of the Flopsy Bunnies. And no-one will ever guess that you, Gemima Puddleduck, are really the vicar.
Personally, I always try fetching in person (FIPing). The early eye contact and cheesy smile can do much to assuage the anxiety of embarrassing itch. FIPing also allows the doctor to secretly observe his next patient through the crack in the waiting room door. Mrs Bishop is doing ‘unobserved’ handstands in the toy-corner but assumes a look of chronic world-weariness the moment a doctor appears. Why?
FIPing gives you more guessing time with patients, from the moment they try to get out of those ludicrously-low bucket seats to the moment they set foot in your consulting room. Do they look sick? Can they limp without changing legs? How will she fit that double buggy through the door without chipping the paintwork?
I usually see if patients can pass me on the corridor – as much to suss out my level of fitness as theirs – but a colleague is convinced he can dictate the pace and style of his consultations by the manner in which he leads the patients to his room. A leisurely stroll if he’s not too pushed for time, a brisk trot if he is. The brisk trot looks like he’s concealing a tuberous vegetable, but there might be something in it.
FIPing is particularly useful if someone’s left an unfriendly aroma in your room and you need a few moments to clear your head. And patients seem to like it. If they’re seeing a familiar doctor, they can pack in an extra minute by addressing the bunions on the landing. And if it’s a new doctor, they can decide whether they want to bring up psychological issues (e.g. the husband who locks himself in the closet and sniffs tennis shoes) or stick to the tennis elbow.
In theory, FIPing should also cut down on mistaken identity but for new and amnesiac doctors, it’s a source of constant embarrassment. Say your next patient is Mrs Thomas, aged fifty. When you get to the waiting room, there are four women fitting that description. So who do you bestow the all important early eye-contact on? And what if you saw her only last week and haven’t the faintest recollection what she looks like? Your only option then is to stare at the linoleum which makes Mrs Thomas think you’re not in the least bit interested in her. Also, if none of the women are Mrs Thomas, you can spend a long time staring at the lino. Ten minutes is my record.
Successful FIPing also depends on the geography of the surgery. If it’s on six levels you can never get down the stairs because they’re blocked with patients who’ve collapsed on the way up or are just taking a breather. So you end up examining over the banister on Level 3. ‘And cough, Vicar.’ The other problem with FIPing is that it leaves you no time to do anything in-between patients.
What do doctors do in-between patients?
Split up fights, usually. Sandwiching yourself between patients for pleasure is rare, and the GMC frowns heavily on frottage. When patients finally leave the room, GPs have on average a thirty second turnaround time, but most of that is now spent typing frantically into the computer to claim money for treating whichever disease we’re being paid for this week. In the old days, I used to knock off a few pages of something like Tales of the City in turnaround time. At 800 words a chapter, there’s something very satisfying in polishing off a whole story in-between the worried well. On a bad day, you play catch up. No time to breathe between patients. Years ago, a stressed GP would be writing the previous patient’s notes up as you walked in. So no eye contact and a bad start to the consultation. These days, we’re hunched over a keyboard and hidden behind a screen. So no eye contact and a bad start to the consultation. That’s progress for you.
After a very stressful consultation, we’re advised to take a time out, but usually don’t, and launch headlong into the next very stressful consultation, conscious of the fact that we’re now running forty minutes late. However, this risks transporting the angst from one consultation to the next. Why is the doctor crying behind the computer?
Others try ‘stress control techniques’; relaxation, yoga, self-hypnosis, meditation, putting on sandals and growing a beard – you name it, GPs have done it. I know one who keeps a punch bag in the treatment room, but less obtrusive is to squeeze a squidgy stress-reliever that doubles as a prosthetic testicle. Almost as therapeutic as squeezing a real one, and a lot more ethical. Failing that, you’ll always find twenty Silk Cut and a packet of Polos in Doctor’s secret drawer (third down on the left, behind the rubber nun suit and the tube of body butter. Or is that just me?).
Why do some doctors stare at your face and others at your feet?
It depends on the personality disorder of the doctor. Starers may have mild psychopathic tendencies or just be fresh from my communication skills training. Perhaps they had their eyelids removed in a Freshers’ Week prank. Or it may just be a function of the doctor’s speciality; anaesthetists spend a lot of time staring at you in the hope you’ll wake up, psychiatrists do it to put you to sleep. Or the staring may be down to the fact that you’ve got something to stare at, like a big lump or jug ears or a Bowie knife.
Doctors who prefer feet to faces aren’t always orthopaedic surgeons. A geriatrician once taught me to look at the feet first: ‘If a man can do up his shoe-laces, there can’t be much wrong with him.’ He had a point. Whether you do bunny-ears or snake-around-the-tree, lace tying requires eyesight, balance, flexibility, co-ordination, motivation and memory. But you could still have prostate cancer.
Many foot-starers are the poor sods who sailed into medical school with three Grade A science A levels and the communication skills of a dead skunk. They may glance at you at the beginning of the consultation, but if you’ve got something awry in the emotional department (grief, anger, despair, hyperventilation), they start shifting in their seats and fidgeting with their fringes and you won’t get a whiff of a pupil. They’ll happily hide behind a screen and ask you about your cholesterol when you’ve come in to talk about your dead dog.
Averting eye contact can be entirely appropriate, like when you’re banding a haemorrhoid or you stumble across someone undressing. It’s an odd thing, undressing. Doctors are allowed to see you
buck-naked or fully clothed, but if we catch you in the process of removing your wonder-truss, it becomes horribly inappropriate. The process of de-robing is ritualistically sexy, or at least it might be if we looked.
Outside undressing, observation is the heart of medicine. As one of my consultants used to say: ‘The jaw line reveals inheritance, the lips show what life has done to the patient and the eyes reveal the emotions of the moment.’ There’s far more to looking at someone than spotting a diagnosis. And it’s worth observing your doctor too. Why has he got egg in his beard? Does she look sicker than I do? And is he about to trip over his shoelaces? All feedback welcome.
Why do doctors always come at you from the right?
Because we’re taught to approach the bed from the left (which is your right), and if you don’t do what you’re taught to do at medical school, you get kicked out early and bring shame on your family. To be fair, there’s more to it than ritual. Most doctors hold the stethoscope in the right hand so leaning over from the left (your right) makes examination of your left-leaning heart (on our right) a bit easier.
Also, wards were usually built with the bedside locker on the patient’s right so the religious trinkets would always be on the right. Doctors approaching from that side then had the double whammy of being closer to God and closer to the box of Roses, so we can pocket a few under the pretence of listening to the back of the chest or getting you to look ‘up there to your left’ or, my favourite:
‘Close your eyes and touch your nose with that finger.’
‘Why this finger?’
‘It just is, alrht?’
Sex, Sleep or Scrabble Page 4
