He sat back in his chair, the wind gone from his sails. ‘But that’s bloody outrageous,’ he said. ‘This problem only started when that Dr Emma gave my missus the bloody HGV.’
‘Do you mean HRT?’
‘Yeah, that’s the one. She’s a changed woman ever since. It’s killing me, I tell you.’
‘Well, I sympathise – not from any position of personal experience, you understand – but you don’t tick any of the necessary boxes so there’s not a great deal I can do for you, Viagra-wise.’
I wrote him a private prescription, and he left looking rather crestfallen, with a slightly hunted expression in his eyes. Clearly, the tigerish Mrs Leeford was waiting for him back at base.
FAKING IT
THAT LUNCHTIME, OVER a supermarket chicken salad sarnie which cost £3 and tasted mostly of cardboard, I got chatting to Sami Patel about Viagra.
‘I reckon most blokes I turn down for an NHS script just go home, open the spam folder in their email inbox and send off for some fakes,’ he said.
‘You’re probably right,’ I said.
‘Of course I’m right. Think about it. You can buy generic 100mg sildenafil tablets made in India and China for about £2 apiece on the internet, so who’s going to pay the pharmacy rate? Ask yourself this, of all the guys you’ve ever prescribed an ED drug who don’t qualify on the NHS, how many of them ever return for a repeat prescription? Have you ever bothered to ask why?’
He had a point. Our local pharmacist has recently adorned his window with a home-made, A4 poster warning passers-by, ‘Don’t buy drugs off the internet’.
What he doesn’t mention is that of the sixty quid your eight Viagra tablets will cost you, a third of that is his ‘dispensing fee’. Nice work if you can get it: £23 to take a packet down off a shelf and stick a label on it.
Of course, the pharmacy industry’s spokesmen talk more about the dangers of shopping for meds online: they’d have you believe that every product supplied is counterfeit, cut with toilet cleaner and a danger to health. And, to be fair, one in four GPs reckons he or she has treated a patient who has suffered a side effect from a drug bought online without a prescription. But when you consider that four out of four of us have treated patients suffering side effects of drugs we’ve actually prescribed ourselves, you might argue those aren’t bad odds.
Obviously, I’m no more going to advise you to buy your ‘Propecia’ or ‘Prozac’ online than I’d suggest you buy the brake pads for your car from a back-street set-up in Mumbai. ‘Original parts’ for my ‘Nissam’ or ‘Toyata’? Er, na thonks (and I’m not being ironic here, I really mean this – don’t buy pills off the internet). But we live in the real world, and most patients ignore everything I say anyway.
Fire up your web browser and Google any of the generic names for P5 inhibitors (the chemical class of drugs that includes Viagra, Cialis and Levitra); within seconds you’ll find links to Indian and Chinese manufacturers who knock out unlicensed generic product. These aren’t always shifty blokes with buckets of powdered chalk and a printing press in a lock-up; they’re often the same firms that manufacture the beta-blockers, antibiotics and anti-inflammatories that pharmacists hand out quite happily in exchange for an FP10.
Just then, Dr Emma came in.
‘Ah!’ I said. ‘Just the girl I wanted to see.’
‘Really?’ she said. ‘Has anyone seen my coffee mug?’
Sami shifted guiltily. ‘Er, I think I used it earlier,’ he said. ‘It’s in the sink.’
‘You think you used it?’ said Dr Emma. She walked to the sink. ‘It’s chipped!’ she said. ‘You’ve chipped my coffee mug! That was an original Greenpeace “Don’t Make A Wave” mug. It cost me £25 on eBay!’
‘Gosh, is that the time?’ said Sami Patel. ‘I really must…’
The rest was lost as he slid out of the common room.
‘Shame about your mug, Emma,’ I said. ‘Look, can you do me a favour, and stop prescribing HRT to every slightly sweaty woman over 45 who darkens your door? It’s causing mayhem with their menfolk.’
‘I don’t know what you mean,’ she said. ‘Don’t be so ridiculous. I don’t prescribe anything to anyone who doesn’t need it.’
‘Look,’ I said. ‘I know we don’t dish out HRT like we used to, not since people started accepting the menopause as a natural part of the ageing process. But it’s still a damn sight easier to get hold of than Viagra, thanks to the inherent sexism in the NHS.’
‘Oh, you’re not going to start banging on about that again, are you?’ she said. ‘It’s a bit of a stuck record, Tony.’
‘It’s a fact, you mean,’ I said. ‘Look at the way we pour money into cervical and mammographic screening, which are exclusively female and, in diagnostic terms, clinically controversial. All this talk of women GPs for female patients, and never a murmur about a reciprocal arrangement for blokes. Free contraception for women, while men have to cough up for condoms. For years, HRT was handed out to pretty much any woman who asked. When Viagra arrived, a drug for blokes that was – for once – fashionable, it was immediately rationed. The fact is, men’s health isn’t politicised, and this whole Viagra/HRT thing is the clearest evidence of that.’
PIERCINGS, TATTS AND OLD MEN WITH THE CLAP
ACTUALLY, IT WAS a day for sex maniacs of one sort or another.
On the way back to my consulting room, I bumped into another of them, in the slightly potato-shaped shape of the reception manager, Mrs Peggotty.
‘Now then, Dr Copperfield?’ she said, in her warm, Irish brogue. ‘Can I just ask you, would you have had unprotected sex, or been pierced or tattooed lately?’
‘That’s rather forward, Mrs Peggotty,’ I said. ‘I mean, I had a big night last Friday but I certainly wouldn’t…’
‘No, you big silly,’ she said, playfully slapping my arm. ‘It’s just this new poster which came today.’
She held it up; an horrific teenaged Goth stared back at me under a heading which asked about sex, piercings and tatts. I think it was designed to warn our local yoot as to the terrors of hepatitis B, the blood-borne variety of the virus, but I fear most of them will see it as more of an ad: a good percentage of them appear to regard all three activities as essential components of a good evening.
I walked through the waiting area and back to my desk.
My final patient of the day turned out to be precisely the sort of oddbod the poster was aimed at – though he was slightly older than you might have thought.
Mr Maylie, a middle-aged office manager with a gammy leg and a lazy eye, didn’t waste any time in getting to the point.
‘I think I’ve got a dose, doc,’ he said, with a knowing wink. ‘I used to be in the army in the ’70s and I reckon I know the signs.’
A quick inspection revealed that he did, and he had.
‘So you’re enjoying an adventurous sex life, are you?’ I said, struggling to keep the bitterness out of my voice.
‘Well, there’s Jackie in accounts, and Margaret at the Red Lion, and Smutty Sal from the cab firm, and…’
‘I’ve heard enough,’ I said. ‘For God’s sake, stop.’
I gave him a stern lecture as to the importance of morality – or, at least, condoms – and sent him on his way to the clap clinic so they could do the tests to find out exactly what type of VD he had.
It seems odd discussing safe sex with people of his age – who ought to be more worried about infarction than infection – but at least the conversation tends to go beyond, ‘Whatever’. And it’s becoming an increasingly important conversation to have. I don’t know if you realise this, but the middle aged and even elderly are experiencing an epidemic of sexually-transmitted diseases – a ‘clapidemic’, I like to call it. A recent Health Protection Agency study showed that sexually-transmitted infections, such as genital warts, herpes and gonorrhoea, have doubled in the middle aged, particularly in men over 45, in the last decade or so.
Since the arrival of the aforementioned
Viagra, the quickie divorce and the internet (sites like Friends Reunited have opened up lots of old doors from days gone by), people in their forties, fifties and above are enjoying bedroom action of the sort which was previously confined to the orgiasts of ancient Rome. (Or so I hear – it’s not like that in my house, obviously.)
Add in the menopausal binning of condoms and you have a recipe for disaster. Well, unpleasant oozing and odd penile growths, anyway.
AIRFIX MAN
BY NOW, YOU may be drawing up a mental image of me as a burnt-out old cynic whose relationship with his patients is akin to that of a molar with a drill.
If so, you’re almost completely right. Except that, occasionally, something like this happens.
Mr Haredale came to see me the other day.
He’s 80 years old, and was sprightly, smiley and superbly turned-out. His attendance record is exemplary, in the sense that he hardly ever comes and he apologises for bothering us when he does.
As soon as he popped his head round the door, I recognised him and started putting the AK-47 – always primed for action at the beginning of any consultation – back in its drawer.
‘I’ve just got the one problem, doctor,’ he said, and I felt my default froideur melt still further. ‘It’s these shakes. By the time I get from the kitchen to my armchair, my tea’s in the saucer. I’ve had them for ages and I’m about fed up with it.’
Typical essential tremor. He was a lovely man and this was a straightforward problem, so I turned Nice Family Doctor up to max.
‘You’re probably worried it’s Parkinson’s, aren’t you Mr Haredale?’ I said. ‘Well, it isn’t, so you can relax on that score.’
He exhaled deeply and sat back, a weight off his shoulders. ‘Well, that’s good to hear, doctor,’ he said.
‘But you say you’ve had it for ages, so why’s it worrying you now?’
‘It’s my Airfix models,’ he explained. ‘I can’t do the fiddly bits anymore. I’ve got a lovely 1:24 scale model of HMS Hood on the go and I just can’t get the Oerlikons... they were the anti-aircraft guns... I just can’t get them sited properly. I knew a chap who died on the Hood, as it happens. Lovely lad. He was the butcher’s son. They never got over it.’
He looked downwards at his shaky hands.
This is enough to get him to bother the GP?
Well, actually, yes, and rightly so. Because his wife died three years ago, and his hobby fills in those moments when he’d otherwise be pining for her, which is all the time.
My own hands used to tremble when I did Airfix kits, but that was because I was a six-year-old banished to the Arctic temperatures of the garden shed, so it wasn’t just my hands shaking, it was my whole body. Maybe that was why Mr Haredale touched me so much. Or maybe it was just that this consultation cut through the dross and reminded me why I do this job. It may be a cliché that doctors need to have an interest in people as well as pathology, but it’s a trait of all decent GPs, albeit one which gets buffeted and eroded by the moaning, manipulative, multisymptomatic masses.
The tiny minority who create the vast majority of our work distort our view and pervert our attitude. Most of humanity gets by each day without consulting, phoning or complaining, it’s just that it doesn’t always feel like that to us GPs. So maybe we should have an ‘Infrequent Attenders Day’, when we invite all Thin-Files for a consultation. Most wouldn’t come, and those who did wouldn’t bring lists or say ‘While I’m here’, so we could OD on caffeine and Hob Nobs.
Perfect.
As for Mr Haredale, I suggested he tries a little Glenmorangie. Then maybe we’ll give beta-blockers a go. If we’re still stuck, hell, I’ll go round and do the fiddly bits for him myself.
PARKINSON’S DISEASE
UNLIKE MR HAREDALE, around 1 in 500 Britons – or 120,000 people in total – do have Parkinson’s, with some 10,000 new cases diagnosed each year, mostly in patients over 50. Named after the London doctor James Parkinson who first identified it in 1817, it is a progressive neurological condition caused by the loss of nerve cells in a part of the brain called the substantia nigra, where dopamine is produced; this chemical helps the brain to co-ordinate movement and its depletion causes patients to struggle with walking, talking and other activities. It is ‘idiopathic’ in nature, which means that its causes are not yet fully understood; however, they are thought to include genetic factors and exposure to environmental toxins, herbicides and pesticides. There is no current cure, but there are treatments and therapies which can alleviate the symptoms.
Essential Tremor is a less serious condition which sees patients trembling involuntarily. Alcohol intake – in moderation, of course – can reduce the symptoms (which is why so many snooker and darts players have been boozers) and drugs including beta blockers, which work by blocking the transmission of certain nerve impulses, are also used.
THINGS I REALLY LIKE ABOUT GENERAL PRACTICE
I MENTIONED THAT Mr Haredale was superbly turned out.
Coming from me, who often turns up to work looking like a Big Issue seller, that might strike you as odd. But there’s something about the sight of an old suit and a frayed shirt collar held together by a well-pressed tie that brings out the softy in me.
You may think my outlook on life, and particularly work, is relentlessly bleak, and that it is thus doing bugger all for recruitment. If so, it looks like I’m hitting the spot. But, to redress the balance, here’s a list of all the things I really like about general practice.
Obviously, frail widowers who attend resplendent in tie and jacket (even if they put me to shame).
I also like elderly ladies who decline scripts for paracetamol or aspirin because they’ll buy them instead, to save the NHS some money. That’s excellent – if everyone took that attitude with the drug budget, the same old ladies would be able to get their hip replacements done in time for them to actually enjoy their new-found mobility.
I like child patients who talk to me. Most don’t. Most cough, pout, whine, puke, wail, scream, or all of the above. Yesterday, I asked a boy with earache how old he was and he said, ‘Five. But before that I was four.’ Encouraged by this, I asked him why he’d come. Without hesitation, he replied, ‘To play with your toys.’ Brilliant.
What else? I like patients who bring me presents, even if I don’t like the presents. I’ve tried hard to develop a fondness for Liebfraumilch and lardy cake but it’s not possible.
Then there are relatives who offer me tea on a visit. Marvellous. I’ve never accepted, though: there’s always the outside chance that they’re trying to poison me. This would be understandable – half an hour previously I was suggesting to them on the phone that faecal incontinence and complete immobility in a 95-year-old shouldn’t necessarily be seen as barriers to bringing the patient to the surgery.
I’m nearing the bottom of the barrel now. I do quite like it when patients say amusing things.
Such as, ‘Doctor, I need counselling’. This doesn’t sound that amusing but it is, because they usually want counselling on spurious grounds, such as Birmingham City being relegated.
Also, I like that feeling you get when the patient’s body language indicates that he’s about to leave. The pleasure of closure; the sense of progression towards coffee; the impression of your career clock ticking from consultation 143,999 to 144,000, with only another 153,000 to go. Yes, I have just worked that out, and, no, it probably isn’t healthy. Sadly, in most of those 153,000 remaining consultations, there will be a list, a ‘while I’m here’, a TATT. Occasionally there will something nasty. Set against this monument of negativity, my reasons to be cheerful do look slightly flimsy. Which is why, if you want to know the truth, I’m more likely to be humming AC/DC’s Highway To Hell than Julie Andrews’ Favourite Things on the road in to work of a Monday. But, hey, if you’re a registrar or a student reading this, don’t let that put you off.
SURELY EVERYONE IN TOWN HASN’T GOT A URINARY TRACT INFECTION?
‘HAVE YOU EVER n
oticed,’ asked Sami Patel, as we walked to our cars, ‘how everyone we send to the hospital turns out to have a urinary tract infection? In the last fortnight, off the top of my head, I’ve had patients attend A&E with heart attacks, broken ankles, tonsillitis and suspected rabies and every single one of them has turned out to have problems in the waterworks as well.’
‘I have noticed that, Sami,’ I said. ‘And in fact, I can top-trump your little collection.’
And I told him a story. A true one. The other day, an elderly patient of mine called Mr Feeder suddenly went numb and weak all the way down one side. His wife, understandably alarmed by the flaccid and slobbery appearance of one half of her husband, took him up to the local hospital. I know all this because I’ve got the A&E letter in front of me.
It states: ‘Diagnosis: TIA’
A transient ischaemic attack, or mini-stroke: even a Cas. Officer couldn’t get that wrong.
Hang on, though. That’s just diagnosis number one. There was another.
Diagnosis number two, according to the letter is, as you will have guessed, a ‘UTI.’
So, as I said to Sami, ‘You see what he had?’
Sami looked blank.
‘No idea?’ I said. ‘I’ll put you out of your misery. He had….a UTIA. Geddit?’
As medical jokes go, it was quite a good one. In fact, so proud was I of this mini-stroke of genius that I repeated it to the senior partner over coffee.
Sick Notes: True Stories from the GP's Surgery Page 11
