Confessions of a British Doctor - Benjamin Daniels

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Stop it, Lionel. You know I don’t like it that way. If you’ve got to put it in, at least put it in around the front.’ Poor Lionel was standing outside the cubicle in full view of all the patients and staff who were trying to hold back their giggles. He looked very embarrassed as he made his way back into the cubicle.

      Julia

      Julia was young, attractive and articulate.

      ‘I need you to lock my boyfriend away in a mental hospital. He’s completely mad and unreasonable and yesterday he smashed up my moped for no reason.’

      I wasn’t expecting that one.

      ‘Your boyfriend doesn’t sound very nice but we aren’t going to be able to put him in a psychiatric hospital.’

      ‘But he’s mad! It wasn’t just any moped. It was my twenty-first birthday present. I drove it everywhere. It was my most precious possession! He knew that!’

      I was tempted to explain that there wasn’t a special subclause in the Mental Health Act that allowed us to involuntarily confine someone if the moped he smashed up was a very special birthday present. I held back and instead explained how a person would need to have a mental disorder and pose a risk of harming themselves or others before they could be confined.

      ‘He is a risk to me. He beats me up!’ Julia then proceeded to lift her shirt to reveal an impressive array of bruises on her torso.

      ‘Why don’t you leave him? There is a local domestic violence support group. Perhaps I could –’

      Julia interrupted me. ‘He needs me. He says he would kill himself if I left him and I couldn’t have that on my conscience for the rest of my life. He needs help and all you’re telling me to do is leave him. He was abused as a child and so was his mum. His whole family is fucked up. I’m all he’s got.’

      I wasn’t sure where to go from here. From the outside it seemed so straightforward. Leave, run away, start again. Julia had a lot going for her. She could have a whole new life. It clearly isn’t this straightforward as there are thousands of women like Julia who don’t leave or run away or start again. I would never really understand the complexities of Julia’s violent relationship but one thing was very clear. When she said that Andy had nobody else, what she was really saying was that she didn’t have anyone else. She was alone and, however difficult and abusive her relationship was, she clearly felt that it was all she had.

      I was feeling guilty now. Initially, I hadn’t really been taking Julia seriously. I had thought that she wanted her boyfriend sectioned because they had had a tiff. It was now clear that things were more complex. Deep down Julia knew that I wasn’t going to section Andy but she was crying out for help and somehow it was me who was expected to provide this help. At medical school I had learnt about the role of mitochondrial antibodies in primary biliary cirrhosis and the parasympathetic nerve distribution to the salivary glands. It wasn’t the greatest preparation for dealing with a vulnerable desperate woman who got beaten up every day by the man who supposedly loved her. Regardless of my lack of training, at that moment I was all she had and I had to do my best.

      ‘If you leave him and he harms himself, that’s not your fault.’

      ‘Is that the best you can do? He needs help.’

      Andy was a patient at another practice and I had never met him. I couldn’t really speculate what he needed but psychotherapy is usually our get-out clause when faced with a difficult psychological issue that is complex and not fixed with a tablet.

      ‘Maybe psychotherapy would help Andy?’

      Julia looked hopeful until I explained that there was a two-year wait for psychotherapy in this town.

      ‘That’s really useful, thanks a lot.’

      ‘You have to leave him,’ I said again. I tried to say it with compassion but I really did feel it was her only option. Julia got up, left and slammed the door. I clearly hadn’t handled that very well. I had failed again. Would another doctor have handled that better? What would a counsellor have said, or a priest or even bloody Jerry Springer? I was not sure if Julia would come back to see me. If she did, maybe next time I’d just listen.

      Good doctors

      What makes a good doctor? I seem to remember being asked something like this during my medical school interview. The interview panel yawned through my contrived answer that mentioned some naïve nonsense about being caring and good at working in a team. As part of our target-based existence, the patient plays a large role in deciding if we are good doctors or not. The government introduced patient satisfaction questionnaires as part of our performance targets.

      During my training year I saw a middle-aged woman with stomach pains. I was very concerned and referred her urgently to the hospital because I thought she might have stomach cancer. She was seen and investigated within a week and turned out to simply have bad indigestion. When the snotty letter came back from the consultant, I was feeling a little red in the face. I had made an inappropriate expensive referral to the hospital and had caused unnecessary anxiety to the patient. I could just imagine the consultant grumbling into his endoscope as he cursed me for adding to his already busy day.

      The patient and her husband, however, thought the sun shone out of my arse. ‘That wonderful Dr Daniels arranged for me to be seen so quickly.’ She bought me a very nice bottle of single malt to say thank you and told anyone who’d listen how fantastic I was. My poor medical judgement earned me a rather nice bottle of whisky and if my patient got to fill in one of the patient satisfaction questionnaires, I’d have been reported as the best doctor in the world.

      Most medical practitioners have an idea whether they’re being good or bad doctors. On a Friday afternoon when I’m drained and tired, I know that I’m not giving my all. I try my best to remain professional but have to admit that I find it that bit harder to resist inappropriate requests for hospital referrals, sick notes and antibiotics. As GPs, we are supposed to be the ‘gatekeepers of the NHS’ but sometimes it can feel much easier to leave the gate permanently ajar rather than carefully defend the NHS hospital waiting lists by fending off the worried well. I’m very popular with my patients on a Friday afternoon because they are getting what they want, but I’m not always practising good medicine. Making the patient happy isn’t always the same as being a good doctor.

      When I started as a GP I was told that it was easy to be a bad GP but hard to be a good one. A good doctor won’t prescribe antibiotics for a cold and won’t refer every patient with a headache for an expensive MRI scan. A good doctor should also be able to explain to the patient why he’s not agreeing to their demands, but sometimes, however hard you try, the patient leaves feeling dissatisfied and the doctor goes home feeling distinctly unpopular. It is a difficult balance to run on time but give each patient adequate individual attention, to allow patient choice but not give in to inappropriate demands, to keep referral rates low but make sure the patients get the expert input they need. I’m still not sure exactly what a good doctor is, but it is certainly more complex than earning a few smiley faces on a government questionnaire.

      Connor

      ‘It’s my kids, Doctor. They’re little fuckers. I can’t control ’em no more. Something’s gotta be done about it. My youngest, Connor, was brought home by the police the other day.’

      ‘How old is Connor?’

      ‘He’s three.’

      I rack my brains trying to think what a three-year-old could possibly do to get himself in trouble with the police.

      ‘They caught him putting rubbish through the neighbours’ letter boxes.’

      ‘Was he out on his own?’ I ask incredulously.

      ‘Oh no, Doctor, Bradley and Kylie was with him, but they was the ones telling him to do it.’

      I

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