Further Confessions of a GP

Despite the make-up girl’s best efforts, Maggie still had the yellow tinge all corpses seem to have. I’d come to complete the paperwork, and as the last doctor to see her alive I was supposed to do a final examination of her body. Maggie had been at the undertakers since Saturday afternoon and it was now Monday morning. If my examination revealed anything other than a diagnosis of death, something had gone very, very wrong.

I nodded at the undertaker to confirm that it was definitely Maggie lying on the metal trolley in front of me. I left my stethoscope in my bag, but stuck on some gloves and had a prod between her ribs on the left side of her chest to make sure she didn’t have a pacemaker fitted. I knew Maggie’s medical history well enough to know she didn’t have one, but I checked just in case. We are always told that cremating a body with a pacemaker still inside can blow up the crematorium. I imagine this is in fact a bit of an exaggeration and it’s more likely that the grieving relatives don’t really want to find the remnants of charred batteries while spreading the deceased’s ashes over her favourite rose bushes in the back garden.

I did mention to the undertaker that Maggie had had a silicone breast implant following her mastectomy some years before. There is no risk that the implants will blow up the crematorium, but they do leave a damaging sticky goo on the walls of the incinerator. Nowadays, most undertakers will remove them, which was an idea that tickled Maggie when she was alive. She told me she had suggested to her husband that he put her implant on the mantelpiece next to the urn containing her ashes, but apparently he hadn’t found it funny.

I was going to miss Maggie. She had an amazing spirit that shone through and she always made me smile however gloomy our discussions. For all the amazing medical breakthroughs of modern years, once she received her diagnosis, all we ended up offering her were steroids and morphine. Both are cheap old-fashioned drugs that we’ve been using for decades. In their defence, the morphine gave her a pain-free death and the steroids probably gave her an extra couple of weeks. Maggie had promised me that she would try to open up to her husband, talk about her feelings and say goodbye to him. In the end, her condition deteriorated very quickly and just two days after she made me that promise she was gone.

For those last few weeks I was Maggie’s confidant. I was someone outside the family to whom she could talk and on whom she could rely when she was in genuine need. It isn’t something ever taught at medical school. It can’t be measured or turned into a government target, but for those six weeks Maggie was my most important patient and although I was unable to cure her or prevent her death, nothing could make me feel more like a doctor than giving her my time.

When I’d heard the news of her death, I’d phoned her husband Tony to offer my condolences. I’d suggested that once the funeral was dealt with, he might want to pop in and have a chat. He didn’t take me up on the offer, but a couple of weeks later he did leave an envelope for me at the reception. It was a photograph of Maggie looking young and carefree. Her head was tilted back and she was laughing at something. It really did capture her spirit beautifully. On the back it just said, ‘Thank you for everything you’ve done for us, love Maggie and Tony.’

Can’t be too careful (#ulink_bb00d384-85ff-5725-858a-7ce4132c2f17)

Tracey’s entrance was never quiet. Buggy, shopping and three boisterous children piled into my room in a swirl of chaos.

‘’Allo again, Doc,’ Tracey chirped cheerily. ‘You must be sick of the sight of us, eh?’

‘Not at all,’ I fibbed back. ‘So what brings you in today?’

‘Well, it’s all of us really,’ and with that Tracey listed various transient minor ailments that seemed to be causing her and her brood great concern.

‘This one’s the worst,’ she said, pointing at her son Bradley who was jumping most energetically off my couch. ‘He’s really poorly. Not himself at all. He’s right off colour, he is. We was up the ’ospital all Saturday with him. ’Ad to call an ambulance and everything, but after nearly four hours waiting around in A&E they just said he had a virus and sent us home with paracetamol.’

Tracey spends a lot of time requesting medical attention. It seems that however many times either I or the other doctors offer reassurance, she needs more and will seek out medical help at the drop of a hat. I don’t begrudge Tracey her frequent attendances. Well, if I’m honest, at the time I often do, but in the cold light of day I can accept that she is trying to be the best mum she can be. She worries about her children like all parents do, and she doesn’t have the means to alleviate this anxiety without a trip to the doctor. For the last few years, I haven’t really paid much heed to Tracey’s frequent visits, but her name had now cropped up on our list of patients who attend A&E too frequently.

As we all know, the NHS has no spare money and one of the directives for saving funds is to persuade our patients to stop going to the hospital so often. For each attendance at the emergency department around £70 is charged to the NHS, and that cost doesn’t change much whether the treatment is simply some gentle reassurance, as in the case of Tracey, or if 10 doctors wrestle to save your life after getting knocked down by a bus. Our GP surgery gets paid £65 a year to look after Tracey however many times she comes in. The simple logic is, therefore, that for minor ailments it is much cheaper for Tracey to see us at the GP surgery than for her to go to A&E. It also frees up time for the emergency doctors to see patients needing genuine emergency care! That is why my bosses were telling me to make an ‘action plan’ with Tracey in an attempt to prevent her from visiting the hospital so often.

After painstakingly reassuring Tracey that she and her children were going to survive the morning, I decided there was no time like the present and I was going to make the ‘action plan’ with her this very visit. We discussed all sorts of options to reduce her hospital attendances. I started by suggesting that she phoned the surgery rather than dial 999.

‘But sometimes I ain’t got no credit on my phone,’ she replied.

‘You could also take a taxi to the surgery rather than keep calling ambulances to go to A&E.’

‘Taxi! How can I afford a bloody taxi?’

Finally, I proposed waiting for minor ailments to get better on their own, rather than instantly rushing to find a doctor.

‘Thing is, Doctor, you can’t be too careful,’ she replied.

I printed out a copy of our ‘action plan’ and handed it to Tracey, but if I’m honest I didn’t think it was going to make a great deal of difference to Tracey’s attendance rate. It’s easy to view frequent attendees like Tracey as time-wasters and malingerers, but the truth is that from this side of the fence it is very easy to label which emergency hospital attendances are appropriate and which aren’t. GPs like me have the benefit of many years of medical training behind us to back up our decisions as to whether a patient needs to be seen in hospital – and we still often get it wrong! Tracey has no real support network and so she falls back on the medical profession. She is simply trying her hardest to keep herself and her family safe and for that I have to respect her.

I know that I’ll get more letters from up above telling me that Tracey and her family attend A&E too often, but I think we just have to accept that some of the more vulnerable people in our society seek out our services to compensate for the lack of local support around them. However frustrating this can be for medical staff and the accountants trying to balance the books, I can’t see any real alternative. If an attempt is made to try to ration Tracey’s medical visits, my big fear is that she would stay at home for that one genuine emergency that really needed our help.

Crackhead Kenny II (#ulink_1debb9a5-4901-54fa-a313-003c1c1d7da9)

I didn’t initially recognise Kenny when he came to see me. It had been a few months since he’d been a patient I’d seen high as a kite and handcuffed to a prison officer in A&E. We were now in the very different context of my GP surgery on a drizzly Monday afternoon. Kenny seemed very different too. His face looked greyer and older in the daylight, and although he tried to manage a smile, without the aid of his narcotic buzz he had lost his infectious grin.

‘I wanted to come and see you ’cos you was nice to me that time when we met in the casualty department.’

‘Oh, how did you know I worked here?’

‘Well, since I’ve been out, I’ve been back to A&E a few times. I was asking after you and that big Scottish male nurse told me you worked here as a GP, so here I am.’

I tried to muster a smile, but I could tell that having Kenny as a regular patient was going to be hard work. I could just imagine Barry the charge nurse thinking it hilarious to direct Kenny to me.

‘How long have you been out of prison?’

‘Nearly a month now. I’m staying at a friend’s, but I’m going to get myself sorted out this time. No more smack for me, Dr Ben. I’m going clean for good this time.’

‘Great, so are you involved with the drug and alcohol team? Are they doing a rehab programme with you?’

‘No, Doctor. They’re all useless there. I won’t ’ave nothing to do with them. You’re the only doctor I trust. That’s why I’m here. I want you to help me.’

I like being told that I’m a good doctor and even though I knew that Kenny was after something, I couldn’t help but feel flattered by his compliments however loaded they might have been. I’m sure one of the reasons that I wanted to be a doctor was some sort of unhealthy need to be liked. Many medics are, like me, constantly searching to be appreciated, and some patients can’t help but try to manipulate that flaw at times. When I first started as a GP, my trainer told me that wanting to be loved by everyone is an admirable trait in a Labrador or a prostitute, but it doesn’t make for a good doctor. I had a feeling that Kenny was going to prove this to be true.

‘I really want to make it work this time, Dr Ben. If I can just get off the crack I can get myself a place to live and a job and most importantly back in touch with my little girl. She needs her dad.’

Kenny looked up at a scribbled picture on my wall that my eldest had drawn for me.

‘If you’ve got kids, Dr Ben, you’ll understand how important it is that I stay off the crack right now.’

‘Absolutely,’ I said, still waiting for the but …

‘But I just need something to get me off the crack. Just to settle me down a bit and stop me losing it. Not much … Just a few Diazzies and some Temazzies and Zoppies. In prison they gave me Pregabbies, so I could do with a few of those.’

Patients who take meds for their weak bladder or high blood pressure tend not to have pet names for their tablets. When someone affectionately shortens the names of their medications, it always worries me. Diazzies are diazepam, temazzies are temazepam and zoppies are zopiclone. The meds that Kenny were asking for are all addictive and can cause a sort of spaced-out stupor when abused. Pregabbies are pregabalin, which are a type of painkiller, but they can be crushed up and injected to cause a high.

‘Kenny, what’s the point of coming off one drug and replacing it with another? If you really want me to help you and you want to clean up, we need to work out a programme of getting you off all drugs. It’s the only way.’

Kenny had been working hard to pull on my heartstrings, but as soon as it seemed that I might not prescribe him what he wanted, his lip started to curl and his voice was on the rise: ‘But I came to see you ’cos I thought you were gonna help me.’ He scowled at me.

‘Come on, Kenny, we both know that there is no point in me prescribing new addictive drugs to take up the job of the old addictive drugs. You need a proper supervised detox as an inpatient.’

‘But I want to come off the crack today. There’s a wait for detox, so that’s why I need a little something now, just to get me off the really bad stuff.’

I really wanted to believe that Kenny was serious about giving up his habit for good, but I knew from painful previous experience that many addicts either misuse their prescription drugs or simply sell them to get enough money for the harder stuff.

‘I won’t do it, Kenny. The drug and alcohol team have a walk-in service that’s open this afternoon. You could go round there right now and see them.’

‘I can’t believe you are refusing to help me. If you don’t prescribe nothing for me I’ll be back to using crack tonight. I could be dead in a month. You’ll have to live with that on your conscience.’

‘You don’t have to go back to using crack, Kenny. That’s a decision that you still have control over. If you really want to change your life around you can—’

I didn’t manage to finish my last sentence as Kenny was already out the door and gone.

Army medical I (#ulink_5170d95c-4ec4-558d-838a-9eb81a7c35e0)

Lee was here for an army medical examination and looked very nervous. He was tall, but looked more like an oversized 15-year-old than an adult. The prospect of him becoming a soldier seemed ridiculous.