I felt a massive wave of relief wash over me. It was heroin that had killed Lee, not the diazepam I had prescribed him. Lee was still dead and I had let him down as his doctor, but I lived to fight another day. Lesson learnt, I hoped.
Hugging
Would you think it was strange if your GP gave you a hug? Probably yes if you were just asking him to look at your athlete’s foot. What about if you were upset and needed some human contact?
One of the GPs near me has been suspended for the last two years for allegedly hugging his patients. He worked single-handedly for many years with no apparent problems, but two years ago, shortly after firing his receptionist, she reported him to the General Medical Council for having had ‘inappropriate contact’ with patients. A letter was sent to all his past and present patients and one or two of them then confessed that they felt he had been slightly inappropriately tactile with them over the years. Interestingly, nobody actually complained, but he was suspended and is still awaiting the conclusion of an investigation. He is an older GP, originally from Italy, and he claims that he was simply comforting upset patients. I’ve never met the doctor involved but I’ve met some of his ex-patients and they explained to me that they always assumed he was ‘just a bit Italian’ and was simply less reserved than us Brits. I have no idea if there is any truth behind the allegations, but it has made me very conscious of how I am with my patients.
I’m not sure whether there was more than meets the eye with regard to the Italian doctor, but I do think that cultural differences concerning human contact are important. I saw a very cute little three-year-old Italian girl once. She was very snotty and full of cold but basically fine. After reassuring the mum, she said to the little girl: ‘Give the nice doctor a kiss for looking after you so nicely.’ I was quite surprised. It just isn’t something we do here. I also wasn’t too pleased to receive a snotty kiss from a virus-ridden three-year-old.
There also seem to be cultural differences between nationalities with regard to women being examined by male doctors. The general rule for women appears to be that they tend to feel awkward about being intimately examined by a young male doctor until they have had a baby. It would seem that the experience of having legs akimbo and ten medical students trying to feel how dilated your cervix is provides an instant cure for ever feeling self-conscious. Eastern European women seem to feel no embarrassment about stripping off in front of the doctor. I saw a young Czech woman who needed her blood pressure taken. She was wearing a thick jumper and I couldn’t roll up her sleeve sufficiently to put the cuff round her upper arm. I asked if she could take off her jumper. She whipped it off without a care in the world and I was rather taken aback to find that she had absolutely nothing on underneath. Not even a bra. The Czech woman herself wasn’t bothered in the slightest and this was supported by her normal blood pressure reading. I dread to think how high mine had gone! Later that surgery a woman from Hong Kong came in with a lump on her back. She was absolutely horrified when I suggested that I would need to have a look and in the end I had to send her to a female GP.
I am often faced with somebody very upset and in floods of tears in front of me. They may be someone I’ve just met or perhaps a patient that I’ve known for some time and have built up a close relationship with. Regardless of this I just wouldn’t give them a hug. One of my GP friends says that he puts a consoling hand on the shoulder of his upset patients. He maintains that it is a comforting form of human contact but not too invasive. I just hand them a box of tissues and try to look sympathetic. I can’t think of anything more awkward than a patient asking me for a hug. Funnily enough, though, if they told me that they had rectal bleeding, I wouldn’t blink an eyelid about sticking my finger up their bum. Just one of those odd quirks of being a doctor, I suppose.
Tough Life Syndrome
I had a call to visit Jackie again. She is in her late thirties and lives in a tiny two up two down council house with her three teenage children. The house is thick with smoke and painfully cramped. The TV takes up most of the lounge and lying on the sofa in front of it was Jackie.
‘You’ve gotta help me, Doctor. It’s the pain. I can barely walk. Those pills don’t work. None of it works!’
Jackie has been a patient at my surgery for years. She switches from doctor to doctor and has been on almost every painkiller known to modern medicine.
‘Are you going to see Jackie?’ my colleague asked me as I picked up her notes and headed out of the door of the surgery. ‘She’s got the worst case of TLS I’ve ever seen.’ TLS stands for ‘tough life syndrome’. Jackie has had a really tough life and this now manifests as chronic pain and fatigue. Jackie was abused as a child and young teenager by her stepdad. She then ran away from home and worked as a sex worker for a bit before she became pregnant at 17 by an abusive partner. Two more abusive partners and two more children later, she was alone at 21 with three children and an alcohol problem. Her children are now teenagers. Her son threatens her and regularly steals her benefit money and her daughter is a heroin user. Her eldest son is constantly in and out of prison. It’s not exactly The Waltons.
Jackie has pain all over her body. Her abdominal and back pains have been fairly constant over the last ten years or so and now she has general pains in her legs, arms, chest and hands. Jackie has had multiple scans and X-rays that have all been normal. She has seen neurologists and rheumatologists who have examined her thoroughly and run specialist blood tests and scans looking for rare disorders. They all drew blanks. She was finally diagnosed last year with fibromyalgia. The definition of fibromyalgia is ‘fatigue and widespread pain in the muscles’. It is a diagnosis of exclusion which means that we diagnose it when we haven’t found anything else that could be causing the symptoms.
Officially there is no known cause for fibromyalgia, but time after time when I dig deeply in to the sufferer’s past, I find stories of trauma, abuse and unhappy childhoods. Perhaps in years to come they will find some odd hormone or virus that is responsible for this condition and find a cure, but in my experience it almost always occurs in people who have had tough and troubled lives and can’t articulate that pain verbally so it is expressed instead as physical pain.
I’m clearly not the first doctor to have recognised the likely association between Jackie’s physical symptoms and her emotional state. She has been tried on antidepressants and been referred to counsellors in the past, but she has always been reluctant to accept them. ‘I’m not depressed, Doctor. If you could just get rid of this pain then I’d be fine.’
Whenever I visit Jackie she wants me to try her on a new painkiller. Giving out a quick prescription is the easiest option for me as it is the quickest way that I can get out of the house. The problem is that I know that whatever I prescribe won’t work. She has tried every painkiller I can think of and now the only step up from here is morphine. I really don’t want to be responsible for making her a medicalised heroin addict; besides I know her kids will steal it and either take it themselves or sell it on the estate. Perhaps if I could just help her take some ownership of her condition and recognise the psychological element to it, maybe I could genuinely help her.
‘Jackie, why do you think you’re having all this pain?’
‘I dunno. You’re the doctor.’
‘It looks like you have had quite a hard time over the years.’
‘You can say that again.’
‘Some people find that going through large amounts of stress and upset can contribute to having physical pains and low energy.’
‘You think I’m making it up, don’t you? This pain is real, you know.’