Lynn's story

On the 3rd December 2008, Lynn Gilderdale persuaded her mother to help her to die. She had been suffering from a severe form of ME since her teens, and at 31 she was tired of living her life confined to her bed, unable to speak or feed herself. She wanted a way out. A 'Do not resuscitate' order lay in her medical notes, her 'Living Will' alongside it, but to actually end her life, she needed help. I cannot imagine how painful it must have been for her mother to have been a part of this, and how terrifying. When the syringes of morphine didn't work Kay Gilderdale tried crushing anti-depressants and sleeping pills and passing them down Lynn's nasogastric tube. The deed still not done she added further morphine injections along with syringes full of air with the aim of blocking the blood supply to her lungs. It took 28 hours for Lynn to die.

This tragic story has finally been put to rest this week, with a jury clearing Kay Gilderdale of attempted murder. But it should never have gone to court. The real crime was to put a grieving mother through this extended ordeal for a prosecution which would have served no one. But there is another reason why I believe that this trial has been harmful, and that is because it has suggested to us that what Kay Gilderdale did was right.

Please don't get me wrong, it's clear that given the terrible circumstances that she found herself in, what Kay did was selfless, compassionate and brave. But are we truly to believe that it was right?

If you believe that it was, then what you are calling for is a change to UK law to legalise assisted suicide, or euthanasia. You must then consider the barrage of troublesome questions that this would raise. What if in a future case the 'assistant' had something to gain from the death? What of the pressure it could impose on those who are terrified that they have become a burden on family and friends? Where and how do you draw the line between what is acceptable and what is not?

If on the other hand you believe that what Mrs Gilderdale did was wrong, then you must maintain that it is preferable for someone like Lynn, with unbearable suffering, to struggle on. That it is reasonable to deny the help that she so desperately craved.

The truth is that it's disconcertingly hard to know where to stand on this. As a doctor I would never want to be involved in ending someone's life prematurely, yet nor would I want to be responsible for extending suffering. What I do believe is that we should not be encouraging people to take these decisions into their own hands. What took place in December 2008 would have been distressing and frightening for both mother and daughter and must not be seen as a satisfactory course of events.

So where do we go from here? Despite recent guidance from the director of public prosecutions, the legalities of assisted suicide remain unhelpfully vague and open to interpretation. Even so, I can't help thinking that new legislation is unlikely to be the answer here, in a field where each case will vary enormously and therefore should be looked at individually.

We do have a duty to help and support those who can bear life no longer, but whether this should be extended to assisting in ending life remains an enormous ethical question. The current situation however, where families are being forced into making these decisions in isolation and secrecy, not knowing whether criminal charges may follow, seems less than ideal.

"Next!"

If there's one thing that I dislike about being a GP in the NHS, it's the terrible ten minute appointment slots. Let me take you through a typical morning to show you why:

8.30am - Patient 1 arrives

8.40am - Patient 1 leaves (well done me I think, an impressive start)

8.43am - Patient 2 arrives (he doesn't think he's late, I do)

8.50am - Patient 3 arrives

8.55am - Patient 2 leaves. Patient 3 enters and promptly bursts into tears.

9.00am - Patient 4 arrives

9.10am - Patient 5 arrives

9.20am - Patient 6 arrives

9.30am - Patient 7 arrives. I'm still with Patient 3. Very subtly (years of practice) I manage to flick to my computer's control screen. I see the word "waiting" repeated again and again down the morning list. I panic. I manage to lose Patient 3. But it's too late. I know that I am now destined to spend the rest of the morning frantically trying to catch up on time at the expense of listening to my patients. The day will pass in a frenzy of irritated patients, inadequate consultations and an increasingly stressed me.

I suppose to be fair, there are a few things that can be done in 10 minutes. Dealing with coughs and colds, toenail infections, diagnosing an ear full of wax, boiling an egg, having a shower, feeding the dog (I hasten to add that not all of these are recommended work time activities). There are however, many things that can't. Managing depression, admitting a patient to hospital, dealing with a new diagnosis of diabetes. Oh yes, and of course the; "Well there are a few things actually doctor - I've made a list so I wouldn't forget them". Groan.

Thankfully the BMA have recently acknowledged this problem, detailing the need to lengthen GP appointments in their pre-election manifesto. Unfortunately however they have also admitted that this can only be 'an aspiration' since it would require many more doctors which is clearly unrealistic in the current climate. More groans.

I however have been lucky. The practice I have now joined does offer 15 minute appointments and whilst an extra 5 minutes may not seem like a lot, it has revolutionised my working life. I have started to enjoy my job again and I feel that I can do it properly now. I am happier and my patients are happier. I have more time to listen, time for health education, time even perhaps just to chat. We of course are fortunate that we are a small enough practice to do this and still be able to offer enough appointments to meet our targets, the majority can't. But having seen it work and seen the difference it makes, I will be championing the idea that in the case of appointment times, we really do need quantity to achieve quality.

Let them eat cake

Something happened to me this week that has changed my perspective on what makes my job worthwhile. It has proved to be a momentous event, a milestone in my career.

Someone brought me a cake.

You may not immediately understand the significance of this, but you see it wasn't just any cake. It was a chocolate cake, it was made for one (sharing not an option) and it came in its own pretty little box so that I could take it away, without fear of spoiling, and devour it in the comfort of my own home. But there's even more to it than that. It came from a patient who I do not know particularly well, not as a christmas present and not for a birthday, but just because. It was delicious, but more than that, it made me feel valued and that made me feel good.

I remember an incident a few years ago at the end of a long, busy night shift on a general medical ward. There's a particular sensation that you get at the end of a night shift, when the daylight breaks and it is time to go home. You feel shattered, disorientated, a little dizzy and usually pretty nauseated. So there I was, feeling shattered, disorientated, a little dizzy and pretty nauseated, quietly making my way in the lift down to the ground floor and the way out. I had planned to pop into the ward on my way home to check one last thing but when the doors opened on level 3 I could not face it and stayed where I was. There were two middle aged patients in the lift with me (no doubt on their way for a cigarette); "Aren't you going to get out?" they interrogated accusingly - they must have seen me press the button for that floor. "No sorry, I've changed my mind" I replied. They glared at me and under her breath one of them muttered, "urgh, doctors".

I remember wondering why on earth I did this job.

But now it's clear. For me, job satisfaction is not just about helping people, seeing people get better or making a brilliant diagnosis (which is lucky as this doesn't happen terribly often). If I do all of that and the patient in question doesn't appear to appreciate it, I will feel frustrated. Clearly I am not the altruist I always hoped I was. So whilst I'm sure that this does not apply to all, my hypothesis for the many is this; that to get real fulfillment from a job, whether as a doctor, a teacher or an estate agent, or perhaps even to get fulfillment from life itself, you need to feel valued. In turn, to get the best out of people, you also need to show that you value them. And a chocolate cake seems as good a way as any....

Battle lines drawn

Back from the Christmas holidays, and so it seems are a host of nasty viral illnesses. They've taken full advantage of our tendency to run ourselves into the ground during the silly season, seeing as many people as we can and giving our viral friends their very own reason to celebrate. It means that my usually peaceful waiting room has been converted into a mass of runny noses and hacking coughs. Their owners have come for antibiotics, and will feel cheated if they leave empty handed.

And so I prepare for battle. The tactics are diverse, the terrain treacherous. There are those who launch straight in with their request, standing over me with a loaded gun... (or is that my imagination?) Others remain under camouflage initially, but are so crushed by my suggestion of paracetamol that they then take up their attack. A few go for a more underhand tactic, comparing me unfavourably to my colleges; "Dr Jones always gives me antibiotics when I've asked in the past". Once or twice I have even heard a patient change their symptoms mid consultation having caught wind of my unwillingness to prescribe.

My defences are limited. Most are already bored of my 'virus versus bacteria' speech and since I have no way of proving to them that theirs is a virus, few are satisfied. Of course there's the strong argument of the need to avoid encouraging bacterial resistance but many won't see this as relevant to them or else they are so bored by my spiel by this point that they have begun to drop off. If I'm getting desperate I do occasionally throw in a few nasty sounding side effects, but those who have used antibiotics before are not swayed by this one.

The fight goes on, patient after patient, and I am tiring. I think to myself how much easier my morning could be if I just signed the prescriptions and got on with it. The temptation is huge, but unfortunately for me my irritatingly pious conscious will not allow it and so by the end of the morning I am battered and bruised, in desperate need of some R & R.

You may wonder why it is that I feel compelled to fight so hard, but there truly are plenty of reasons why we shouldn't be too liberal with antibiotics. Remember the c difficile horror stories of patients dying in their hospital beds from uncontrollable diarrhoea? Antibiotic overuse was largely responsible. It's also worth noting that no new classes of antibiotics have been discovered since the 1960's and so the ever growing problem of resistance really does pose a substantial threat.

Of course I'm being a little facetious as there are plenty of people who are fully aware of these facts and are happy to accept my explanations. Certainly there are also those who actually do need antibiotics and it's clearly always better to check if you're worried. But for those who can do without them, I will continue with my own peculiar war, confident in the knowledge that I am far more likely to become a casualty of the process than they are.

Worried well

This week has brought James (23), Mark (35) and David (55). None of these men have any symptoms, and yet all were coming with deep concerns, all of them requesting a general health check, a 'medical MOT'. They've got their reasons. James has recently become a city banker. He now spends approximately 14 hours a day in an office, can no longer find the time to exercise, eats junk food at his desk and has put on 2 stone of weight. Ah, these poor bankers. Mark on the other hand is the healthy type. He cycles to work (lycra clad), eats organic, takes part in triathlons and shops with a re-usable hessian bag. But an equally healthy living friend has just been diagnosed with cancer and now he too feels vulnerable. David is a man in his 50's who has heard about prostate cancer.

Such non-specific but deep rooted health concerns are becoming more and more common. They're encouraged by health horror stories from family, friends and from the media and deepened by searching on the internet. Privately, you can have screening blood tests, full body scans, computerised images of your brain, blood vessels or intestines - pretty much anything and everything that takes your fancy. But I wonder whether this is something that should be encouraged? The NHS doesn't think so, as apart from anything else it is about as cost-effective as a diamond encrusted toothbrush. But if money was unlimited, would it be a good idea for us to be fed through a scanner at regular intervals, just incase?

As far as I'm concerned, the answer should be a definite no, and I'll use David as an example of why. His request for a blood test to screen for prostate cancer was a perfectly sensible one. Prostate cancer is the second most common cause of cancer deaths in men in the UK, and it becomes more common over the age of 50. So, after a long discussion about the pro's and con's of testing, he went ahead and had the test. But it's no easy decision, as becomes apparent when you take a closer look at these pros and cons.

Pro's: If the test is negative, you'll feel reassured. If it's positive, you may pick up a cancer early, get treated quickly and not die. That's a pretty big pro. But here are the con's: 2 out of 3 men with a positive test will not have prostate cancer. This means that two thirds of men who go on to have a biopsy will turn out not to have cancer after all. When you know that a biopsy means having a probe with a needle attached inserted through your rectum and into your prostate this suddenly seems like a notable con. It doesn't get any better from here either, because if you are unluckily enough to have a positive biopsy result, there's often no way of telling whether the cancer that you have would ever cause you problems. Some do, some don't. So then you must decide whether you want to have treatment which can involve surgery (with the potential of nasty complications including impotence), radiotherapy and chemotherapy. If you decide not to, you have to live with the knowledge that you have a cancer that may or may not kill you. There's one further important con, and that's that a PSA test can miss a cancer and so can a biopsy.

The NHS has decided that the cons outweigh the pros in this case, and so whilst you can have the test if you ask for it, there is no national screening program in place. But this is just one disease. Imagine the possibilities for misadventure if we were to look for any conceivable problem with our health, year in and year out?

So whilst David had his test (it was negative), I tried to persuade James and Mark that in most cases, ignorance is bliss. I'm not sure that I did a great job of convincing them and I wouldn't be at all surprised if the private sector gets some revenue from these two. For me though, I'm just not in the business of looking for trouble...

Yours or mine?

Sometimes it can be pretty hard to know where my responsibilities start and finish when it comes to patients. Take Martin, who was worried that he might have thyroid disease. Having read on the internet about the symptoms of tiredness, weight gain and low mood (average British person in mid-winter?) he made an appointment to get some bloods taken. We discussed that he should telephone in 3 days time for the results, but as often happens, he never did. Should I call him?

David obviously thinks so. He came in for a repeat prescription this week and in passing mentioned that he had never found out the results of a blood test taken over a year ago; 'I assumed if there was something wrong the doc would have called me'.

Actually, there's no real question that checking test results is a doctor's obligation. After all, if we're not interested in the results, why bother doing the test in the first place? But at the same time, I do find it a little frustrating if a patient doesn't also check for themselves. It's largely because it increases my work load but it's also because it gives the impression that by coming to see me they have absolved themselves completely of all responsibility for their own health.

Another example is that of Mr Shaw. His problem was of food sticking in his throat when he tried to swallow. This was worrying, and so I referred him to a specialist straight away. I explained that he needed to telephone to make the appointment himself but on checking my outstanding referrals a few months later I saw that he had never done this. Despite the fact that we had discussed a plan which he had understood and agreed to, he had not followed the instructions. So should I chase him up? Is that my responsibility? (In this case I did, and I'm sure you'll be pleased to know that his symptoms have resolved)

Of course there's no black and white answer here and in practice what you do and don't do for your patients comes down to how worried you are about their symptoms and what you can realistically achieve. It just isn't possible for any one doctor to keep tabs on all of their patients all of the time. There are too many uncertainties: Are they attending appointments? Are they picking up prescriptions? Will they come back as I asked them to? With thousands of patients on your list, these questions will inevitably often go unanswered.

To some extent then, you have to be able to rely on patients to be accountable for themselves, to take back some of the responsibility. This isn't a risk free strategy. There are always going to be situations when there is a mismatch of expectations between patient and doctor and in these circumstances there is a real danger that something important could get missed. Fortunately for me it seems that on the whole my patients are worryingly well versed on the fallibility of doctors (...must have been the one before me...) and so, with a bit of teamwork, we seem to be doing pretty well.

Big Brother

We've had a new healthcare initiative added to our remit this year. The idea is to screen as many of our patients as possible for alcohol misuse, with the aim of making people more aware as to what constitutes dangerous drinking, and helping them to make changes before it is too late.

According to the Department of Health, 23% of adults aged between 16 and 64 years are thought to drink at hazardous or harmful levels. This includes a massive 32% of men (15% of women), and equates to approximately 7.1 million people in England.

Some definitions are needed here. The World Health Organization divides alcohol problems into three main categories; hazardous drinking, harmful drinking and alcohol dependence. Hazardous drinking describes drinking above safe levels, 14 units a week for women and 21 for men. Harmful drinking is the same but with evidence of alcohol related problems. Alcohol dependence has a much more complicated definition but basically describes the group that we would know as alcoholics.

So what's interesting about the 23% statistic is that it isn't talking about alcoholics, but about people who drink in excess of what the medical profession considers safe. It's referring to anyone you know who drinks more than a couple of glasses of wine a night, and according to the stats that's nearly one in four of us - in reality, it's probably more.

The problem of course, is that this group of drinkers doesn't think there is a problem. The government and the NHS do however, and in fairness, rightly so. Any sort of prolonged hazardous drinking can lead to liver disease, heart disease, even some cancers, and that's before you look at the social problems of relationship breakdown, financial problems and alcohol related crime.

So I do understand this drive to identify problem drinkers, and there's evidence to show that some brief advice from your GP can make all the difference. On the other hand, actually performing this mass screening is pretty uncomfortable. It's understandably difficult to launch into questioning someone about their alcohol intake when they've come to ask you about a toenail infection. It hasn't happened yet, but I'm just waiting to be told to mind my own business, an attitude that I would sympathize with completely.

So the point is, is it our business? The powers that be would say that anything that impacts on the nation's health should be, but as individuals surely we must be allowed to make at least some of our own lifestyle choices. I feel pretty strongly that what we eat and drink should be one of them. However that then leaves the question of where to draw the line; is smoking a lifestyle choice? Is injecting heroin?

It all comes back to that age old conflict between wanting to help and interfering, trying to protect and smothering. I have no desire to play the role of nanny, and yet I have seen the desolation that problem drinking can bring. So I do my best to follow this new initiative where I can, apart from anything else we will lose out financially if I don't. I try hard not to be too intrusive. As for how much the toenail guy drinks though, I didn't ask.