The Complete Confessions of a GP. Benjamin Daniels

a prescription for the contraceptive pill under the bed of my 15-year-old daughter? It’s got your signature on it.’

      It was an awkward moment. My first reaction was to ask what she was thinking looking under her daughter’s bed. Surely that must be the first rule of having a teenager. Don’t look under their beds, as you’ll only find something you don’t want to know about! Carolina’s mum was furious. It was a shame, really, as she came to see me fairly often herself and we actually got on quite well. She was one of those really grateful patients who always thanked me profusely even when I hadn’t really done much. She was Polish and I romanticise that in Poland they have an old-fashioned respect and admiration for their doctors long since vanished in the UK. The problem was that alongside the old-fashioned value of respecting doctors was the old-fashioned value of expecting your teenage daughter to keep her virginity until her wedding night.

      The rules on prescribing the pill to minors are fairly clear. Girls under 16 can go on the pill without their parents’ permission. They must have capacity, which basically means that they are able to understand the decision they are making and the pros and cons. As the doctor, I am supposed to encourage the girl to speak to her parents but if I think she will have sex anyway it is recommended that the doctor prescribe her the pill. This was contested in 1983 by a Catholic mother called Victoria Gillick. She didn’t want her underage daughters being given the pill without her permission. She lost the case. Interestingly, although under-16s can make their own decisions about treatments that they want, they can’t refuse treatment. For example, if a 15-year-old has appendicitis and needs to be operated on but she or he declines surgery, the parents can overrule the decision.

      For me, prescribing the pill for 15-year-olds is something that I do fairly frequently. Some people feel that as a GP prescribing the pill, I’m encouraging underage sex. As far as I’m concerned, teenagers are influenced by friends, music, TV and magazines. They’re not influenced by slightly geeky 30-year-old doctors with bad hair and Marks and Spencer’s trousers. She might later regret having her first sexual experience too young, but she’ll be more damaged by having an abortion or a baby. The decisions are much harder if the girl is 14 or 13 or if the boyfriend is much older. It is such a grey area. If Carolina had a boyfriend who was 16 or 17, I guess that would be okay. What if he was 20 or 25? When do I break confidentiality and call the police or social services? These sorts of issues are difficult to judge but faced by GPs every day. I imagine that doctors who have strong religious convictions or those who have teenage daughters themselves may view the whole issue very differently from me.

      Back to Carolina’s angry mum. I was a bit stuck. I wanted to tell her how sensible her daughter was and that the very fact that the prescription hadn’t been cashed in demonstrated her maturity. The problem was that I owed Carolina her confidentiality and couldn’t really say anything to mum at all other than to explain that I was within the law to prescribe her daughter the pill. I did sympathise with Carolina’s mum. Although I remember feeling very grown up at 15, it is pretty young really. I wasn’t having sex at 15 but that wasn’t by choice. My combination of bad skin, unfashionable clothes and a disabling tendency to blush and then stammer awkward nonsense whenever within about 15 yards of a girl, meant that I didn’t lose my virginity until my late teens. Perhaps my opinions will change in the future, but at the moment I sort of feel that at around that age teenagers will want to be having sex. They will probably make mistakes and have experiences they regret, but if my teenage-girl patients can get into their twenties without getting pregnant or becoming riddled with venereal disease, then I’m probably doing a good job.

       Lee

      Lee was 36 and was just out of prison. He had been due to be my last patient of the morning but his appointment was at 12.20 and he turned up at 1.30, just as I was about to leave the surgery to do a visit and grab some lunch. I was in the office and could hear him getting slightly aggressive with the receptionist as she explained that I wouldn’t see him. It was only fair that I went out and gave her some support.

      ‘Are you the doctor? Will you just see me quickly? I need something to calm me down.’

      ‘No, you’re over an hour late so you’ll have to rebook in to see me or one of the other doctors this afternoon.’

      ‘Well, can you just give me something to help me sleep?’

      I’m not a big fan of prescribing sleeping tablets such as diazepam. I try to avoid prescribing them myself, but looking through Lee’s medication list on the computer, I saw that he had a repeat prescription of diazepam still on his screen from before he went into prison. The computer showed he had been prescribed diazepam regularly for years and so I agreed to let him have a prescription for a week’s worth now with the plan to start cutting them down at his next appointment. I quickly printed and signed his prescription for diazepam and booked him an appointment for later that afternoon.

      That was my one and only consultation with Lee. It took place in the reception area of the surgery and I dished him out a few pills to get him out of my hair so I could get on with my day. Lee didn’t attend his afternoon appointment and by the next morning he was dead, having taken an overdose the night before. I read and reread the automatic and very impersonal fax that is generated for every A&E presentation:

      Dear Doctor Daniels,

      Your patient was admitted at 03.45 with a presentation of overdose. He was discharged with a diagnosis of death.

      I felt like shit now. Had Lee overdosed on the medication I prescribed him? I hadn’t seen Lee because I was hungry and tired from a long morning surgery and didn’t want to get held up. Was that a good excuse? If I had seen him properly and listened, maybe I wouldn’t have given him the prescription at all. Perhaps he would have told me a few of his worries, felt a bit better and not topped himself. Had I missed a rare chance to make a real difference? I had an unpleasant morning stewing over Lee’s death, imagining explaining myself to the judge.

      ‘So Dr Daniels, the deceased came to see you feeling vulnerable and desperate. He had a history of violence and depression. You were his only source of help and what did you do next?’

      ‘I gave him a week’s worth of sleeping pills and told him to bugger off, your honour.’

      It didn’t look good, did it?

      Suicide is a difficult case for GPs to deal with. We see depression and self-harm by the truckload but not many patients actually successfully kill themselves. When I was an A&E doctor, the cubicles were full of teenage girls who had taken eight paracetamol after a row with a boyfriend or parent. There were a lot more cries for help than genuine suicide attempts and most of the ‘overdoses’ were generally dismissed by A&E doctors as time-wasters. When I was working in psychiatry we saw the next step up. These were genuinely depressed people who took big overdoses and really wanted to die at the time. They only very rarely succeeded in causing themselves any real harm and still ended up in an A&E cubicle with the casualty doctors equally reluctant to have to treat them. Only one of my patients successfully committed suicide during my time in psychiatry. He was a nice young lad of 19 who was just recovering from his first episode of schizophrenia. He had just returned from a gap year travelling round Asia and was looking forward to starting university when he became really psychotic and unwell. He was hearing voices and getting very paranoid. He had to be sectioned and admitted to the ward but he started to improve with medication. I was really pleased with his progress and happy that he was ready to be discharged home. He was realising his potential future of daily medication, psychotic relapses and social stigma. He got into his mum’s car, took off his seat belt and drove very fast into a wall. It made me appreciate that, actually, if you really do want to die it isn’t that difficult.

      I felt pretty shitty when that lad died. The consultant took me aside and said that a cardiologist can’t expect to stop all his patients from ever having heart attacks, he just has to look after his patients as best he can and try to prevent as many as possible. It’s the same being a psychiatrist or GP. You can’t expect to save all your patients from suicide. If I had done everything that I could for Lee, it would have been easier to take. It was