Benjamin Daniels - Confessions of a GP

Sticking to evidence-based medicine can be very frustrating. For years I had enjoyed advising my patients to drink lots of cranberry juice when they have a urine infection. They always loved this advice. It helped stop the bugs from sticking to the wall of the bladder I used to say. I don’t know where I got this information from but it sounded good and someone clever must have told me it at some point. I guess it was just one of those urban myths that we all buy into sometimes. Patients always love a risk-free natural remedy, especially when advised by the doctor. Unfortunately, a big study recently showed that although drinking cranberry juice can help prevent urine infections, it can’t actually rid you of the bacteria once you have an infection. Bugger, sticking to evidence-based medicine can be very boring sometimes.

Carolina was 15 and, unlike the vast majority of teenagers who come to see me, she actually spoke to me in normal words and sentences rather than in grunts and shrugs. I had seen her on several occasions with minor problems, but this time she came in wanting to talk about going on the pill. She didn’t have a boyfriend but some of her friends were having sex. She didn’t feel ready to have sex yet but wanted to make sure that if anything unexpected did happen that she would be protected. She understood all about sexually transmitted infections and knew how important it was to use condoms. She had also looked up online all about the pill and how it worked. I suggested that she spoke to her mum about this but Carolina told me that her mum was a strict Catholic and she couldn’t talk to her about sex. We had a long chat and she decided that she was going to take the prescription for the pill away with her and then have a think about things before potentially cashing it in for the tablets themselves. I remember thinking to myself that if I ever have a teenage daughter, I hope she can talk as openly and honestly about sex as Carolina.

A month later I got an angry phone call: ‘Dr Daniels, it is Carolina’s mother here. I was just wondering if you could tell me the age of consent in this country.’

‘It’s, erm, 16.’

‘In that case, why have I found 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 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: