Benjamin Daniels - The Complete Confessions of a GP

As those of you who have had the misfortune to have had your bottom examined by the doctor will know, we generally expect you to drop your trousers, jump up on the bed, pull your knees up to your chest and lie on your side facing away from the doctor. I usually have a blanket handy so the patient can remain covered until the examination itself takes place. Normally, the whole ordeal is quick and relatively painless – well, painless for me, anyway. Unfortunately, it would appear that things are done slightly differently in Bulgaria. I pulled back the curtain to find Olga naked from the waist down leaning over the couch with her bottom pointing to the ceiling. ‘No no, you need to be up on the bed!’ I cried. ‘ON THE BED,’ I repeated slowly and loudly. I pulled the curtain across again and after a few polite moments went back in. This time Olga was on all fours on top of the couch still with her bum pointing up in the air. After much gesticulating and loud slow explanations, I was still no closer to having Olga in a position in which I could examine her. I motioned for her to get off the bed and got on myself lying in the correct position. ‘LIKE THIS, YOU SEE.’ I was lying curled up on the bed while my half-naked patient was standing beside me still looking very puzzled. It was a moment that I was very glad wasn’t interrupted by a receptionist bringing in a cup of tea.

I did finally manage to examine Olga’s bottom, only to find nothing unusual at all. In theory I should have done a rectal examination as well, but poor Olga had faced enough already and inserting my finger up her back passage without her really being able to understand my explanation of what I was doing seemed a bit unfair, bordering on abuse. I managed to book her in for an appointment another time with an interpreter present but she didn’t turn up, possibly having somewhat lost faith in me.

I recall another difficult rectal examination back when I was an A&E doctor. An elderly lady called Ethel had been brought in by her husband, Lionel, because of her having some tummy pains and bleeding from her anus. Ethel herself was quite demented and also very deaf. Lionel was a retired vicar and now caring for Ethel full time at home.

After taking a history from Lionel and feeling Ethel’s tummy, I needed to do a rectal examination. It was important to make sure that there wasn’t a blockage in the rectum causing her symptoms. ‘I'm going to need to examine your rectum, Ethel.’ ‘You what, love? I can't hear you.’ ‘I need to put a digit up your back passage, Ethel,’ I say again a bit louder and into her good ear. ‘What’s he saying, eh?’ ‘I’M GOING TO HAVE TO PUT A FINGER UP YOUR BOTTOM.’ This time I was shouting at the top of my lungs. It was only a set of curtains that separated us from the rest of the A&E department and, as you can imagine, curtains aren’t particularly soundproof. The entirety of the A&E department was now aware of Ethel’s impending rectal examination but, unfortunately, Ethel wasn’t. Her confusion was such that she couldn’t really comprehend what I was doing or why. Despite my best efforts to put her at ease, she was getting increasingly agitated. I put on a pair of gloves, moved her into as comfortable a position as possible and gently eased my right index finger into her anus. Suddenly, there was an almighty shriek. ‘Oooh, Lionel. Stop it, Lionel. You know I don’t like it that way. If you’ve got to put it in, at least put it in around the front.’ Poor Lionel was standing outside the cubicle in full view of all the patients and staff who were trying to hold back their giggles. He looked very embarrassed as he made his way back into the cubicle.

Julia was young, attractive and articulate.

‘I need you to section my boyfriend Andy. He’s completely mad and unreasonable and yesterday he smashed up my moped for no reason.’

I wasn’t expecting that one.

‘Your boyfriend doesn’t sound very nice but we aren’t going to be able to section him.’

‘But he’s mad! It wasn’t just any moped. It was my twenty-first birthday present. I drove it everywhere. It was my most precious possession! He knew that!’

I was tempted to explain that there wasn’t a special subclause in the Mental Health Act that allowed us to section people if the moped they smashed up was a very special birthday present. I held back and instead explained how a person would need to have a mental disorder and pose a risk of harming themselves or others before they could be sectioned.

‘He is a risk to me. He beats me up!’ Julia then proceeded to lift her shirt to reveal an impressive array of bruises on her torso.

‘Why don’t you leave him? There is a local domestic violence support group. Perhaps I could –’

Julia interrupted me. ‘He needs me. He says he would kill himself if I left him and I couldn’t have that on my conscience for the rest of my life. He needs help and all you’re telling me to do is leave him. He was abused as a child and so was his mum. His whole family is fucked up. I’m all he’s got.’

I wasn’t sure where to go from here. From the outside it seemed so straightforward. Leave, run away, start again. Julia had a lot going for her. She could have a whole new life. It clearly isn’t this straightforward as there are thousands of women like Julia who don’t leave or run away or start again. I would never really understand the complexities of Julia’s violent relationship but one thing was very clear. When she said that Andy had nobody else, what she was really saying was that she didn’t have anyone else. She was alone and, however difficult and abusive her relationship was, she clearly felt that it was all she had.

I was feeling guilty now. Initially, I hadn’t really been taking Julia seriously. I had thought that she wanted her boyfriend sectioned because they had had a tiff. It was now clear that things were more complex. Deep down Julia knew that I wasn’t going to section Andy but she was crying out for help and somehow it was me who was expected to provide this help. At medical school I had learnt about the role of mitochondrial antibodies in primary biliary cirrhosis and the parasympathetic nerve distribution to the salivary glands. It wasn’t the greatest preparation for dealing with a vulnerable desperate woman who got beaten up every day by the man who supposedly loved her. Regardless of my lack of training, at that moment I was all she had and I had to do my best.

‘If you leave him and he harms himself, that’s not your fault.’

‘Is that the best you can do? He needs help.’

Andy was a patient at another practice and I had never met him. I couldn’t really speculate what he needed but psychotherapy is usually our get-out clause when faced with a difficult psychological issue that is complex and not fixed with a tablet.

‘Maybe psychotherapy would help Andy?’

Julia looked hopeful until I explained that there was a two-year wait for psychotherapy in this town.

‘That’s really useful, thanks a lot.’

‘You have to leave him,’ I said again. I tried to say it with compassion but I really did feel it was her only option. Julia got up, left and slammed the door. I clearly hadn’t handled that very well. I had failed again. Would another doctor have handled that better? What would a counsellor have said, or a priest or even bloody Jeremy Kyle? I was not sure if Julia would come back to see me. If she did, maybe next time I’d just listen.

What makes a good doctor? I seem to remember being asked something like this during my medical school interview. The interview panel yawned through my contrived answer that mentioned some naïve nonsense about being caring and good at working in a team. As part of our target-based existence, the patient plays a large role in deciding if we are good doctors or not. The Labour government introduced patient satisfaction questionnaires as part of our performance targets.