Confessions of a GP

The births that I am concerned about are those from the young, isolated, council-estate mums who are often bringing their children into less savoury environments. I spend a lot of time trying to make sure that these mothers have the support they need and, with the help of social workers, midwives and health visitors, that the child will be safe from potential neglect and abuse. Sophie feels that a bad birth experience, and particularly a Caesarean, can affect the future development and personality of the child. I personally doubt that is true. I feel that far more important is the mother’s ability to make an early bond with the child and give that child a stable, nurtured and safe start in life. Postnatal depression is perhaps the biggest contributor to mothers struggling to bond with their children. This can affect women of all classes and ages, but poverty, isolation and being a teenage mum are, in my experience, the biggest risk factors. I personally would rather money was spent providing for these vulnerable mothers than on funding home births.

Michael

It was a drizzly Tuesday morning in November and Michael was my fourth patient complaining of a cough and sore throat. My initial reaction was that I was seeing yet another case of man flu. Young men make such a fuss when they have a bit of a cold. They demand mountains of sympathy and expect you to discuss with them for hours the merits of Lemsip vs Beechams.

Unfortunately, Michael didn’t just have man flu. There was something not quite right. He had already had three courses of antibiotics for recent chest infections and was losing weight. On closer inspection, he also had a white furry tongue that was almost certainly oral thrush.

Michael was 33 and a teacher at the local school. He was from Zimbabwe and had moved to England two years ago with his wife and baby daughter. His symptoms suggested a weakened immune system and I had to consider AIDS as a definite possibility. I discussed with Michael doing more blood tests. It is never easy bringing up the subject of HIV but it was important that I asked him directly about it and whether he felt he had ever put himself at risk. I talked to him about doing an HIV test and counselled him fully on what we would do if the result was positive.

Sexual health clinics are much better than GPs at managing HIV testing and I suggested that he attended our local walk-in centre. Michael looked horrified. Teachers tend to avoid the clap clinic as there is always a good chance that they’ll be sitting in the waiting room surrounded by their teenage pupils. Michael denied that he had ever put himself at risk but agreed to talk to his wife and come back the next day for me to do a blood test.

Michael missed his appointment. I wrote a letter and phoned twice but he never got back to me. I had a dilemma. Michael could well be HIV-positive but didn’t want an HIV test. He was, of course, completely within his rights to make this decision, but what about his wife and daughter? They could well be HIV-positive, too, and if diagnosed early, could potentially live long healthy lives on antiretroviral medication. I doubted strongly that Michael had spoken to his wife about his suspected diagnosis. The whole family were my patients so I had a duty of care for them all; however, I couldn’t break Michael’s right to confidentiality.

I was searching for a solution when one found me. Michael’s wife brought in their four-year-old daughter Cynthia to see me because of a lump on her neck. I had no idea if this lump was related to being HIV-positive or not, but it was an opportunity that I couldn’t miss. I talked with Michael’s wife about the many different causes for neck lumps in children, including AIDS, and discussed the option of a referral to the sexual health clinic for HIV testing. I wasn’t breaking Michael’s confidentiality but my actions did result in all three of them being tested. Unfortunately, the whole family tested HIV-positive with Michael and his daughter already having symptoms of AIDS.

I didn’t officially break Michael’s confidentiality but in some ways I did break his trust. He hasn’t come back to see me since but instead saw one of the other GPs at the practice. Michael and his wife and daughter were now on antiretroviral drugs and doing well. I feel I can ethically defend my actions; however, I do wonder if I would handle things differently next time. What a relief it was when my next young male patient with a cough and sore throat genuinely just had man flu.

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