Continuity or access in patient care?

Patients often complain in general practice that they cannot see their own doctor. There is no problem with access but it is continuity of care that is lacking.

GP’s used to pride themselves knowing their patients and families well. In our practice we have 12,000 patients. We used to have six fulltime partners- that is 2,000 patients each. Now for the same number of patients there are 3 full time partners, 2 part time partners, 1 full time salaried doctor, 2 part time salaried doctors, a GP registrar, an F1 doctor and innumerable locums.

I saw a 12year old boy last week that had recurrent severe abdominal pains over 3 months. He had seen consulted ten doctors. He had seen two out of hours doctors, visited casualty twice, seen a specialist, and had consulted five doctors at our practice. He had lost lots of time at school and was on regular painkillers. The parents had no complaints about the doctors attention but they felt nothing had been achieved to relief his suffering or find the cause. I tended to agree, as the symptoms seemed genuine although difficult to explain. No professional had stood back at look at the whole story.

A call to the paediatric consultant was needed to get him admitted and sorted. I felt if he had one doctor who could have seen the pattern and knew the family well he could have been sorted out quicker. That is the job of a good family physician

I have tried everything

‘I have spent over a thousand pounds on my neck and I want it sorted,’ was Mrs Harrington’s opening statement. Indeed she had tried lots of treatments; acupuncture, physiotherapy, osteopathy and a variety of medications. She had seen a specialist and had an mri scan which did show some wear and tear of the vertebrae. He offered to inject her neck but she did not fancy that.
She is lady that has her own business and cannot afford anymore time off. Her husband sent her to get it sorted.
It is not easy to deal with a personality that has a mechanistic view of their body and a high achiever that is used to getting rsults.
Well listening and empathy always helps. Going a bit deeper with some quaestions can open things up. When did it start? What makes it better? What does she think is the cause? What is really important in her life? There was some resistance, but I think she began to reflect on her situation from a different perspective.
The consulatation ended with me suggesting to her to view ‘painful neck’ as a chronic condition that she needed to adapt to rather than look for a cure. Maybe some seeds were sown for her to begin to change her attitude.

Spiritual care

Spiritual care, what is it? How do we give spiritual care in our day-to-day consultations with patients? For holistic practitioners it is challenging because for them the question is, ‘Can spiritual care be separated from mental and physical care, or is it essentially part of everything?’

The answer has to be yes and no, and both. How we are in ourselves, and how we are with patients determines the space that allows a caring spiritual atmosphere to be present. With the intention of bringing benefit to the patient, whatever is meant to happen, will happen. A spiritual relationship in a consultation is when we are fully attentive and yet are detached from the outcome. I mean attentive mentally and detached emotionally.

However there are some prompt questions that are helpful in directing the conversation towards the spiritual dimension:

What is really important to you?
How do you find inner peace?
What do you think is happening to you- concerning your illness, etc?
What and who gives you support?

I like the picture of a visitor playing her guitar and singing to residents at a nursing home. Simply anything that can lift your spirits, is spiritual care.

Holism versus reductionism.

Sometimes I despair. Where are we going with this reductionist, target driven medical care?

Mary was referred to my morning surgery by the nurse. She was 83 years old. Her blood pressure was 160/90. For goodness sake she is 83!

Protocol guidelines say that her blood pressure should be 140/90. Mary had been taking tablets for her blood pressure for 15 years and her blood pressure had not altered over the last 4 years. But guidelines are guidelines.

She asked me if it was her nerves that maybe had put her blood pressure up. I asked what she meant and of course what she really wanted to do was tell her story. She had been a widow for 20 years and she was finding it increasingly difficult to look after her elder brother that lived nearby. She was getting more and more tired having to cope with him as well as her own house. She did all the shopping and looking after the bills. A cleaner came in once a week. Her family lived by and helped out when they could but she did not want to bother them too much with her troubles.

We as doctors want to check her blood pressure presumably to lower her risk of a stroke. Or is to reach our targets and get paid? She wants someone to listen to her story and offer a bit of support and advise. I hope she left feeling she had shared her troubles. After she left I contacted social services to see if they could offer some help for her brother.

My mother's death

Last week my mother died. She was 94years old and had been in a nursing home for 3 years. However up until the last 6 weeks she was alert and interested in everything around her. Despite her difficulty with speech when visiting her, she was first to ask how you were. She took a keen interest in everyone’s life. She always looked on the bright side. She was a happy, generous caring soul and that is how I will remember her, not the frail body of the last 6 months.

As a holistic practitioner we need to acknowledge that things happen to us and affect us too. We often deal with others grief and distress but how do we deal with our own? Who do we look for support? Doctors generally are not good at this and tend to deny many of the feelings and carry on at work regardless. If it happens to you, have time off to reflect and learn from the experience. It will help you develop and be a better doctor.

What did I learn? The most important thing when sitting with a dying person is the state of your own mind. I focused on creating a peaceful atmosphere for my mother. I ensured that she was physically comfortable then spent time meditating in her presence. I focused on love, light and peace. I felt calm and a comfortable feeling was created in the room. When the nurses came to attend her they commented on it.

One evening I went through all her own photograph albums, which gave me a perspective on her life. I felt many of the special people in her life were close and ready to welcome her. Although she was not responding for the last three days I spoke to her softly and reassuringly of how much she had given to life and how much she had been appreciated. It was now OK for her to go when she was ready and that everything was in order.

In the end it was very gentle and peaceful passing. Of course we will miss her, but I feel good that it was a good death.

Robert Burns and Holism

Jan Smuts coined the phrase ‘holism’ at the beginning of the last century. Robert Burns was a great example of holism a 150 years before that.

Rabbie died at the age of 37yrs from complications of Rheumatic fever (sub acute bacterial endocarditis). His physician at the time advised that he bathed every day in the cold River Nith. We are not told if this was an alternative therapy or a common prescription for his condition. However like any good patient he followed instructions despite his deteriorating health.

He had an acute sensitivity to the fine balance in nature and his environmental awareness was centuries ahead of its time Just read these verses of ‘To a mouse’ to really appreciated his simple genius.

Wee, sleekit, cowran, tim'rous beastie,

O, what panic's in thy breastie!

Thou need na start awa sae hasty,

Wi' bickering brattle!

I wad be laith to rin an' chase thee,

Wi' murd'ring pattle!

I'm truly sorry Man's dominion

Has broken Nature's social union,

An' justifies that ill opinion,

Which makes thee startle,

At me, thy poor, earth-born companion,

An' fellow-mortal!

But Mousie, thou are no thy-lane,

In proving foresight may be vain:

The best laid schemes o' Mice an' Men,

Gang aft agley,

An' lea'e us nought but grief an' pain,

For promis'd joy!

Still, thou art blest, compar'd wi' me!

The present only toucheth thee:

But Och! I backward cast my e'e,

On prospects drear!

An' forward, tho' I canna see,

I guess an' fear!

Check out that last verse again of his mindfulness of being in the present and not looking back or forward. He must have studied Zen practices.

As Scotland’s national bard he promoted a brotherhood of all men through his poem ‘A Man’s a man for a that.’ He was a liberal in his thinking and a socialist in action.



Robert Burns is truly an international figure as I learnt when teaching a group of doctors in Beijing last year. I asked them what was their favourite song and one participant said ‘Auld Lang Syne,’ as it gave him a feeling of friendship and good memories.

Many of his poems were love poems such as ‘A red red rose,’ yet he showed his feminine side by writing from a woman’s perspective with the beautiful song ‘Ye Banks and Braes of Bonny Doon.’

The holistic consultation

A holistic consultation is like sitting on a beach talking to a friend.



People often ask me, ‘How can you practice holistically in general practice when you have so little time?’ I think they mean attend to all the physical ailments and include their mental and emotional well being, while also taking into account the social and environmental factors.

Firstly, it is good to be in the mind-set that 10 minutes is plenty of time. It helps me feel relaxed and comfortable.

For patients it is important they feel that they have time to tell their story. So an opening question like, ‘Tell me what can I do for you?’ allows them to go through things in their own way. I listen, attentively without interrupting. Curiously most patients will complete what they want to say within 3 minutes.

I will then ask some specific questions about their condition so I can begin to formulate what the problems are. They may need examining to help with a diagnosis.

I will have already checked on the computer their past medical conditions and drug medication before the consultation. In most cases I will know something of their family and social situation as I have been in the practice for 30 years.

I can now think how to manage their issues and give information and advise.

When all this is done I may ask how they feel about what is happening, or why they feel this may be happening to them now?

And perhaps some time for social conversation, the weather and news.

All done in 10 minutes. Well it is possible, but if not I can ask them to come back for another appointment.

Often for difficult emotional consultations I say nothing and just listen. Often when leaving they will say, ‘Thanks very much doctor for all your advise.’ -a very satisfying consultation for both of us.