Duncan Still is a GP with a difference. He has a long-standing interest in holistic and integrative approaches to healthcare and is passionate about nutrition and the role of the natural world in gaining and maintaining optimum health. Duncan works as an integrative doctor at Penny Brohn UK, a charity which specialises in holistic support for people living with and beyond cancer. He also runs a two-year Diploma with The National Centre for Integrative Medicine (NCIM) for healthcare professionals and for complementary and alternative (CAM) practitioners to learn about the practice of Integrative Medicine as well as providing 1:1 appointments and other educational services.
Sue: Welcome Duncan! I’m really interested in the fact that you’re a GP and you also practice holistic medicine. How did this start for you?
Duncan: Very early on. My grandmother was a bit of a white witch. She was interested in plants and nature in the capacity to heal. She was way ahead of her time. She was also a vegetarian for health and environmental reasons, and she relished in the power and the importance of nature. That came down to my mum and then to me.
Sue: Did you always want to be a doctor?
Duncan: Not initially. I studied languages first, travelled a lot and developed an interest in philosophy, meditation and massage. I went into medicine when I was around thirty.
Sue: Having done languages why did you end up choosing to train as a doctor?
Duncan: Languages led me to teaching English as a foreign language, and I lived in Bosnia for a few years doing teacher training, managing other teachers and writing material and doing a whole range of things that teaching English doesn’t normally entail. I knew I wanted to return to the UK, but I also knew that teaching English in a classroom would not be such a diverse challenge. So, I needed to do something else.
Back in the UK I ended up doing basic nursing care in a hospital where I met doctors, nurses and physiotherapists. I saw the workings of the machine and had sparky conversations with some of the doctors. One of them mentioned, ‘Did you know there’s this new way of getting into medicine for people who don’t have a science background like you? You just have to pass an aptitude test.’
I looked into it and managed to pass the aptitude test, which, Interestingly, really favoured communication skills and the conveying of meaning. I thought this was a really forward-looking approach to selecting medical students. I am not sure that having five stars in sciences is such a good filter for producing the best doctors in the world – I think what you need is a balance of skills and communication.
Sue: It’s really interesting that you were looking for something new and suddenly you meet this doctor who says, ‘Hey, you can do this too.’
Duncan: Yes, and it’s also interesting that the original meaning of the word ‘doctor’ actually means teacher. So much of what we do as doctors could be and should be about educating our patients and bringing them alongside to connect with their role in looking after their own body. We’re only with them for ten minutes of the consultation, whereas they are with their body, mind and soul for the whole of their life.
Sue: My goodness, the medical industry would change hugely if doctors started to do that rather than tell patients what they should do.
Duncan: Absolutely, and I think the medical profession bears some responsibility for building up the hierarchical top-down approach. I do think this is changing – we’ve still got a long way to go, but that conversation is already happening and certainly one of the things that we get across at the Bristol Medical School is how important shared decision-making is with patients. I believe this needs to be wider than just in the medical profession. It needs to be in society and our children need to learn about their role in their own health in schools.
Sue: I think the trouble is that we’re so used to being told what to do with our bodies, it’s hard to learn that we are fundamentally responsible for our own health.
Duncan: The medical profession bears some responsibility for that too, because we have built ourselves up as the authority figures with the knowledge. I can see why, and there’s good reason for this. Of course, we do have a lot of knowledge, and science is constantly evolving and there are constantly new discoveries and treatments. I am not belittling the advances we’ve made in technology and surgery – they give us enormous options. But it is at the expense of the patients. Sometimes we forget what role they play in preventative stuff. If we could involve more preventative support, perhaps there wouldn’t be the need for so much intervention further down the line.
Sue: I wonder some people would be very resistant to this because they prefer to be told what’s wrong with them and then sit back and accept it.
Duncan: Yeah, and that’s a cultural thing. But again, we have bred what we’ve created. In other societies and in other times, I think very often it was more of a shared process.
Sue: When you went to medical school with all your understanding of languages, massage and communication skills, was it a cultural shock for you or did you feel you fitted in right away?
Duncan: Fortunately, I went in as a graduate entry, which is quite different – the kinds of people who ended up there were not your run of the mill. I think usually if you go into medicine at aged eighteen or nineteen with straight A’s sciences, you’re on a path that is pre-determined. No disrespect to younger colleagues, but often the impetus can be parental pressure or schools funnelling the way. I do ask the question, ‘how can you know you want to be a doctor at sixteen or seventeen, which is when you need to start making that decision. I think it should be more often a postgraduate thing. But to answer your question, was it a shock? Certainly, my approach wasn’t the norm.
For example, my health care assistant job [before going to med school] included an interview as part of the process. They just need to make sure you can communicate adequately, and you know what the job entails and you’re physically able to do it. But I managed to nearly fail my interview when they asked if I had any questions. I said, ‘If at the end of my shift when I’ve managed to change all the beds and look after the patients and do whatever is needed, would it be okay for me to offer massage to any of them?’ I had no idea what an inappropriate question this was. They were horrified at the thought someone would be offering to touch patients. Of course, I understand the reasons why there might need to be some sensitivity around this but for it to be completely off the charts was a real shame.
Sue: I think you were really brave to ask the question! Yet touch is so important for us all.
Duncan: Yes, it is. As a junior doctor, one of the things you do is to take blood from people, and I remember one time working on an elderly care ward. When you take blood from people with older skin, it tends to be a bit looser on the hand, so you have to stretch it out a bit to get more easily to the vein. This means you hold people’s hands as you pull the skin. I used to do that often, and some of the older patients would feel I was holding their hand as touch and they would give me a squeeze. They would want to be holding hands. I found that so touching. The message seemed to be, ‘I haven’t been touched for a long time.’ Of course, they’ve been touched functionally – such as being rolled over in bed or helped to the toilet or being examined. But being touched like that is different.
Sue: It sounds to me that becoming a holistic doctor was an obvious route for you.
Duncan: The seeds were certainly laid early on in my life and it’s just the kind of person I am. I am a broad rather than a narrow person and I got involved in teaching even as a very junior doctor. That put me in touch with a remarkable doctor called Trevor Thompson who used to run a course called Whole Person Care and has also masterminded a transformation in the way we teach medical students to consult. I also met other doctors who were important to me. In fact, two of them have become my bosses where I work at NCIM. The main thrust of my work is the educational programme. I also work with Penny Brohn, a charity in Bristol, which provides holistic support for people and their families affected by cancer.
Sue: Can you explain what Integrative Medicine actually means for you as a doctor and for the patient.
Duncan: Integrative Medicine is the intelligent combination of conventional medicine, lifestyle and holistic approaches including herbal medicine, stress management, mindfulness meditation, massage, shiatsu, osteopathy, craniosacral, chiropractic, and also things a little bit further out of the spectrum like healing Reiki. It’s about understanding what value those things might bring.
Of course, we have to be rigorous within medicine in terms of approaching the evidence base. That’s really important – it’s not that we wholeheartedly accept every possible approach under the sun. We have to have reasons to believe that this is helpful and not harmful. So, it’s not about acceptance of everything nor it is blind rejection.
I think that within conventional medicine there can be a tendency to say, ‘If there isn’t a randomised, double blind, placebo-controlled trial to prove the efficacy of something, I’m not going to look at it.’ But I think we miss a trick when we do that. I understand the reasons for those trials when it comes to pharmaceutical interventions, which are usually single interventions rather than these complex [integrative] interventions. Touch is part of the complex integrative intervention because it soothes the parasympathetic nervous system.
Sue: I’m just thinking about my own experience of doctors. It hasn’t been great because in most cases the GP seemed to be clock-watching or literally typing into their computers without much connection with me. I don’t know how I would feel if a doctor suddenly said, ‘I’m just going to touch you.’
Duncan: Well, it has to be appropriate touch with consent and coming from a place of trust. For example, I also work at The Haven, which is a refugee and asylum seeker health centre. When I am with someone who is traumatised and in high levels of distress and those traumatic feeling are in danger of escalating, I feel very comfortable placing my hand on that person’s shoulder. It feels human, and I think sometimes you need to step beyond the bounds of distance that’s imposed by professional relationships.
Sue: It’s about being kind and empathetic to someone who’s really struggling, isn’t it?
Duncan: Yes. Even in general practise, I think examining the patient can be a therapeutic intervention in itself. It’s saying to the patient, ‘I’m really here with you and I want to get close to you to find out more about what’s going on.’ When I put my stethoscope on someone’s back, yes, I’m listening to the breath sounds and trying to work out the pathology, but I’m also laying my hand on their shoulder as a process of touch.
Sue: Compassion is so important. I hear a lot of stories through the Death Cafes from participants talking about their experiences with nursing and medical staff around death and dying. Some have had great experiences, but some have had terrible ones.
Duncan: I know that to be true. I hear it a lot and this is a really good lesson for all healthcare professionals. A patient or a family member will remember the bad things with a burning intensity, especially with the heightened level of emotional intensity that is there when someone is dying or approaching death. But we need to remember lots of good things were also going on around it, and try and hold onto this.
Words are incredibly important because they have such power. Unless you’re really conscious about your use of them, all sorts of things can be misinterpreted with underlying meaning. To do a really good consultation, you need to spend time checking with the person: How are they? Who are they? What kind of personality do they have? What kind of words do they respond to? What do they know? What do they want to know? It’s certainly a minefield because there’s so many ways you can get it wrong. Having said that, there are also many ways you can get it right. I think it starts with being human rather than staying in our clinical hierarchical status.
Sue: I’m curious about your take on how we can all improve our communication around death and dying.
Duncan: Number one is to bring it into societal awareness much earlier for it not to be as taboo, uncertain and awkward as it currently is. It’s still a relatively rare thing to talk about and we’re not skilled or practiced at it.
When I lived in Bosnia, I noticed how they were much more expressive about all the good and the bad, and direct in their communication in a way that we cannot be in the UK. Death was more present and visible, and this was not because of the war. I remember seeing a funeral procession in the street with some people wailing and really collapsing with grief. Other people were able to deal with it by taking them in their arms and sitting them down and allowing them to cry. It was okay and necessary – it felt properly cathartic. That doesn’t happen here, so I wonder what happens to our grief.
Sue: Well, it’s hidden behind closed doors, isn’t it? But I think things are getting better because we’re more of a multicultural society now with a lot of mix raced families and I believe this has helped.
Duncan: Yeah, for sure. I think there is a richness there that we shouldn’t ignore. I think there’s also something happening within our society to do with emotional expression being okay, and knowing your own emotional terrain being an important thing. It’s very easy to ridicule emotional awareness and education. Some people would call it indulgence, and I think it can go too far. But I think there’s a lot of very positive things about it as well.
Sue: Do you believe holistic or integrative medicine includes becoming conscious of our mortality?
Duncan: Oh, for sure. That’s a massive part of life. The one commonality we all share is that we are all going to die, and we ignore it at our peril. Ignoring it adds to our distress because when we approach it, which we inevitably will do, if we’re not ready, if we haven’t contemplated it, if we haven’t got some kind of strategy or approach, then it’s the unknown. And, there’s nothing more anxiety-raising than the unknown.
Sue: How do you involve this in the training you do at the Bristol Medical School?
Duncan: Well, it’s a good question. I’m not involved in the mainstream. I teach on one module for the first years on effective consulting. We don’t specifically deal with death, but a lot of skills we talk about, such as how to hold a good consultation and how to make sure you’re asking open questions, so you are getting alongside the patient with their ideas, concerns and expectations, helps with this.
There’s a new model being brought into Bristol Medical School. It’s really quite ahead of the game, I would say, which opens up a platform for potential conversations about death. Otherwise, I also run a small course on optimum health in later life. Within that we have a whole session on death and dying.
Sue: I think all of us – young and old – need this kind of open session to help us talk about death.
Duncan: Yes, but most doctors will be dealing with people in later life – unless you’re a paediatrician or a perhaps a gynaecologist. We hope medical students will be taking some of this wisdom into their own lives and also into their own families and spreading it that way.
Liz Thompson, the director of NCIM, also runs a session on death and dying for NCIM students. Older people come along who are comfortable talking about death, so there’s a free forum for the students to ask older people about what they think and feel about it. This opens up a chance for creative responses. I think creativity is a really important avenue to go down when you’re talking about something like that because it doesn’t always belong in the realm of words. It’s not a mental cognitive thing that we can understand with our minds. It’s the unknown.
Sue: During the Death Cafes, people often talk about strange phenomena that happens towards the end of someone’s life. For example, the dying person speaking about a dead relative ‘waiting for them’, or relatives feeling the presence of the person who has died for quite some time. I wonder whether you’ve had experiences like this during your work as a doctor?
Duncan: I’ve certainly heard people talk about this and also about relatives feeling that the dead person is still present for some time afterwards. There are all kinds of experiences which are mysterious and difficult to explain depending on your philosophical background or religion.
Sue: I am curious whether this is ever mentioned during medical training because reports of end-of-life experiences and near-death-experiences are becoming increasingly common.
Duncan: That could be particularly interesting for medical staff who might be working on elderly care wards. Or perhaps in a palliative care setting. I hope we’re trying to generate curiosity and compassion for our medical students but it’s a tricky one because you need the time to have these sensitive conversations. However, it doesn’t fit into the main medical model where it is a lot about finding the diagnosis, finding the solution to that diagnosis, and then moving the patient back home, rather than keeping them in hospital. So, I’m not sure it is for all medics to be able to have those conversations because of time restrictions.
Sue: I would imagine it’s incredibly hard to be an empathetic doctor when you are under such time restrictions.
Duncan: Yeah, so I think we need to pick and choose who we educate around this and what our expectations are of what they can deliver. But in certain contexts, we certainly should be open to these experiences and be able to normalise them and allow them to be a source of solace for either the person sitting by the bedside or the person actually experiencing them.
Sue: As you know, my blog is about what it means to live more consciously for a better world, so I am curious about what this means to you as a holistic doctor.
Duncan: Much of it starts from the self. I know I am a better doctor when I am taking care of myself, eating right, using my body right and sleeping right. I also meditate and find time for peace, silence and nature. Those things are all absolutely central to me. It’s about being the best person I can be and therefore the best doctor I can be.
I suppose in the practise of medicine, I would be trying to convey this to all my patients as well. I can provide a solution to that thing you come in with, yet the biggest issue might be about how to stay well through a much broader preventative approach. But this is not just about us as a single entity, it’s to do with society. Are we taking care of our community, our city, our planet? We have to be thinking at that level. We have to be thinking about climate change and environmental collapse. These are the major pressing health concerns of the day and they are not being talked about. I think it is incumbent on us as medical professionals to somehow gently weave this into conversations; weave it into how we approach health and to be talking to the powers that be about it.
Sue: Are your patients talking about climate anxiety and this growing sense that things are increasingly out of control?
Duncan: There is an awareness. I’m part of networks that are having this conversation so I might be giving a skewed viewpoint. I could say, ‘yes, we know all about it and we are addressing it as much as we can.’ But I’m sure that’s not the case throughout every single level of the health service.
Regarding patients in my own GP practice, climate anxiety is more likely to manifest as personal anxiety or chronic tension, headaches, insomnia or gastrointestinal things. If someone comes in with a potentially stress related problem, I think most GPs are quite good at recognising it and digging a little deeper, but it’s how to address existential angst. That is the harder question. I think being empowered, as in taking responsibility for what you do in the world and for linking arms with people around you, feels like a more supportive and connected place to come from.
