David Robinson Interviews: Malcolm Alexander

PART OF THE Escape Into Books ISSUE

‘Entranced by medicine, it would take illness and its associated fear to remind him of the reason he wanted to become a doctor all those years ago.’

In interviewing Malcolm Alexander about his book, Close to Where the Heart Gives Out, David Robinson finds a doctor who discovered time is often the best medicine.


Close to Where the Heart Gives Out: A Year in the Life of an Orkney Doctor
By Malcolm Alexander
Published by Michael O’ Mara


Looking back, Malcolm Alexander can hardly understand why he took the job. It’s not as though he liked island life: even a month as a junior doctor in Shetland had been long enough. So why he even applied to be a GP on the Orkney island of Eday (population 125) in the late 1980s was something he can’t properly explain. It’s not as though the island had made a particularly good first impression either: on his first visit, he decided to rule himself out as a candidate at the interview in Kirkwall the following day.

He changed his mind, took the job, moved there with his wife Maggie, a trained anaesthetist, and their four young boys, and in turn Eday changed his life. How it did so, and how he and his family learnt to love the island is the subject of his thoughtful, well-written and engaging memoir Close to Where the Heart Gives Out. 

Alexander, 63, worked on Eday for only four years in his thirties, and his book is mainly about his first year there. The rest of career – indeed, the rest of his life – hardly gets much of a look-in, though he has held a number of top-level medical posts, and was associate medical director of  Scotland’s telephone triage service, NHS 24, before he retired three years ago. So why, I ask, did he give his memoir such a tight – and come to that, rather non-egotistical – focus? What was so special about that first year on Eday that it dominates his life’s rear-view mirror?

‘The original intent,’ he tells over the phone from his home on Bute,’was to show how a doctor thinks and to write about things which they don’t often express – such as fear of failure. To be honest, I’m not sure how well it achieves that aim, because in the writing I often got distracted by the environment and the people.’

That’s understandable. In his previous practice in suburban Glasgow, he’d never experienced the kind of ferocious winds he did on Eday (‘It’s only a proper gale,’ locals tell him, ‘when the grass goes black.’) ‘Growing up in West Linton, I’d always enjoyed nature, yet on Eday … Well, the wildlife was everywhere. I’d never seen curlew chicks, for example, yet there you might see them walking down the road.’  He writes well about the island’s ‘intake and exhalation of wildlife’ and it’s somehow no surprise to find him working as a de facto vet for the occasional injured seal or sick swan.

The main focus, though, is on the islanders.  In Glasgow, he treated an average of 30 to 35 people in a morning’s surgery.  On Eday that number dropped down to around seven. Even so, he says, that’s not the best patient-doctor ratio in the NHS: that honour belongs to North Ronaldsay, whose GP has to look after a mere 90 potential patients.

‘Doesn’t that mean it’s all a bit of a skoosh?’ I ask with my customary tact.

‘This is why Eday was so pivotal for me. You had so much more time with the patient. The consultation in the surgery might still average 10 or 15 minutes, because there would be people in the waiting room: they trended to arrive at the same time and all have a blether, but you didn’t want to keep them waiting all the same. A home visit, however, could take an hour and a half, because you then had the time to immerse yourself in the patient’s whole history. And the central realisation from that is that it’s lives that are important, not the prescription.’

Many of his patients were elderly people whose lives had barely changed since the 1950s, many of them with a stoicism engrained in pre-NHS days when it had cost money to see the doctor.  One such was a woman whom he treated in the same box bed in which she’d been born. Her croft had no electricity and the only water supply was the rain collected in buckets by her front door.

Alexander’s book is dedicated ‘to the people of Eday, who helped me understand the important things in life’.  Like what? ‘The key realisation was that I needed them just as much as they needed me. And when you really fit into a community you become more tolerant of people. You realise that everyone has stress in their jobs – maybe the boat couldn’t get to the pier that day or there wasn’t enough flour on the island or the farmers hadn’t been able to make hay. The island taught me that I was part of the community, and that I was no more and no less important than anyone else.’

That lesson stayed with him when he helped to write the clinical algorithms underpinning NHS 24 in Scotland. ‘When I started working there in 2005, the questions you’d be asked in the telephone triage were too long and boring and we had to rewrite them to make them quicker and easier to understand. All the time, I had in mind whether those questions would still be appropriate for someone ringing from Eday. If you write them just for, say, Glasgow, you might be assuming that people can just go down the road and buy some paracetamol, that they can hop into a car and go to A&E. But that’s not going to work for Eday, so why not write an algorithm that’s helps them to do what they can at home and then move them to an A&E environment that might involve a boat or a plane but which would just be a taxi in Glasgow?’

Although he doesn’t mention any of this in his book, I notice that he talks about NHS 24 as ‘a general practice with five million people in it’. And somehow it’s entirely apposite that such an important part of the whole nation’s health care has its roots in the attentiveness and experience of a doctor working on with a maximum potential caseload of just 125 souls.

This is a wonderful portrait of island life and a year of family adventure, discoveries and occasional moments of fear, as when his heavily pregnant wife has to be flown off the island for emergency care in Aberdeen – the only time he kicks himself for living in such a remote place. I will, however, take issue with Alexander on two points: first, for thinking that he hasn’t conveyed a sense of the fear of failure any island doctor must surely feel when they alone have to deal with an emergency.  Secondly, for writing that ‘We don’t spend enough time truly doing nothing.’  Really? Even in lockdown? ‘Well,’ he concedes, ‘maybe I should rewrite that bit now.’


Close to Where the Heart Gives Out: A Year in the Life of an Orkney Doctor by Malcolm Alexander is published by Michael O’ Mara, priced £8.99

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