How impossibly difficult the whole undertaking is

Abstract

John Berger and Jean Mohr. A fortunate man. The story of a country doctor. London: Penguin Press, 1967

The idea of looking is fundamental to this wonderful book because many of the pages are filled by Jean Mohr’s extraordinary photographs of the doctor, his patients and the isolated, deprived rural environment that they shared. In its very structure, the book models the power of collaboration. In the BBC series Another Way of Telling, Jean Mohr explained how both he and John Berger stayed in the house of the doctor for over a month watching his consultations and accompanying him on visits both day and night. Jean shot 30 or 40 rolls of black and white film and then they both returned to their own homes and worked independently. John turned his notes into the first draft of a text, and Jean produced about 200 black and white prints. Then they met to show each other what they had done and almost immediately it became clear that, as John Berger put it, ‘Both of us have made the same mistake, we have tried to do the book all by ourselves’. Each had to rescind that exclusivity so that the power of the book could be fully realized. More than half of Jean’s photos were put to one side and John sat down to rewrite his text completely. Brought together, the immediacy of the photographs means that the text can begin its exploration of what it is to be a patient and a doctor at a much deeper level than would be possible without them. The words can move immediately behind the faces and begin to imagine what is being felt and understood in the minds of doctor and patients. Together, the photographs and the descriptions of the doctor–patient encounters capture both the diversity and the rhythm of practice, and, beyond that, the almost shocking intimacy of what doctors are told and what they are required to see. The photographs do not illustrate the text; they provide a different and absolutely complementary truth.

John Berger evokes and quotes from both Joseph Conrad and Jean-Paul Sartre and in so doing he illustrates the multiplicity of ways in which great writing can help us to make sense of a life which may be quite different from that depicted by the author.

He began to realize that the way Conrad's Master Mariners came to terms with their imagination – denying it any expression but projecting it all on to the sea which they then faced as though it were simultaneously their personal justification and their personal enemy – was not suitable for a doctor in his position.

Yet this was how, like so many of us, Dr Sassall began, regarding disease and injury as both justification and enemy, and valuing technical skill above all other virtues. Then, as he slowly learns to see each of his patients in all the particularity of their personality, history and context, he arrives at the humbling realization that technical skill, while essential, comes nowhere close to being enough.

He had exchanged an obvious and youthful form of extremism for a more complex and mature one: the life-and-death emergency for the intimation that the patient should be treated as a total personality, that illness is frequently a form of expression rather than a surrender to natural hazards.

This insight that illness can be a form of expression is hugely important and anticipates all of the recent science which has revealed the remarkable extent to which biography modulates biology, the ways in which abuse and violence, both structural and interpersonal, affect the functioning of the body through a multiplicity of mechanisms that include effects on the coordination and functioning of the nervous, endocrine and immune systems, and the epigenetic effects on gene function. These processes have the greatest effects in response to early life experience, and they serve to accelerate or decelerate the natural ageing of body cells. Adverse experiences early in childhood include physical, emotional or sexual abuse; witnessing domestic violence; growing up with household substance abuse, mental illness, parental divorce or an incarcerated household member. Such experiences have been shown to predict future premature mortality to the extent that people with six or more adverse childhood experiences die nearly 20 years earlier on average than those without any.¹ Illness both expresses and reveals the history of a life.

Sooner rather than later, as science continues to unravel the connections understood intuitively by John Berger’s Dr Sassall, it will no longer be possible to relegate the biographical experience of the patient to irrelevance and discount the terrible health consequences of structural violence within society.² General practitioners (GPs) and public health physicians should be leading the application of this knowledge to health care systems: the former because continuity of care throughout the life course is a founding and defining characteristic of general practice and; the latter because their preventive efforts seem increasingly misdirected.

An unhappy patient comes to a doctor to offer him an illness – in the hope that this part of him at least (the illness) may be recognizable. His proper self he believes to be unknowable. In the light of the world he is nobody: by his own lights the world is nothing. Clearly the task of the doctor – unless he merely accepts the illness on its face value and incidentally guarantees for himself a ‘difficult' patient – is to recognize the man. If the man can begin to feel recognized – and such recognition may well include aspects of his character which he has not yet recognized himself – the hopeless nature of his unhappiness will have been changed: he may even have the chance of being happy.

This recognition seems to result from the exercise of what the philosopher Simone Weil described as the giving of attention:

Those who are unhappy have no need for anything in this world but people capable of giving them their attention. The capacity to give one’s attention to a sufferer is a very rare and difficult thing; it is almost a miracle; it is a miracle. Nearly all those who think they have this capacity do not possess it. Warmth of heart, impulsiveness, pity are not enough.³

Both Sassall and Weil, in their own ways, have understood that the mechanisms through which harm becomes imprinted on the body are not one-way processes. The body’s capacity for adaptation can also be a means of making people better. Each of us constructs a more or less coherent autobiographical narrative which is constantly reviewed and refined. It is through the story of a life that we make sense of what is happening to us and begin to make sense of the world. The freedom and the delight is that stories can be changed and doctors, by listening and by investing the experience and perspectives of patients with respect and dignity, can help to shift stories that have become damaging and stuck. A story of failure and suffering can be recast as one of courage and endurance in the face of impossible odds; one of inability to cope at work can become one of exploitation and seeking solutions in forming alliances and activism. This understanding is what turns Dr Sassall into a fortunate man, despite the great challenges of his work and temperament.

I read the book first when I was 19 and a second-year pre-clinical medical student, again when I was almost 40 and had been working in general practice for 15 years, and, most recently, now I am 64, four years since I stopped seeing patients of my own. It is a book which describes the progress of a career and which has punctuated and enriched my own. From my current superannuated perspective, looking back to the ingenousness and ignorance of my 19-year-old self, I cannot remember what captivated me or, indeed, how I could have made any sense of the book’s profound understanding of what it is to work as a GP. Yet I am fairly certain that the book must have been part of my determination to become just such a doctor, albeit in a troubled and troubling urban environment rather than a rural one. By the time of my second reading, I had begun to copy out the portions of text which carried particular resonance and so it is easier to recall the extraordinary sense of recognition that I experienced. As I read, I felt that my struggle to find meaning in the stories and wounds, both biological and biographical, that I encountered every working day was being validated by a deep understanding of how impossibly difficult the whole undertaking is, and will always remain. Most recently, with my longer biographical perspective, I saw more clearly, and again recognized in myself, the change in the doctor as a career unfolds.

So, as the politics of self-interest fragments the health service around us and threatens continuity of care, even in general practice, A Fortunate Man is surely worth at least a second look.

References

Brown

Anda

Tiemeier

. Adverse childhood experiences and the risk of premature mortality. Am J Prev Med 2009; 37: 389–396.

Scheper-Hughes

. Dangerous and endangered youth: social structures and determinants of violence. Ann N Y Acad Sci 2004; 1036: 13–46.

Weil S. Reflections on the right use of school studies, 1942.