How I...made sure hypertension guidelines did not cost us quality points
Professor Gene Feder on a book that has inspired two generations of GP careers
A GP working in the Forest of Dean in the mid-1960s comes to life in A Fortunate Man, still the best book about general practice almost 40 years after it was written.
We read about his encounters with patients and his struggle to respond to their illnesses and lives. His demanding and fallible humanity is described as clearly as the everyday courage and despair of his patients. The book's photographs by Jean Mohr portray the GP, John Sassall, at work and in conversation, his patients as individuals and in groups set against sky and landscape, both beautiful and full of foreboding.
I remember reading the book as a medical student and thinking: this is why I want to be a doctor. Now, working in inner city Hackney, an entirely different landscape from the Forest of Dean, I still feel that. Long before I had come to know patients and their families, this book illuminated the deep potential of medicine, and particularly general practice, to express solidarity with people as they move through their lives.
The mix of darkness and light in the text and the pictures resonates even more in me now, a middle-aged GP academic, than it did 30 years ago. John Sassall's story reminds us all that part of what we give to our patients is a reflection of our own weaknesses, although I am not clear how to reconcile this with the onwards and upwards rhetoric of modern primary care.
You can hear the voices of patients through the text, as the book moves from half a dozen brief stories of their lives to Sassall's evolution as a doctor.
He starts his career thriving on medical emergencies, impatient with non-specific symptoms and the absence of clear-cut underlying pathology. He moves gradually towards an empathic listening and companionship with his patients, striving to recognise who they are and what their illness means to them. Physical and psychological intimacy is central to his relationship with his patients. Sassall's identity in relation to his patients becomes that of an older brother, clearly distinct from medicine's traditional paternalism but also light years away from the chilling 'provider-customer' relationship that seems to be the goal of current health service policy.
He witnesses and records the lives of his patients, simultaneously standing inside and outside their stories. The book moves from a depiction of Sassall and his patients framed by their homes, the consulting room and the landscape, into a reflection on the meaning of 'good' doctoring, the naming of illness and the ambiguity of scientific medicine in the context of general practice. Sassall embraces this ambiguity. He is as exacting about applying scientific evidence to his work as he is committed to the fraternal bond that develops over years with his patients. This bond includes sitting with them and their families at the threshold of death.
Even the brief asides in this book make you reflect (and smile), such as this pearl:
'Sassall has to a large extent liberated himself and the image of himself in the eyes of his patients from the conventions of social etiquette. He had done this by becoming unconventional. Yet the unconventional doctor is a traditional figure.'
As with so much of John Berger's work,
A Fortunate Man packs a subtle political punch, finally asking what kind of doctoring is possible within prevailing social and economic structures. The question remains salient today. It is particularly acute for general practice within the UK because the possibility of long-term relationships with patients is actively undermined by a Government that either does not understand the value of these relationships or does not care enough to sustain them.
·Based on a longer article in the British Journal of General Practice, March 2005.
A Fortunate Man: The Story of a Country Doctor by John Berger is available from the RCGP bookshop: www.rcgp.org.uk/acatalog
John Berger evening in London
·As part of a season in London exploring the work of John Berger, the author of
A Fortunate Man, there will be an event celebrating the book on April 26 from 7:30 to 9:30pm at Queen Mary University of London. Speakers include broadcaster and writer Michael Rosen, writer Sukdhev Shandu, recently qualified doctor Dr Jane Simpson and recently qualified doctor and author of Confronting an Ill Society Dr Patrick Hutt. Also present will be Dr Tony Calland, who was a partner in John Sassall's practice.
For booking: www.johnberger.org
Gene Feder is professor of primary care research and development, general practice at Queen Mary University of London