This is a short book, modestly described by the author as an ‘essay’. In it a GP working in the Forest of Dean in the mid-1960s comes to life. We read about his encounters with patients and his struggle to respond to their illnesses and lives. The demanding and fallible humanity of John Sassall, the doctor, is described as clearly as the everyday courage and despair of his patients. As if this were not enough, the book's photos by Jean Mohr are the visual equivalent of a choral passion. They portray Sassall at work and in conversation, his patients as individuals and in groups, and the ever-changing dialogue between sky and landscape, both beautiful and full of foreboding.
You can hear the voices of patients through the text, as the book moves from half a dozen brief stories of their lives to John 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 physical diagnoses and underlying pathology. He moves gradually towards an empathic listening and companionship with his patients and their families, striving to recognise who they are and the meaning of their illness to them. Physical and psychological intimacy is central to his relationship to 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.
Short quotes from Josef Conrad, Michael Balint, Jean Piaget, Jean Paul Sartre, WB Yeats and Antonio Gramsci are scattered through the text, but it wears these references lightly, turning back again and again to Sassall's thoughts, feelings and experiences.
As a GP, 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 bedrooms, kitchens, the consulting room and the surrounding 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 (before evidence-based medicine was a twinkle in the eye of its inventors) 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.’1
Or this one:
‘One of the most widespread adult illusions is the belief in second chances.’1
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, a different landscape from the Forest of Dean, I still feel that. Long before I had come to know patients and their families, Berger, an art critic and writer, had illuminated the deep potential of medicine, and particularly general practice, to express solidarity with people as they move through their lives. The mixture of darkness and light in the text and the pictures resonate even more in me now, a middle-aged GP academic, then it did 30 years ago.
The archetype of the wounded healer emerges in different forms across cultures and across historical epochs, from the Greek myth of Chiron (the wounded centaur), to shamanistic healing in aboriginal societies to the complex figure of Paracelsus in 16th century Europe. Re-reading this book again, particularly in the light of his subsequent suicide, I think that John Sassall expresses that archetype. His story reminds us all that part of what we have to give to our patients is a reflection of our own weaknesses and failings, although I am not clear how to reconcile this with the onwards and upwards rhetoric of contemporary primary care.
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.
As part of a season in London celebrating the work of John Berger (John Berger: here is where we meet), there will be an event on A Fortunate Man held on 26 April from 7:00–10:00 pm at Queen Mary University of London. Speakers will include Iona Heath, Tony Calland (who was a partner in John Sassall's practice), Patrick Hutt (a recently qualified doctors and author of Confronting an III Society), Jane Simpson (junior doctor), Michael Rosen (broadcaster and writer) and Sukhdev Sandu (critic and writer). They will talk about what the book means to them and what it still has to tell us almost four decades after it was first published.
Further details on the event and the whole season: www.johnberger.org. Although we are not charging for seats, these need to be booked in advance: 020 8510 9786. Copies of the book can be purchased from the RCGP Bookshop: www.rcgp.org.uk/acatalog.
- © British Journal of General Practice, 2005.