In the March issue of this Journal, Gene Feder described John Berger's A Fortunate Man as ‘still the most important book about general practice every written’.1 This ‘story of a country doctor’ is full of profound insights and provocative aphorisms (www.johnberger.org).
Berger wrote that the task of the doctor when confronted with an unhappy patient offering an illness was to recognise the person behind the illness.2 This act of recognition itself could help to overcome hopelessness and even begin to offer ‘the chance of being happy’. To make an unhappy person feel recognised, the doctor ‘has to be oblique’ and yet has to appear to the patient as a comparable person, a process that demands ‘a true imaginative effort and precise self-knowledge’. This well captures the challenge of general practice.
‘The whole process’ of recognition, observed Berger, ‘as it includes doctor and patient, is a dialectical one’. The doctor must recognise the patient as a person, but for the patient, ‘the doctor's recognition of his illness is a help because it separates and depersonalises that illness’. This is why ‘patients are inordinately relieved when doctors give their complaint a name’. Even if the name means little, it gives their condition an independent existence: ‘they can now struggle or complain against it’. For the patient to have a complaint ‘recognised’, in the form of a diagnosis that is ‘defined, limited and depersonalised … is to be made stronger’.
Reading Berger's account nearly 40 years after it was written, we can still appreciate the importance he placed on recognition. What has changed is the healing power of diagnosis: we can no longer claim that giving the patient a name for their illness makes them stronger, even if it may still give them some relief.
Take, for example, the sphere of psychiatry. If we look at the features of the diagnosis that Berger considered gave people strength to deal with their afflictions, major changes are apparent. Whereas in the past mental illnesses were few and clearly defined, today disease labels are both more numerous and more diffuse. At the time that Berger wrote, there was a general inclination to emphasise the discontinuity between the normal and the abnormal; today, the concept of a continuum has become fashionable. The invention of new disease labels — such as ‘attention deficit hyperactivity disorder’ in children or diverse forms of addiction in adults — reflects the trend to define a wider range of experience in psychiatric terms. It also results in a further blurring of the boundary between the normal and the abnormal.
Whereas diagnoses previously suggested the limited character of the condition, modern disease labels imply disorders that are unrestricted in the scope of the symptoms to which they give rise and in the duration of their effects. Post-traumatic stress disorder or recovered memory syndrome, for example, can be expressed in the widest variety of symptoms, which may arise long after the traumatic events believed to have triggered them. There is also a widespread conviction that these may continue indefinitely as people are ‘scarred for life’ by past traumas. Today's sufferers from addictions or compulsions can never claim to have been cured; they live their lives ‘one day at a time’ in an on-going process of ‘recovery’.
The depersonalised character of traditional diagnoses allowed the sufferer to objectify the condition as something ‘out there’, perhaps a somewhat forced abstraction, but one with some pragmatic value. By contrast, a diagnosis like ‘chronic fatigue syndrome’ is inescapably personal and subjective in character. Every sufferer exhibits a different range of symptoms, and there is no way of objectively confirming or monitoring the course of the illness. The net effect of the dramatic expansion in the range of psychiatric diagnosis is that, instead of conferring strength on the patient, bestowing any such label is more likely to intensify and prolong incapacity.
As Berger put it, ‘all frustration magnifies its own dissimilarity and so nourishes itself’, resulting in a process of enduring suffering doctors are now more likely to intensify than alleviate.
- © British Journal of General Practice, 2005.