David Zigmond. CreateSpace Independent Publishing Platform, 2015, PB, 716pp, £25.90, 978-15061733821
This is a book about meaning and shared humanity in medicine. David Zigmond, GP and psychiatrist for 40 years, rekindles our half-forgotten understandings of suffering and resilience, often overshadowed by the extraordinary cleverness of modern medicine. He does this through stories, suffused with wisdom and practical good sense; stories that allow us to notice what attracts us to them; stories about how to use medicine and not be used by it. He writes in the form of essays, case descriptions, and letters, spanning 1976 to 2014. He shows us our present medical world reflected in the mirror of the past, and using his keen memory for small details he gives the stories new life and meaning for today. We are jolted into awareness by understandings and inspirations that help us to articulate our otherwise often inchoate thoughts and feelings. For the medical reader, these new insights invite a rekindled fascination and even joy in practising medicine.
For most of his career, Zigmond, with his long-term associates, ran his small practice from a surgery cloistered in the north aisle of St James’s Church in Bermondsey. His stories emerge from this often socially troubled, multicultural, and multiethnic district of South-East London. From this ‘hinterland’ of humanity, we see the rawness, the laughter, the tragedy, the intimacy of everyday life, and the ‘perverse results’ of ‘proceduralised and industrialised healthcare’. Medicine practised at the interface of science and art, of treatment and healing, of verbal and non-verbal communication, of agony and joy, of love, sex, and violence, of birth and death and bereavement; it is all there.
The full anthology is in three sections. Section 1, What Can Go Right, or Hidden Personal Meaning In Healthcare, contains the earliest writings with 13 substantial essays, epitomised by ‘The Psychoecology of Gladys Parlett’ (1988). This beautifully told and moving story is about the isolation and loneliness of old age, and the GP surgery as a surrogate friendly community. The ordinariness of the story and the language used to evoke the suffering have stayed with me.
Section 2, entitled What Can Go Wrong, or Lost Personal Meaning In Healthcare, comprises 29 essays spanning 2005 to 2014 and mostly a little shorter. This was a period of fundamental structural change in the NHS and epitomised by the short 2012 essay, ‘From Family to Factory — The Dying Ethos of Personal Healthcare’. Zigmond’s metaphor elucidates the serial revelations of gross neglect in health and social care towards the end of the 21st century’s first decade. He fervently argues for the family as the better model.
Section 3, entitled What We May Do, or the Struggle for Personal Meaning, includes 24 mostly short pieces from 2010 to 2014: letters to newspapers, to medical journals, to the Secretary of State for Health, and to various institutions. This is epitomised by ‘Bureaucratyrannohypoxia’ (2010) — an open letter to Zigmond’s mental health services director concerning the extreme difficulty in arranging urgent support for a middle-aged woman in crisis. Most GPs will recognise this.
The story that gives the book its title recalls skills perhaps becoming scarce in medicine. It concerns a doctor’s visit with his dog to a vet. He is so impressed by her guileless and effortless rapport and liking for the animals that he arranges to join her in one of her clinic sessions.
Zigmond does not analyse the stories, but rather invites us to allow them, by their resonance, to analyse us. Through their moral sensitivity, the stories invite us to become the person we really want to be. This book is not about the ‘good old days’, and neither does it belittle our remarkable technological improvements. It is rather about moral values and interpersonal skills, once second nature, but now frozen out, leaving us with a demoralised awareness that, amidst the technology, guidelines, protocols, and financial incentives, something important is missing. Zigmond cogently describes what this is and what happens without it. At its core is an erosion of relationships that nourish: both therapeutic and fraternal. We ignore his message at our peril.
Postscript
In July 2016, 1 year after the book’s publication, Zigmond’s surgery was closed as an emergency, 5 days after their second CQC inspection. This was enforced by a carefully and expensively choreographed summons and 8-hour hearing in Camberwell Magistrates’ Court with neither opportunity for legal representation nor adjournment. The previous CQC inspection in February 2014 produced a glowing report. This time, remarkably, his practice was considered to be: ‘… so extremely hazardous that the public need[ed] immediate protection by its closure’. There had been no significant changes to his practice since the previous inspection and he never had a substantive complaint in 40 years of practice. He was always polite, but doggedly persistent; a maverick whose GP career ended ignominiously, or perhaps gloriously. The day after the hearing his patients turning up for their appointments found the surgery door locked and an official notice advising them to seek care elsewhere. It seems that Zigmond’s real crime was to expose the roots of oppression and to scatter seeds of hope.
- © British Journal of General Practice 2018