A Fortunate Man by John Berger

Years ago I was at a dinner party, one of the group being a quietly spoken woman who had largely stayed mute. Somebody happened to say that she had a good dentist. Suddenly this woman exploded. ‘How do you know he’s a good dentist’, she practically spat the words out. It wasn’t a question, it was an accusation. None of us really knew how to respond and I still don’t, despite having considered it a lot. Not being a dentist, how could I possibly ‘know’? Whereas she, it now transpired, was both a practising and academic dentist. We’d strayed onto her turf and there didn’t seem to be any getting off it. She mentioned no names, but talked darkly of dentists who were popular in Melbourne but who were clueless at their work. Gulp. My dentist was popular. I liked him. I went about calling him a ‘good dentist’. Suddenly my very teeth seemed to loosen in my jaw. I got a tooth ache on the spot.

So, let’s change that question to ‘How do we define why we see one doctor as good and another not?’

For me, it’s ‘bedside manner’. Some doctors have it, others don’t. Despite thinking it is vital, I have never tried to explain what it is. I’ve only felt either that I’ve been in its presence, or, more often, I haven’t. Having read this book, I can see how trivial my thoughts were. Berger took the opportunity to explore the question profoundly. I think it is important to note the wording of the question. We are not asking which doctor is better, we are asking which doctor we perceive as better and why.

Enter Dr Eskell, presented in the book as Dr Sassall.

How is it that Sassall is acknowledged as a good doctor? By his cures? This would seem to be the answer. But I doubt it. You have to be a startlingly bad doctor and make many mistakes before the results tell against you. In the eyes of the layman the results always tend to favour the doctor. No, he is acknowledged as a good doctor because he meets the deep but unformulated expectation of the sick for a sense of fraternity. He recognizes them.

The book begins by following Sassall about as he attends to patients. From the very beginning we are aware that he is nothing if not fallible. In the first scenario he tells witnesses to an accident in the forest that the victim will not lose his leg. He does. What confidence on the part of both doctor and writer to begin this way.

And then, after these descriptions, Berger starts his process of analysing what it all means.

This individual and closely intimate recognition is required on both a physical and psychological level. On the former it constitutes the art of diagnosis. Good general diagnosticians are rare, not because most doctors lack medical knowledge, but because most are incapable of taking in all the possibly relevant facts – emotional, historical, environmental as well as physical. They are searching for specific conditions instead of the truth about a man which may then suggest various conditions. It may be that computers will soon diagnose better than doctors. But the facts fed to the computers will still have to be the result of intimate, individual recognition of the patient.

On the psychological level recognition means support. As soon as we are ill we fear that our illness is unique. We argue with ourselves and rationalize, but a ghost of the fear remains. And it remains for a very good reason. The illness, as an undefined force, is a potential threat to our very being and we are bound to be highly conscious of the uniqueness of that being. The illness, in other words, shares in our own uniqueness. By fearing its threat, we embrace it and make it specially our own. That is why patients are inordinately relieved when doctors give their complaint a name. The name may mean very little to them; they may understand nothing of what it signifies; but because it has a name, it has an independent existence from them. They can now struggle or complain against it. To have a complaint recognized, that is to say defined, limited and depersonalized, is to be made stronger. The whole process, as it includes doctor and patient, is a dialectical one. The doctor in order to recognize the illness fully – I say fully because the recognition must be such as to indicate the specific treatment – must first recognize the patient as a person: but for the patient – provided that he trusts the doctor and that trust finally depends upon the efficacy of his treatment – the doctor’s recognition of his illness is a help because it separates and depersonalizes that illness.

There are certainly openings for criticising this book. Berger perhaps goes too far in his attempts to explain what he sees. As some have noted, he is not exactly waving the flag for feminism either. I think it’s obvious that Berger is feeling his way and that we may see this book as the precursor to what then became his life’s work, writing of the European peasant and his vanishing world. Without his thinking hard about Sassell and his community, I find it difficult to see that he would have picked up that cause.

But the most interesting point to be made is that both individual doctors and the medical establishment at large still place such great weight upon it. The faint praise waved in its direction by the ordinary reader, as represented on Goodreads, is incredibly different from the place it holds in medical literature.

Professor Roger Jones, in 2015 as editor of the British Journal of General Practice wrote that ‘First published in 1967, this is one of those must-read general practice books, essential for every trainer, trainee and practice library, and one, I suspect, which has been more frequently recommended than read.’ The review starts out in rather uncomplimentary terms, but grudgingly ends:

However, re-reading it at one sitting very recently, I recognised the limpid beauty of some of Berger’s prose, the subtlety of his descriptions of nature and of human interactions,  and his insights into the needs of ordinary people faced with illness, anguish and loss. His – or is it Sassall’s? – understanding of the role of the general practitioner as a witness and a “clerk of record”, needs to be widely understood, and never more so in these days of therapeutic miracles and performance indicators, when the unmeasurable essence of patient care can so easily be overlooked.

In my opinion, Jones, like lots of others, doesn’t understand that Berger is not painting Sassell as a saint, far from it. He is clearly concerned that Sassell is a human being trying to do things that are humanly not possible. And it is made obvious in the text that the ‘Fortunate’ of the title is not a positive thing. Rather, it is the cause of the doctor’s undoing. I don’t see at any point during the book anything but concern from Berger. Nobody could read this book and be surprised that its subject killed himself.

In 2005, on the occasion of a general celebration of Berger’s work, a special session on A Fortunate Man was held.  Leading up to it,  Dr Gene Feder said that it was ‘…still the most important book about general practice ever written.’

The plug for it continued:

Speakers will include Iona Heath, Tony Calland (who was a partner in John Sassall’s practice), Patrick Hutt (a recently qualified doctor 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.

In 2009, in a post by Dr Peter Kramer, he comments not only on how influential this book was on his own determination to become a doctor, but quotes Iona Heath  “If I could choose only one book on the planet, it would be this book.” She said it on the occasion of the 2005 event at which a reissue of the book was launched.

On the evening of 26 April 2005, nearly forty years after its publication, and as part of a short London season of events based around the work of John Berger, over 200 people, many of them doctors, packed into one of the lecture theatres at Queen Mary College, London, to testify to one extraordinary book which had shaped their lives and political beliefs. The event was sponsored by the Royal College of General Practitioners, who have just republished it.

Professor Ken Worpole, later commented in his report of the event that ‘Rereading A Fortunate Man I was astonished to realise that I had absorbed many of the passages in it by heart and have paraphrased them as my own thoughts and insights over the past forty years, forgetful of their origins in this remarkable work.’ His report continues

Two junior doctors, Jane Simpson and Patrick Hutt, dwelt on the impact A Fortunate Man had had on them during medical training, when they experienced the feeling of belonging to two completely different worlds, of clinical practice and human community, the understanding of the latter being almost entirely missing from their training. While their medical education had prepared them for the functions and malfunctions of the human body, it had in no way prepared them for the glaring inequalities in life experience and shocking levels of material deprivation they found out in the wider world. Nor for the stresses and feelings of guilt when tragedies occurred.

To an audience made up largely of men and women in general practice, the National Health Service as a political ideal still seemed to have been one of the great achievements of British politics in the 20th century. Yet its implicit political meanings were perceived to be under attack as never before. Ideals of public service were being replaced by market-based contracts. While it was a good thing that the older deference of the past had been replaced by a greater degree of parity of esteem between doctor and patient, the more communitarian aspects of the doctor’s role had been negated in a target and output-based culture.

In 2016 we find in the British Journal of General Practice The process of empathy: insights from John Berger’s A Fortunate Man by David Jeffrey.

And somewhat earlier,  in 2001 In search of A Fortunate Man by JS Huntley, DPhil, also appearing in The Lancet. Huntley literally went on this search.

Why is this book so enduring, even though the very idea of the sort of doctor inspiring it has been killed by the system long ago? The Lancet used to (still does?) have a section called Literature and Medicine. Gillie Bolton in Stories at work: reflective writing for practitioners begins by saying

Every triumph, disaster, or joy of our lives is a story waiting to be written. We create this dynamic literature about ourselves and patients, patients create it about us, and colleagues give us principal or walk-on parts in their own dramas. Stories and poems in The Lancet, the Journal of the American Medical Association, and the British Medical Journal bear witness to this. These are well-thumbed pages; even doctors who claim never to peruse these journals know these stories. Why? Because such stories are data-banks of experience, knowledge, and skill: they are embedded in practice. Reading or hearing stories makes skilled experience and knowledge available not only to colleagues, trainees, and students, but also to the writers themselves. Reflective writers can study their own decision-making processes, relationships with colleagues, and responses to patients; analyse their hesitations, and gaps in skill and knowledge; and face difficult and painful episodes.

From this point of view, Berger’s book is merely part of a historical tradition, if one that has survived particularly persistently, perhaps because of his input. But John Berger is one of those who suffers from being many things. Artist, novelist, playwright, non-fiction writer, and this, a new type of book as we discover in Professor Poynor’s piece on A Fortunate Man as design. Here you will see what is special about this book from a completely different point of view and also understand the publication process and its impact. He comments that

In 1965, in an article in Typographica no. 11, Berger argued the need for new relations between words and images: “No editor yet thinks of a photographic library as a possible vocabulary; nobody dares to place images as precisely in relation to a text as a quotation would be placed; few writers yet think of using pictures to make their argument.” His most famous book, Ways of Seeing (1972), designed by Richard Hollis, applies exactly this principle.

A Fortunate Man, the first in a trilogy of innovative collaborations with Mohr — see also A Seventh Man (1975) and Another Way of Telling (1982) — was Berger’s first book-length attempt to mix words and images together in a way that invited readers to treat them on their own terms as contiguous but distinct kinds of information. Berger and Mohr had certainly seen Walker Evans and James Agee’s Let Us Now Praise Famous Men (1941) about sharecropper families in the depression, though the photographic section and Agee’s documentary text are not permitted to intermingle in that book. And it’s possible that they were also aware of W. Eugene Smith’s ground-breaking “Country Doctor” photo-story in Life, October 11, 1948. “Both Jean and I have a considerable admiration for Eugene Smith,” Berger writes in their book At the Edge of the World (1999).

Fortunate_Man8_525

Poynor has this thoughtful comment to make about the manipulation of the book’s last photo for the paperback edition:

Perhaps the most striking change Cinamon made in the paperback was to the final image of Sassall climbing the path to his house. “I hesitate to admit that, to make more visual sense of the ending of the book, I reversed the photograph so that the doctor was trudging off the right-hand page — nothing less than a criminal act! I hope I had Berger’s approval,” he writes in an unpublished private note he made about his design. On the following spread, Cinamon also repeats the central detail of Sassall climbing: a kind of cinematic “iris-in.” For me, these devices don’t feel necessary, though most of the book’s readers will know it in this form. The original Sisyphean image, in which Sassall seems to double back and return with a determined stride to the pages of his own story, is perfectly appropriate to the intense, troubled nature of the man and the book’s inward-turning reflectiveness.

And thus he ends with a plea for ‘republication in a new fully restored and annotated edition of the original fluid design.’ I can see I’m going to have to get a copy of the original if I can.

I’m old enough to have seen the changes in what a GP is supposed to be. From somebody involved in your life, to one who spits out patients at a rate of 8 minutes per appointment. Ready, set…your time starts now, keep your eye on the clock please. Mostly you see strangers at large clinics which are devoid of any human touch. Yet only a couple of months ago one could see this in the British press:

Keeping the same doctor reduces death risk, study finds. New research suggests continuity and bond between patient and doctor not only improves level of care, but can also save lives.

Could anybody possibly be surprised by this? However dehumanised the process of doctoring and patienting has become, evidently there is something else that is better, perhaps something that both doctor and patient want. That this book still haunts us is a clue as to why.

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