Phil Whitaker is a GP and medical editor of the New Statesman. Phil’s book, What is a Doctor? A GP’s Prescription for the Future, was published by Canongate in 2023.
This book is both fascinating and saddening. The fascinating part is easy enough to explain. Iona Heath, a former president of the Royal College of General Practitioners (RCGP) and for 35 years an inner-London GP, has compiled letters, quotations, and reminiscences from her 20-year friendship with John Berger — art and cultural critic, essayist, novelist, and author of A Fortunate Man: The Story of a Country Doctor.
Berger’s 1967 book, a collaboration with photographer Jean Mohr, rapidly became a classic. It describes the life and work of John Sassall, the pseudonym of a GP in the Forest of Dean. A study of the power of continuity of care and the importance of trust in doctor– patient relationships, A Fortunate Man is regarded by many as having captured the quintessence of the general medical practitioner. It helped Heath as a medical student to decide on general practice as her career path. Yet in 1996, with 20 years’ experience under her belt, and some 30 years after the book’s publication, she was disturbed to find Berger write that he had ‘come to mistrust most doctors because they no longer really love people.’ By then, Heath was a leading figure in the RCGP. She invited Berger to address the College and explain where he thought the profession was losing its way. The invitation started a correspondence between them that only ended with Berger’s death in 2017.
Heath’s subtitle, Ways of Learning, echoes Berger’s 1972 BBC TV series, Ways of Seeing, which brought art criticism to a mass audience and cemented concepts such as ‘the male gaze’ in popular culture. Just as Berger enlightened a generation with new perspectives on art, so he profoundly influenced Heath in her understanding of her patients and her role as their GP. She arranges her material in short chapters, each dealing with an aspect of the doctor’s art: Looking, Seeing, Listening, and so on. Through excerpts and anecdotes, she traces the impact Berger had on her development — and offers us the chance to be influenced in our turn.
“[Heath] traces the impact Berger had on her development — and offers us the chance to be influenced in our turn.”
And therein lies the sadness. Heath and Berger’s correspondence spanned two decades at the turn of the 21st century, which, it has become apparent, have seen a transition from Don Berwick’s first era of medicine to his second.1 Sassall firmly inhabited Era 1, in which relational medicine was underpinned by the assumption that doctors were conscientious professionals trustworthy of self-regulation (most were, but not all). Era 2 has now firmly taken hold, in which relational medicine has been supplanted by systemised ‘health care’, girded by incentives and sanctions designed to ensure that professional behaviour conforms to protocolised expectations.
Heath’s book shows this process in train. In the chapter, Connecting, for example, she extracts from a 2005 letter to Berger: ‘You talk about putting still photographs into a sequence and how the one before influences how we see the one that comes after … how much more must it be true for conversations between people and yet we seem to have a government and policy- makers who think that health care can be delivered without any continuity — with the patient seeing a different doctor on each occasion.’ In the chapter, Words, Heath laments the demise of the traditional referral letter from GP to specialist, replaced by standardised forms that dictate, through the tyranny of the tick- and text-box, what information must and must not be conveyed. ‘Much medical discourse, constrained by computers’, Heath writes, has become what Berger described as, ‘a language that can no longer explain what matters.’
Heath’s book articulates a way of practising medicine that appears to be fast dying, yet there are reasons for hope. The new Labour government has stated its intention to ‘bring back the family doctor’,2 and after decades of neglect by policymakers, continuity of care is now firmly on the political agenda (more for the cost savings it offers rather than its centrality to quality holistic care, but never mind). Berwick argues that the stultifying suffocation of Era 2 will eventually cede to an Era 3, in which — born of the necessity of finding some way of reining in the juggernaut that modern medicine has become — the question ‘What’s the matter with you?’ will increasingly give way to another: ‘What matters to you?’ Berger’s philosophical commitment to understanding and cherishing the depth and complexity of each unique human being may yet prove as relevant for a new generation of GPs as it was for those of us now retired or retiring from the medical stage.
Featured book: Iona Heath, John Berger: Ways of Learning, Oxford University Press, 2024, HB, 192pp, £18.99, 978-0192864239.
References
1. Berwick D. Era 3 for medicine and health care. JAMA 2016; 315(13): 1329–1330.
2. Labour East. Labour’s Wes Streeting visits Hemel Hempstead’s Bennetts End GP Surgery to discuss plans for primary care. 2024. https://www.laboureast.org.uk/news/2024/06/21/labours-wes-streeting-visits-hemel-hempsteads-bennetts-end-gp-surgery-to-discuss-plans-for-primary-care (accessed 29 Aug 2024).
Featured photo by Joanna Kosinska on Unsplash.
