“Good Doctoring”

The road signs pass by, a sea of consonants around which my untrained tongue cannot yet wrap: Llynclys, Llanymynech, Cilcewydd. I practice my “unvoiced apical alveolar lateral fricative”—the elusive “ll” seen in so many Welsh place names—and think I have finally managed to make it sound almost like my Welsh language tutor does (on Skype).

I am driving through Wales to the Forest of Dean to revisit the scenes depicted in “A Fortunate Man: The Story of a Country Doctor,” John Berger and Jean Mohr’s 1967 biographical photographic essay of John Sassall, a country doctor in a small English town. The book is studded with Mohr’s black and white photographs of Sassall, his patients, and the Forest of Dean landscape. I first read it two years ago during my second year of medical school in the United States, and its effect on me was profound enough to carry me to this spot.

I decide to take a brief detour to Hay-on-Wye. Tucked away in a bookstore, a graphic novel catches my eye: “The Bad Doctor: The Troubled Life and Times of Dr. Iwan James,” written by Ian Williams, MD. It is the fictional story of Dr. Iwan James, a modern-day general practitioner in rural Wales. When I open the novel, I see—in place of Mohr’s black and white photographs—the monochromatic sketches of James in his modern Welsh National Health Services office. In an era of abbreviated patient visits and the technological intrusion into the exam room presented by electronic health records, it is with a sense of urgency that I am compelled to examine these two complementary models of the art and science of “doctoring.”

Berger explores the grounding of the doctor-patient relationship. The physician is a near stranger, and yet he or she is given intimate access to bodies. Berger emphasizes that a personal relationship and physical examination will remain the foundations of clinical care despite advances in technology: “[i]t 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.” He describes the almost sacred laying on of Sassall’s hands as an essential ritual in the interaction between doctor and patient. Berger holds space for the possibility that rather than being the last of a dying generation of country physicians, Sassall may in some way herald the future of medicine. In comparison, James’ telephone and computer, are ever present companions in his clinic visits. We often see James at his computer performing mandatory audits, with text bubbles such as, “grumble grumble,” and, “sigh,” followed by detours on Internet Explorer to shop for new bike parts. We see very little physical interaction between James and his patients.

Sassall is generally seen as a “good doctor,” but Berger is careful to explore what this label means and from where it is derived. For Berger, evaluating whether Sassall is a “good doctor” goes beyond evaluating technical skill or the number of ideal clinical outcomes. Sassall’s childhood view of an ideal physician gives insight into how he himself may define a “good doctor”:

A man who was all-knowing but looking haggard. Once a doctor came in the middle of the night and I could see that he slept too—his pyjama trousers were poking out through the bottom of his trousers. But above all I remember he was in command and composed—whereas everybody else was fussing and agitated.

The visible pajamas suggest a level of humanity, and yet, they are covered with work clothes, having taken the time to throw on a pair of trousers in an act that maintains professionalism and authority.

Sassall’s isolated position in the village means that he is the first to witness the sorrows of patients and “the frequent inadequacy of his ability to help them”—feelings perhaps enhanced by his childhood image of the self-sacrificing and uniquely competent physician. Berger is quick to remind us, however, that Sassall’s sense of inadequacy does not stem from professional doubts or clinical mistakes. Instead it is from a disquiet rooted in unanswered questions—do these patients deserve better lives? Berger posits that the disparity between his own expectations of life and those of his patients are what provoke feelings of inadequacy. These feelings, along with the close suffering of his patients, provoke and sustain Sassall’s month-long episodes of depression. These glimpses into Sassall’s psyche are made all the more bittersweet knowing that Sassall tragically took his own life fourteen years after the book’s publication.

James also explores feelings of inadequacy exacerbated by underlying mental illness, this time obsessive-compulsive disorder (OCD). He reflects on ways he could have reached out to a patient who died by suicide: “[m]aybe I could have done more. I might have saved him.” In comparison to Sassall, however, James’ doubts appear as extensions of his underlying negative beliefs about his self-worth: “I doubt everything about myself. Whether I’m a good person or a bad person, a good doctor or a bad doctor. I’m unable to tell.” James’ concern with being a “good” doctor seems more a commentary on being a moral and deserving person—as he says, the “doubt is only about myself. I can be objective about patients. I don’t worry about treatment decisions.” His doubts are likely underpinned by his lifelong struggle with OCD, one which Williams sketches with striking detail.

In examining these two works, we must remember the differences between a biography and a work of fiction. Berger acknowledges the frustrations of his genre. In fiction, “outcomes can be decided. Whereas now I can decide nothing.” Indeed, Berger, as a fiction writer, likely would not have contrived Sassall’s eventual suicide, any more than Berger, as biographer, would have calculated such an outcome. The cruel irony of the matter, however, is that the celebrity accruing to Sassall as a result of “A Fortunate Man” is widely speculated to be a major factor in his decision to end his own life. I wonder if more oppressive to Sassall over time may have been the dark mass of “bitter paradox” as vividly drawn by Berger. Sassall, Berger says, constantly asks himself, “How far should one help a patient to accept conditions which are at least as unjust and wrong as the patient is sick?”

I am driving toward London. The Welsh language falls away from the road signs as surely as the “unvoiced apical alveolar lateral fricative” retreats from my tongue. But I find myself thinking of the Welsh word for “hand,” llaw, regardless of its pronunciation. In thinking about the potential of Berger’s invisible hand potentially at work near the end of Sassall’s life, I consider the blurring of fiction and biography—perhaps inadvertently by Berger and intentionally by Williams in his modern graphic novel which was certainly informed by Sassall’s story, both as chronicled by Berger and by subsequent accounts of his suicide. For a fleeting second, as ephemeral as a perfect “ll”, the optics of literature resolve this blurring into the physician’s inherent dilemma of achieving transformative closeness with her patients while operating in an existential isolation. I reflect on the importance of the llaw to Sassall’s practice in which the doctor’s hand on the patient’s body becomes symbolic of healing, a quantum tunneling between the isolation of fictional interior worlds and the nonfictional world as it is. And, in its absence in James’s practice in “The Bad Doctor,” perhaps the llaw as metaphor is at the heart of James’ angst.

My education at Hopkins is embedded in the traditions of Osler – the pursuit of clinical excellence that is strengthened by deep, meaningful connections with patients. I carry Sassall’s message of the ways physical touch enhances my ability to heal, and how integration into the local community allows for a closeness to patients, and a passion for my profession that a detached physician could not experience. At the same time, James reminds me of the gift that is my professional community—role models and educators certainly, but even more so a body of friends that lift up, encourage, and inspire me daily. The heritage perhaps offers a new, if old, model for us all, in which the best are able and enabled to practice medicine at hand, and in which the fortunate find the resolve, courage, and support to avoid crashing on the rocks of the physician’s dilemma.