I’m a bit of a suggestible reader these days. I learned of this book from one of the comments on the PCHIT blog that I maintain. If you look at the comment and my interests (patient-physician communication, primary care, reducing disparities), it probably makes sense why this work would be of interest to me.
The book was written in 1967 as an essay about a general practice physician in the English countryside. It starts with a few vignettes about Dr. John Sassal’s interaction with patients, continues on into a description of his practice, and into the physician’s life and thoughts on the doctor’s role in society.
He decided to be a doctor when he was 15, when his image of a doctor was “a man who was all knowing but looked haggard,” who could come to your home in the middle of the night, with his pajama trousers hanging out, and still be calm and composed. Into his 20’s and then into his 30’s, his approach changed, to become less about the excitement of the emergency and more about the patient as a “total personality,” who he would work with for life.
The origin of the doctor role is discussed, as starting when medicine men were relived from food procurement duties, in exchange for the awareness of illness in the tribe. A special relationship was created with the physician role – a person (a stranger) who one would submit their body to in the hope that their malady or complaint would not seem so unique. The doctor’s role is to make the patient comparable to himself.
How does he do this?
..he is acknowledged as a good doctor because he meets the deep but unformulated expectation of the sick for a sense of fraternity…It is as though when he talks or listens to a patient, he is also touching them with his hands so as to be less likely to misunderstand; and it as though, when he is physically examining a patient, they were also conversing.
He does more than treat them when they are ill; he is the objective witness of their lives. They seldom refer to him as a witness…that is why I chose the rather humble word clerk: the clerk of their records.
Being a physician takes a greater emotional toll than is shown outwardly.
He is a man of extreme self-control. Nevertheless, when he was unaware of my presence, I saw him weep, walking across a field away from a house where a young patient was dying.
The minor complication that is not recognized by the patient as significant in their disease course is significant to the physician in their role. It causes depression in the professional whose attitude to their work becomes “obsessional.”
In all of this, there is a discussion of the value of this work. Unlike a scientific discovery, how do we measure the “easing” or even saving of thousands of lives by the country doctor? We are reluctant to do so because it would mean measuring the value of human life itself, and this is something that society is incapable of doing.
The book is interspersed with photographs of Dr. Sassal at work in “the surgery (his office)” and of the community members at work and at play. I think every physician today experiences many of the same feelings of a Dr. Sassal, as well as the same accountabilities to the communities they serve. It is useful to remember this as we engage in discussions of how we measure productivity and give people credit for being “good.”
As the comment in the PCHIT blog stated, many of us are only in the business of creating tools. We are not creating the heart of the relationship that the tools support. I think some of these concepts are ones that are personal and as such difficult for physicians to articulate in these discussions, so a work like this is useful.
And what about computers? That’s covered, too:
It may be that computers will soon diagnose better than doctors. But the facts fed to computers will still have to be the result of intimate, individual recognition of the patient.