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The Curse of a Fortunate Man

Posted by Dr No on 12 December 2012

sassall_2.jpgOver the years Dr No has encountered a number of single handed general practices. His first encounter was on a Scottish island, as a student, in a practice made memorable by two things: the sweet malt smell from the oil drum sized barrel of beer that brewed beside the kitchen range, and the loan of the practice Land Rover, with a licence to roam the island. Later, as a locum, he found single-handed GPs on leave a reliable source of work: he could be transported, as if by a revolving door, to the seat of a single handed GP. For a week or two, he had eyes-only access to almost every aspect of the practice. He saw the intimate details first hand, not as a squinting sociologist might, but as a living participant. And living practices they certainly were, but pretty rum many of them were too. Too often for comfort, opening a drawer in search of a prescription pad, Dr No was greeted not with a jumble of papers, tongue depressors and broken tape measures, but with the clink-chink of bottles of high proof but non-surgical spirit.

One of the dangers of single handed general practice is that it allows the GP to ‘do a Kurtz’, while neighbouring practices have no, or perhaps only the vaguest, sense that there is a heart of darkness in their midst. The apocalypse may be now, but no one knows it. And yet, in many ways, single handed general practice, especially in the days when GPs bore absolute responsibility for the patients, is the purest form of medical practice, at once both primitive and all-encompassing, even archetypal. It is intimate, intense, all-absorbing and all-consuming, and – for all these reasons and more – addictive. Like all addictions, it has the power to destroy.

And that’s the rub. These ‘happy few’, like Dr John Sassall, the subject of Berger’s A Fortunate Man, are absorbed and consumed in more ways than one. They are often happy, but as much in the sense of a Happy Larry hooked on an addiction, as in the exercise and fulfilment of a near sacred duty. Just as they are absorbed, so they are consumed. Sassall literally shot the notion that he was truly fortunate by pulling the trigger on himself. More than a few of the single handed GPs Dr No has known have suffered similar unfortunatalities. Too many of the happy few come to an unhappy ending. Dr No can agree with Berger that such lives are, in Aristotle’s true sense of the word, tragedies – the protagonist bears a fatal flaw that will do for him or her – but to suggest that lives so lived are fortunate is – again in the true sense of the word - absurd. It makes as much sense as saying that Lear was a fortunate king.

Which brings Dr No to the to him curious question of why Berger’s book continues to be for many the sacred text of general practice. Some have even accorded it – not that it will be much use when they get there - Desert Island Book status. Yet the book itself is a snapshot in time of one man’s practice, through a Marxist-humanist lens, recounted in costive prose, with an ending that leaves this reader with a sense of incomplete evacuation.

It concludes with a sub-essay on why the author cannot come to a conclusion. To Dr No’s simple mind, an assertion that one cannot come to a conclusion – because Sassall’s life was at the time of writing still a work-in-progress - is of itself sufficient conclusion. But Berger, by this stage of the book freed from the obligation to focus his sociological squint on Sassall, breaks into terminal free-flow. The result is a nine page post-modern neo-Marxist humanist word salad: railings against unseen Establishment opponents, mumbo-jumbo - portentous as it turns out - about why art is not the same art once the artist has died, and mysterious individuals known only by initials yet defined by the fulcrums of history. Dr No could go on, but the map is already in the shredder, and the territory, like Krakatoa, has blown itself to bits. Like the line men in Dylan’s All Along the Watchtower, Berger has drunk Sassall’s wine and ploughed Sassall’s earth, only to exit wailing, not knowing ‘what any of it is worth’.

That, Dr No supposes, is what happens when one squints through a Marxist humanist lens. But other lenses, other assessments, are possible. The book’s final sentence is both a rare direct quote of Sassall’s own words – most of the book is filtered though that infernal Marxist humanist lens - and again portentous: ‘Whenever I am reminded of death – and it happens every day – I think of my own, and this makes me try to work harder [emphasis added].’

Sassall, it seems to Dr No, was running, and running hard, through work, from his own mortality. Seen through this lens, we see not so much a fortunate man, as a man running scared. We see elements of Alice Miller’s doomed grandiosity, with its certainty of eventual catastrophe. In contrast to the proposal at the end of Dr No’s last post for non-attachment, Sassall clung ever harder to work, as if not just his patients’, but his very own life depended on it. Yet his life was, to borrow a phrase from one of Miller’s patients, ‘hanging from a balloon’, a balloon that can fly up very high in a good wind, only suddenly one day to be punctured, and left lying like a little rag on the ground.

Re-reading A Fortunate Man, Dr No is struck by how neatly the life portrayed matches the pattern of grandiosity followed by depression described by Miller in The Drama of Being a Child. It is a pattern that comes naturally to the medical mind: even before arrival at medical school, the doctor-to-be learns to build his or her identity and self-worth on achievements. The doctor’s self-image rests not on what he or she is, but on what he or she achieves. There are no internal girders of support, just external buttresses of achievement. It is a life of exquisite precariousness, for it takes but one or two buttresses to be knocked away for the life to collapse.

There is something particularly shocking about priestly and medical suicide. Both professions concern themselves with healing – in very different ways – and so it seems especially profane that those who profess to heal others should themselves – and here Dr No is prepared for ye counterblast from our humanist and ethical colleagues in the autonomy cults – so visibly fail to heal themselves. As the buttresses fall away, and a life is extinguished, so do the foundations tremble. Some suicides no doubt can be lensed into celebrations of autonomy and monuments to self-determination, but the grim reality is that most suicides are the final act of a desperate soul. Most are not about infinite light, but overwhelming darkness.

Making a cult, even a fetish, of A Fortunate Man, and the way of general practice it portrays is, it seems to Dr No, reckless, even foolish, for it is but a snapshot. It is not, and cannot be, the whole movie, the complete story. To encourage young GPs to emulate Dr Sassall is to risk launching many on a path with, all too often, a dark ending. If there is much to be learnt from A Fortunate Man, perhaps its most potent lesson is this: beware the Curse of a Fortunate Man.


Just to understand what the book is about

... I must lock my drawer next time I have a locum in so they don't find my Whisky and Calvados bottles (which have been there for at least 5 years as they only come out to add to Lemsip and Honey after succumbing to patient bourne viruses).
FWIW I never planned to be single handed but was ostracised by the more conservative senior partners in my profession for daring to be "different" in my choice of lifestyle. Problem now is I am at that funny age in my mid 40s where I'm probably too used to (addicted to?) being single handed to join a big practice (10 years on society is more accepting of my "lifestyle problem") but am finding the workload on my own increasingly difficult as the neurons begin to wither and teenaged kids become increasingly expensive, meaning it is ever difficult to take any annual leave (2 days in the past 18 months) :-(
... where's that booze...??

Definition (OED): favoured by fortune; possessed of or receiving good fortune; lucky, prosperous. Said of persons; also, of an enterprise, event, etc. So we need to look up fortune: Chance, hap, or luck, regarded as a cause of events and changes in men's affairs.

However, perhaps more illuminating - or maybe not - are Berger's words, which provide what amounts to a contextual definition: 'Sassall is nevertheless a man doing want he wants. Or, to be more accurate, a man pursuing what he wishes pursue...Like an artist or like anybody else who believes that his work justifies his life, Sassall - by our society's miserable standards - is a fortunate man'.

'His work justifies his life' - but the man committed suicide... Yes, of course he did so after the book was first published, but when the whole story is known, that phrase becomes a rum old circle to square. What Berger appears perhaps to have missed is that the practice was consuming Sassall, or, if you prefer, he was a vessel for Scott Peck's sacrificial absorption.

Speaking of vessels, Berger more than once likens Sassall to Conrad's Master Mariners. Dr No, who happens to be a YachtMaster Instructor, and so has an inkling of these things, has sympathy for this view (irrelevant note: Dr No bought his copy of A Fortunate Man from a book stall in Lyme Regis while he was cruising the West Country many years ago, so he was so to speak in the right setting to make the connection) but more to the point, single handed GPs can and do 'do a different Conrad', a Mr Kurtz.

SFD - the bottles Dr No encountered were usually empties, and nowhere near as interesting as Calvados, and when it wasn't bottles, it might be vials of diamorphine, these being pre-Shipman days. Some of the single-handers had to be peeled like the most tenacious elastoplast from their practices, their greatest fear being that no one could provide for their practice as well as they did (elements of grandiosity). But the Master Mariner who takes no rest soon imperils both Master and crew. Dr No humbly and cautiously - he is profoundly wary of being even the slightest prescriptive in cyberspace - suggests: take that leave while you still can! Failing that, keep on blogging and commenting. One suspects that had he a blog, Mistah Kurtz might not be dead...

"What Berger appears perhaps to have missed is that the practice was consuming Sassall"

Spot on Dr No. The definition in the OED concentrated on the 'material' and forgot about the 'soul'. Which perhaps proves a point I made long time ago that the dictionary can many a time be proved needy, this is a clear example of one such occurence and the resulting harm it did. It seems Berger himself fell victim to that definition of 'fortunate' to mean money and status but not with the addition of the more important part which is 'contentment' himself - and that is how he became trapped where he would perhaps have not been if the word was better defined. Would he have escaped his fate if it was? ... your say

So, I think his choice for the title "A fortunate man" was not a 'fortunate' choice at all since he was so miserable, he even forgot the first pillar of medicine, or to 'do no harm' and committed the ultimate harm by 'killing', even if it of himself.

That then opens a much wider debate on the meaning of 'compassion' too, or lead one to question how those who do not get it be expected to give it at all, let alone all the time as per medicine's or other stressful 'professional' dictats everywhere. It seems Dr Sassall himself being deprived of compassion or a listening ear and a hug sometimes tried his best to provide same to his patients but the resulting pressure from the lack of receiving same himself became so unbearable, it resulted in him forgetting those very professional standards and ending in killing himself. Very sad, but apply that to many other professions too if you want to deal with a whole array of mental problems and the resulting suicides.

That then makes you question why did he not seek help to cope with that excessive stress due to such professional pressure, and it's all to do with the British psyche itself. You know, when I am abroad and people find out that I live in Britain, they always ask me if the Brits really have a 'stiff upper lip' and I always say; yes they do, it's a defence mechanism to hide a melting heart, the Brits cry over a bird with an injured wing so long as the can do that in private because they hate being 'pitied', which is what most Brits consider showing their true emotions in public to be and end up trying to cope alone ...

I have been living here for so long now, but I have always tried hard not to fall in that same trap that killed Berger ... maybe it's time for change for everybody, if only for the sake of health, mental or otherwise

You've opened a can of worms with this post Dr No, but one that can clear out in no time at all if we all tried 'together' to save each other from such fate near or as that of Berger.

You opinion Dr No

I have not read this fortunate book, but have a fond place for the book "heart of Darkness"; and also for the film "apocalpse Now". Single handed practice is attractive, particularly when seperated from the controlling power of the Commissioners and Inquisitors.

I was at my appraisal recently, and as I do have private practice had to include this for my revalidation. I chose an appraiser who also does private practice. We had an interesting discussion on the enjoyable aspects of PP work. To those who have not supped this intoxicating brew it all appears to be about money. Th reality is that historically it has been that door to single handed practice with all its attractions for doctors who otherwise are forced to work in teams. In many ways we have had the best of both worlds: the moderating and normalising effect of working with others in our NHS duties, and the autonomy and freedom of a PP practice where we stand or fall on our own wits.

The Inquisitors do not like those that like to work independently. They see us as untidy, and recognise that we offer a different world view that is a threat to them. Heretics must be eliminated for the good of the organisation.

"Exterminate the Brutes" is a very ambiguous last note of Mistah (or Colonel) Kurtz. The agent sent from HQ sees it as an instruction to eradicate the ragtag army of Kurtz, but it is perhaps an instruction to exterminate those dissidents that threaten the organisation because of their unorthodox methods.


Not cannibals dancing around a fire as in your 'heart of darkness' book those revalidators, was that appraisal that bad?!

How long does the whole process take then and when do you get know the result?

Dr No is confident most of his readers have more than enough intelligence to join up the dots, but we are in the run up to Christmas, and heads must necessarily be full of turkeys and crackers, so, at the risk of stating the obvious, 'Mistah Kurtz—he dead' comes from Eliot's The Hollow Men, the poem which ends not with a bang but a whimper. Were it not for this final line, we might ponder whether Berger should have called his essay 'A Hollow Man' (a phrasing that is also in tune with the Scott Peck/sacrificial absorption/(empty) vessel notion), but, the final act of Sassall's life was as brutal as it is awkward: Sassall did die with a bang.

Anonyme - although it probably didn't help being British, Dr No suspects Sassall's professional isolation and frank inability to 'look after the machine' (a phrase Dr No uses when teaching skippers: an tired befuddled skipper is no use to anyone) has more to do with the loneliness of command than with national character. Dr No has touched on this before: there is a certain requirement that he who is in command (of a ship, of a practice) must maintain composure. If the boss disintegrates, the crew (patients) are forced to contemplate a terrifying world without axis or order. Thus a cardinal duty of a leader/skipper/doctor is to ensure that he or she does not disintegrate. The skill - and that is all it is, a skill - is to know how to do that.

Boots - 'the moderating and normalising effect of working with others in our NHS duties, and the autonomy and freedom of a PP practice' - consultants are indeed in the enviable position of being able to benefit from the best of both worlds. Dr No has no doubt it is the autonomy of private practice that appeals as much as the money. Ironically, because they have recently all but reversed the order, it was autonomy over money that drove GPs to insist on their hallowed 'independent contractor status' at the start of the NHS.

The more totalitarian the regime, the greater the need to control, and root out and destroy dissent. The medical profession has by and large over the last few decades been sleepwalking towards the defining features of a totalitarian regime (state not citizen codified norms, a growing apparatus of control over individual practice, and an effective machinery for the elimination of dissidents). It is a grim future that lies ahead, but frankly my dear, the doctors have only themselves to blame. But Dr No is not sure that we need - yet - to exterminate the brutes. We can instead attack their ideas, using that curious small stunted weapon: the pen.

"although it probably didn't help being British ... Thus a cardinal duty of a leader/skipper/doctor is to ensure that he or she does not disintegrate. The skill - and that is all it is, a skill - is to know how to do that"

I am British and a proud one too, albeit, I am an adopted one, and why perhaps I have two views of two sets of people and why my comment which meant well. In comparison to the Middle East, for example, professionals, say skippers, still need to maintain composure but are much less stressed because they open up more, and scream more - meaning that 'in general' and IMHO which was acquired through observation and not from the point of view of a professional doctor since I am not one, hence you may disagree, stress levels are higher being a skipper here than being a skipper in Dubai if you like, and it is that stress that causes people to snap, and it is that stress that needs to be treated first if you want to protect people from that fate of 'a fortunate man'

Having a big heart is a gift from God and is what makes us human Dr No and why I hope others consider me a softy too ...

Merry Christmas, I hope you enjoy the season and the turkey :-)

The appraisal was not so bad. I can tick all the pointless boxes required and revalidate with ease. I know the rules and play the game.

But just because I outwardly conform does not mean that I agree with the process, or that I found it a productive week of preparation. Appraisal could have some utility but revalidation is just a waste of time. It will become more onerous as the authorities realise that it is not doing what was desired, the stamping out of dissent. Not since the days of MTAS has such an unpopular policy been forced on the profession.

In Single handed practice the analogy of a Skipper at sea is a fair one, but in a hospital setting the clear lines of command are no longer there. There is no loneliness of command, but rather a bewilderment of command with contradictory orders being shouted by all and sundry. It is no wonder that the ship is foundering on the rocks at the mercy of wind and tide on a lee shore.

Griffiths famously reported that if Florence Nightingale toured the NHS with her lamp she would be looking for someone in charge. What she would find now would be a confusion of command, enforced by the lash, and heading towards a Caine mutiny.

It's aposite for you to follow up your last post with a warning shot accross the bows of a Fortunate Man, but I think that if anything it supports, rather than underlmines its place on top of the Christmas tree of general practice literature. Balint's insight was to show that in order to sustain effective therapeutic relationships GPs need to be aware of and share the burden they carry. A cool attention to the digital template that overshaddows every consultation will keep the practice accountant happy and keep the bottle safely in the drinks cabinet. The literature of general practice by contrast to the cool objectivity of granular metrics is almost all dark, dealing in the tragedies and chronic, unsolveable problems rather than the heroism, or restitution narratives of acute medicine and TV drama.
My short blog about Love and Hate meant also to highlight the fact that for many of us, Balint is as valuable and necessary as ever, but bureaucratic burdens and polical meddling have recently displaced the stress bought on by complex relationships. And we don't have a Balint for that ...
See also Avoiding Isolation and gaining insight

I read the book at the age of 50-ish on the gushing recommendation of a College "sherry list" type.
When we met again and I told him of the suicide-he was very disquieted.
Perhaps the fans haven't twigged that a "Fortunate Man" shot himself? Perhaps they haven't actually read it?

I had considerable hopes when opening this book and at first it read very well; then Berger took over and the reader was suffocated by his musings. I wanted more of Dr John Eskell and far less of Berger. A casual reader would probably suspect bi-polar depression as a factor in this man's life and the news of his suicide was not unexpected, given the reference to months of depression. A potentially fine book if only JB would shut the *@ck up.

At last - I always wondered who the saintly Sassall was. My 1955 Medical Directory shows John Eskell,qual 1944, at St Briavels, in partnership with Patrick Miller of Devauden.
As a GP of 40yrs I have often wondered why this peculiar book is so revered and, worse, recommended reading for budding GPs, unless to serve as a warning of how not to practise.
My favourite 'GP' book is Dr Braadley Remembers, by Francis Brett Young, but I guess no-one remembers it now.

John and Betty were close friends of my parents in the 50s. My father was GP in a neighbouring practice in Yorkley. We often went over to St Briavels and shared family trips. This all ended in 1958 when my dad committed suicide due to recurring clinical depression, which he had suffered from since his teens. Ma and I moved to Sheffield and it was during this period that the John Berger book was written. John was droll about the process: "got this writer living with us following me around for six months.There's a photographer with him. Just as I'm teeing up on the golf course he thrusts the camera up my nostril...". With hindsight John did have bi-polar depression, but his wonderful wife Betty supported him through it. I think it was a year or so after her death that he shot himself. He had made determined efforts to keep going and rebuild his life without her, but finally lost the plot. I agree with Anonymous of 2015 that the book suffers from too much of Berger's musings and would be better if he gave us more of Eskell. However the photographs are magical and conjure up the Forest of Dean in those days for me better than anything else.

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