Over 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.