Promises to keep: Doctor-patient interactions

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Forgetting Emilie Pine’s Notes to Self and Maggie O Farrell’s I Am. I Am. I Am. by mistake on the hall table at home, I had to adjust the plan for this class on my way in to Trinity.

We started, as planned, with the opening scene from the film adaptation of Carlo Levi’s non-fiction Christ stopped at Eboli which shows the Levi figure, aged, (“closed off from this world”) contemplating his portrait paintings of the peasants he treated and knew when he was banished to southern Italy for criticising Mussolini’s government. In the clip, we see close ups of the painted faces and hear the voiceover saying “I’ve been unable to keep the promise I made to those peasants upon leaving: that I’d return to them.”

Moving to another poor community in a rural location, namely, Gloucestershire – I then told them about John Berger’s A Fortunate Man, and showed them some of Jean Mohr’s photographs, pointing out that the commission that led to Fionn McCann’s ‘General Practice’ photographs, which hang in the halls around the Biosciences building, was inspired by A Fortunate Man. We read together the short scene early in the book in which a young woman visits the doctor, John Sassall, complaining about nothing in particular (‘You just feel weepy?’). The episode is mostly dialogue, but we discussed Berger’s observation of the patient: that ‘She is nubile in everything except her education and her chances.’ We compared that to Levi’s painterly observations of the peasants of southern Italy. We also analysed the particularly personal level of care that was shown in the consultation, how it reached into the patient’s circumstances, going way beyond physical and even narrowly defined mental health concerns.

We discussed at some length the last few lines of the vignette, another authorial intervention: “After she had turned the corner, he [Sassall] continued to stare at the stone walls on either side of the lane. Once they were dry walls. Now their stones were cemented together.” We identified the poetic nature of it and the possible metaphorical comment it represents in relation to the lives of the local people becoming more restricted.

To stand in for the more negative experiences of doctors that are a feature of some of the encounters in Pine’s Notes and O Farrell’s I Am.., I simply showed them & read from the front page of the Irish Times from 13 September 2018 when the Scally Report was published.

Irish Times frontcover doctor quotes

We then read Kim Caldwell’s personal essay, ‘Life Lessons’ (from CUP’s ‘Palliative & Supportive Care’), about her recollections of dealing with various patients close to or at the time of their death. We discussed why she might have chosen to address those people in the second person singular; and some other aspects of the style of writing, the structuring of the pieces, and the literary nature of some of the writing. We noted how much detail she was able to recall about the lives of these patients, details which she had picked up from spending time with them and consciously listening to them, details which she still recalls and which she consciously shares with the reader, as if challenging the reader to sit with the patient as well and get to know them. We discussed her reasons for going into so much detail, and for wanting to share the accounts with others. (Prompted by one possible reading and the occasional ‘commodification’ of doctors’ experiences that one encounters, we discussed the possibility of there being an element of flexing or trumpeting about such accounts, but the majority of the class felt that this would be an unfair reading to the author in this case whose genuine nature came across very clearly in how much she obviously cared about these people, wanted to remember them as people – not just patients, and how she pointed to her shortcomings and the system’s pressures that prevented this kind of interaction being the norm.) We discussed the pressures on medics to concern themselves with much more than just the science of health, the symptoms, the diagnoses, the treatments. It was pointed out how helpful it was to get this perspective on the patient-doctor relationship.

I gave them – “to go” – a 1977 Irish Times piece written by Maeve Binchy (whose portrait by Maeve McCarthy was one of the paintings chosen to “go with” a poem during our visit last week to the National Gallery), called ‘Anna’s Abortion’, and one of the ‘In Her Shoes’ personal accounts that had some parallels > https://www.facebook.com/InHerIrishShoes/photos/a.142348133106279/239426283398463/

(Note: It was our first poetry-free and fiction-free day.)

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A fortunate photography exhibtion

Really looking forward to seeing this, not least cause it reminds me of the John Berger – Jean Mohr collaboration in A Fortunate Man:

General Practice is a forthcoming exhibition of photographs at the Gallery of Photography in Temple Bar, Dublin, which highlights the vital role of GPs in contemporary Irish society, providing a glimpse into the usually private interactions between GP and patient. In colour and black-and-white photographs, the photographer Fionn McCann captures the trials, tribulations and sometimes humour of these encounters.

From General Practice, copyright Fionn McCann

Through the sensitivity of McCann’s lens, the frontline work of GPs is revealed in all its diversity. In the consulting room or on home visits, the GP may be called upon to medicate, to perform procedures or simply to explain and reassure. Above all, the confessional quality of the patient-GP encounter, where listening to the patient’s concerns is of prime importance, is underlined.

This exhibition marks the closing event of the tercentenary celebrations of the Medical School of Trinity College Dublin. It is the inspiration of the Professor of General Practice, Tom O’Dowd who commissioned Fionn McCann as photographer. The images were made between 2008 and 2011, and document a series of patients’ visits to six General Practitioners throughout Ireland. The GPs and the featured patients gave permission to have McCann present during these normally private encounters and the project was ethically approved by the Irish College of General Practitioners.

The exhibition runs from 16 – 27 May 2012, admission free. There are 47 images in total and a video installation playing additional imagery. There is accompanying text for both the exhibition and the individual images. An introductory essay will be included in the accompanying catalogue.

http://www.galleryofphotography.ie/exhibitions/general_practice.html

Student notes on John Berger’s ‘A Fortunate Man’

(lochrins)

This non-fiction extended essay was published in 1967, it was written by John Berger (1972 Man Booker Prize winner) and photographs are taken by Jean Mohr. It is set in rural England in an impoverished and struggling community. Berger and Mohr follow a country doctor, John Sassall, whose career serves as the focus of the essay.

John Sassall, the main character, starts his career thriving on medical emergencies, impatient with non-specific symptoms and the absence of clear-cut physical diagnoses and underlying pathology.

‘That was the happiest time of my life, doing major surgery in the Dodecanese.

He moves gradually towards an empathic listening and companionship with his patients and their families, striving to recognise who they are and the meaning of their illness to them. Physical and psychological intimacy becomes central to his relationship to his patients. Sassall establishes a brotherly relationship with his patients, which was very different to the paternal relationship which existed between most doctors and patients at the time.

‘He began to notice how people develop. A girl whom three years before he had treated for measles got married and came to him for her first confinement. A man who had never been ill shot his brains out.’

Sassall is a highly competent and dedicated physician, ’He sees to it that he stays well informed’. He feels compelled to use his occupational life in a quest to explore basic questions about the nature of human relationships and community. This need drives him to be an exceptionally good physician and to involve himself deeply in the life of his rather insular community. While Sassall is an unusual man and physician, many aspects of his experiences in dealing with patients cast light on doctor-patient relationships in general.

The simple task of turning on the electric blanket on fifteen minutes before a patient arrives shows the deep level of care Sassall has for his patients and it highlights his commitment to making them as comfortable as possible.

The consultation with the sixteen year old girl highlights Sassall’s view of the doctor-patient relationship and it also gives us an insight into his view of the doctor’s role in the community. He is very subtle in the way he address the pregnancy issue and is very quick in getting to the root of the problem.       

‘Do you like working in the laundry?’

His attempt to help the young girl find more enjoyable work is very kind and generous, and though giving her a few days off borders on unprofessional behaviour, it shows the need to be flexible in G.P practice and in medicine in general for the greater good of the patient.

Come up again on Wednesday and I’ll phone the Labour Exchange and we’ll talk about what they say’.                                                                                         

The way he consoles her is almost therapeutic. It highlights Sassall’s role in the community, he plays a key role in looking after the locals’ health, both mental and physical.                                                        

‘The fact that you’re crying means you’ve got imagination. ‘                                                                      

This essay is a reflection on the meaning of ‘good’ doctoring, the naming of illness and the ambiguity of scientific medicine in the context of general practice. Sassall is committed to the fraternal bond that develops over years with his patients. Berger illuminates, through John Sassall, the deep potential of medicine, and particularly general practice, to express solidarity with people as they move through their lives.

‘‘That’s where I live, where you’re putting that needle in.’ ‘I know’ Sassall said, ‘I know what it feels like.’’

The description of Sassall’s qualities as a doctor stand as a guide for all doctors in understanding the doctor-patient relationship and particularly for GPs in seeing their role as more than just scientific and approaching the practice of medicine in a holistic way, acting  as a guide and helper in their communities. Sassall sees the patient as the central character in the practice of medicine.

‘He was straight, not afraid of work, easy to talk to, not stand-offish, kind, understanding, a good listener, always willing to come out when needed, very thorough’

I enjoyed reading this extended essay, it cast a new light on the doctor-patient relationship which has definitely influenced and altered  how I view General Practice, and the way I see medicine’s role in society.

Impatient with complexity of patients’ lives

As a young doctor, Sassall “had no patience with anything except emergencies or serious illness… He dealt only with crises in which he was the central character: or to put another way, in which the patient was simplified by the degree of his physical dependence on the doctor. He was also simplified himself, because the chosen pace of his life made it impossible and unnecessary for him to examine his own motives.”

As he matured as a doctor, Sassall exchanged that obsession with the “life-and-death emergency for the intimation that the patient should be treated as a total personality, that illness is frequently a form of expression rather than a surrender to natural hazards.”

Doctor in society

On the theme of what the doctor’s relationship is to her community and to society more generally, we read extracts from the following texts:

John Berger’s A Fortunate Man

Carlo Levi’s Christ Stopped At Eboli

Gabriel Garcia Marquez’s Love in the Time of Cholera

JD O’Connor’s “Doctor in the Dales”

The two presentations will shortly be posted here, but in the meantime, those who missed either class and those who didn’t get a chance to formulate their thoughts during the classes, are invited to add “comment” on this post (by clicking on Leave a comment link above).