John Berger & Jean Mohr: “A Fortunate Man: The story of a country doctor”. The Penguin Press. London. 1967.
Tomei conhecimento deste livro no passado mês de Abril, em New Orleans. Foi durante o Congresso Anual da STFM- Society of Teachers of Family Medicine, congresso ao qual assisto habitualmente. Um dos últimos dias, tendo já realizado as minhas apresentações, vi no programa uma sessão intitulada “Reading A Fortunate Man”. Nada sabia do livro, mas conhecia a maioria dos apresentadores, alguns meus amigos pessoais, e reconhecidos líderes no campo da Medicina de Familia, prestigiosos educadores. Fiquei encantado com as historias relatadas, e com o envolvimento dos professores com o livro. Decidi compra-lo, e pedi para o meu amigo, o Dr. John Frey, um dos apresentadores, o emocionante texto que leu no momento, onde confessa ter sido esse livro o que lhe fez não desistir de ser médico. Está em inglês, mas vale a pena lê-lo com calma (e, se necessário, com dicionário). Um testemunho impactante.
O livro é excepcional. Não é uma biografia, nem mesmo uma reportagem sobre Sassall, um médico rural no interior da Inglaterra. É um verdadeiro ensaio, pois a vida do médico é pauta para considerações profundas que incitam à reflexão. E, lá no fundo, surgem os temas candentes com os quais todo médico –que vive de verdade sua vocação profissional- deve defrontar-se na vida. Como lidar com o sofrimento dos outros, a tremenda responsabilidade da confiança que os pacientes depositam no médico –uma especial fraternidade que lhe confere o poder de adentrar-se na intimidade alheia. E, também, o próprio sofrimento, a angústia de saber que sempre se pode fazer mais. E a solidão, porque no íntimo das decisões profissionais não há com quem compartilhá-las. Alguns trechos são magníficos, serviriam de base para ótimas discussões acadêmicas, com fundo filosófico. Vão alguns exemplos: (alguns traduzidos)
John Berger & Jean Mohr: “A Fortunate Man: The story of a country doctor”. The Penguin Press. London. 1967.
I learned about this book in a session happened at the Annual Spring Meeting of the Society of Teachers of Family Medicine, in New Orleans , in April 2011. The Conference Program noticed a session entitled: “Reading a Fortunate Man”. I didn’t know about the book, but I knew the presenters. And, probably, as many others in the audience, I was there because of the presenters, some of them my personal friends, and respected leaders in the Family Medicine field.
I am not about to provide a brief summary of the book for English readers. Coming from me that will be arrogance and, mainly, something dangerous because people could not be motivated to read it, and this would be undesirable. All I can say is that every doctor should read this book. Let’s copy a brief paragraph in which the core of doctoring is described.
The task of the doctor is to recognize the man. (..) I am fully aware that I am here using the word Recognition to cover whole complicated techniques of psychotherapy, but essentially these techniques are precisely means for furthering the process of recognition. (..) In order the illness fully, the doctor must first recognize the patient as a person. Good general diagnosticians are rare, not because most doctors lack medical knowledge, but because most are incapable of taking in all the possible relevant facts –emotional, historical, environmental as well as physical. They are searching for specific conditions instead of the truth about a patient which may then suggest various conditions. (..) A good doctor is acknowledged because he meets the deep but unformulated expectation of the sick for a sense of fraternity. He recognizes them. Sometimes he fails, but there is about him the constant will of a man trying to recognize”.
John Frey, MD, was one of the presenters and he kindly offered me the fabulous piece of reading he presented. If you have still any doubts about this book, get into Dr. Frey’s writing and you will be convinced.
Seeing A fortunate man
by John Frey, MD
In June of 1967, after my first year of medical school, I sent a letter to the dean of students saying that I would not be returning for my sophomore year. I spent the summer rooming with an old friend from high school working with South Texas migrant workers in the sand hills of central Wisconsin as a day care teacher, school bus driver, and cook in an old rambling house in a town of 200,. During that summer, I contemplated either entering graduate school – in what I was not sure – or being drafted which was a sure thing, given that it was the height of the Vietnam draft. If all else were to fail, I was going to move to Canada. A local GP received cases of dicloxicillin from the government migrant worker program and gave me boxes of it to treat skin infections and abscesses with instructions on who to treat and for what, turning my old yellow school bus into a roving clinic to treat impetigo in farmworkers. He ended up the summer season by encouraging me to go back to medical school. “You can do this stuff”, he said.
I got back a few weeks after everyone else had started. I found friends who I could room with – six of us in a 3 bedroom apartment on the north side of Chicago. I quickly got back into the routine of lecture, lab, study, and also of competitive students scanning grades posted after exams, and felt a returning sense of disconnection with what I thought medicine should be – the same feeling that caused me to quit medical school five months earlier. I began to regret my decision to come back. Chicago was an old city of redlining, class conflict, and what one sociologist called the most apartheid city in America, with vast strips of single race or ethnicity communities in the tens of thousands. Saul Alinsky was running and institute in the city helping community organizers and farmworker unions. The Black Panthers and black power were rising from the near West side and spreading throughout the city. Oblivious to all this, I shuttled from our non-descript apartment to the Northwestern medical school on the Chicago gold coast just off Michigan avenue and then home again at night. I lived in a mental gated community.
I remember the weekend in November when I was just about to formulate another letter to the dean of students, again thanking him for his help and concern, but saying that I was not suited for medicine and that he shouldn’t waste the spot on me. It was one of those dark, cold rainy Fall days in Chicago that preceded the onset of full winter. Some might think that the lights of the stores reflecting off of the rainy pavement of Michigan Avenue between lines of yellow cabs had a sort of urban charm. I simply felt that I was flailing among the serious students who understood physiology and pharmacology and also seemed to understand each other. I had come to the conclusion that, if I couldn’t drag myself out of the hole I was in, I would not only fail medical school but would feel like I had flunked life. I really didn’t know what was next.
I have always been a newspaper reader, probably because I was a newspaper boy for many years. I picked up the Chicago Sun-Times that contained a review of a book, recently published in the US, called “A fortunate man: the story of a country doctor.” I really can’t remember why, perhaps boredom or simply wanting to go for a walk, but I went over from the study lab to Michigan Avenue in the rain and found a bookstore. They had a copy of the book and I bought it.
Harlan Cleveland from the Hubert Humphrey institute, with a career of service to government that stretched back 45 years, defined a career as a series of accidents and unforeseen happenings upon which we stamp a retrospective label. Buying A Fortunate Man was one of those accidents. It was a life preserver flung to a drowning man. I held on for dear life. I was 23. I had gone through a time when I didn’t just doubt medicine; I doubted a purpose for my life. The future I had imagined and the person who was central to that future were both gone. It was all shadows and grief. Reading A Fortunate Man somehow made me want to keep going. I remember wanting to experience patients like Sassall did to see whether there were as many stories, images, and complexities as Berger seemed to see in Sassall’s life. Could I, I asked myself, possibly have a life as rich as his?
While what Berger wrote moved me then and now, over the years, the photos have stayed with me more than the words. As a boy, when I saw something I never wanted to forget, I would pretend to be a camera. I would stand there and close my eyes as if they were a shutter, capturing an image like a Polaroid somewhere in my occipital cortex. Jean Mohr’s photos were like that. I can describe them from memory. I can’t imagine how he gained entrance into that intimate moment when eyes found each other, where patients look both frightened and comforted and the viewer is in the place of the doctor, looking back at the patient with recognition. I have known a number of documentary photographers over my life and they share the ability to be absorbed into the background, hidden behind their cameras. They talk about trying to disappear so that they can capture what is truly there. But photography, as the historian Michael Lesy wrote, often finds a deeper purpose that is religious rather than secular and that photographs are a semi-magical act that symbolically deal with time and mortality. All of the principals and many of the subjects of Mohr’s photographs are dead 45 years later but their images still represent what can and does happen in the act of doctoring.
Doctors can’t retreat to the background. We sit with people who struggle with words, often looking for words of our own to comfort or probe without harming. We are surgeons with words. If we are lazy, we retreat to the mental check boxes or, more often these days, the electronic record checkboxes. How can we understand people, or as Berger wrote, recognize people if we don’t make eye contact. After all, the standard phrase we use in our clinical lives is “seeing patients” not “watching patients” If we don’t look, observe and listen, how can we see patients – or anyone in our lives, for that matter. Thirty years ago I spent some time visiting various doctors as part of my time living and working in the National Health Service in Wales. One very dramatic older physician stood out in my mind for two very different reasons. First of all, he was a chain smoker and had a lit cigarette going on his desk for almost the whole day. But the other was to watch him with patients. He sat across the desk from them and leaned over intently and just listened. After one patient left, in a cloud of smoke, he turned to me and said “Did you see that? Did you see how sad that man was? That’s the secret. You have to use the full force of all of your senses and all of your attention for the first 10 seconds and just see the patient. Those 10 seconds will tell you everything. ”
Jean Mohr did not just spend 10 seconds; he captured the full force of our senses in his photos. Captionless photography in books was relatively new at that point. Only Walker Evans in “Let us now praise famous men” had used the power of the camera in the same way in documenting the lives of sharecroppers in Alabama during the 1930’s. Mohr’s photographs leave us with indelible images that place us in the intimate emotions of the moment with both the patient and the doctor, naked and vulnerable. Who hasn’t felt how Sassal looks in many of those photos. That vulnerability, day after day, year after year, is what challenges us to both question what we are doing and to understand it. Hill Jason once famously noted that he thought doctors often went into teaching because we couldn’t stand the day to day intensity of human contact that characterizes community practice. But that intensity can also be our salvation. Our sense of responsibility for helping patients , who often feel more like family and friends and include all the frustration that relationships bring when we can’t seem to help, that intensity and connection and small epiphanies and also offers, a sense of purpose and, when it is necessary, acceptance of our faults, and forgiveness. If it is working as it should, doctors and patients see each other for who we really are – recognition goes both ways.
The photographs in A Fortunate Man: the eyes are everything.
Intimidade. Existe uma intimidade toda especial entre o paciente e o seu médico que transcende a intimidade dos amantes. Algo muito próximo da intimidade que se tem na infância. Nos entregamos ao médico, abrimos nossa intimidade, como o faríamos quando crianças, e de algum modo o envolvemos nesse sentimento de família. Imaginamos o médico como um membro honorário da família. Não como os pais, mas sim como um irmão ou irmã mais velho.
A morte. O médico tem familiaridade com a morte. O chamamos para que nos cure e nos alivie, e se não puder fazê-lo, o convocamos para que seja testemunha da nossa morte. O médico circula confortavelmente –é isso que pensamos- entre a vida e a morte.
“Recognition”, palavra difícil de traduzir, porque quer significar identificar, entender, compreender, contato empático. É a pura ação médica, conforme o autor descreve, traduzindo livremente: “A função do médico é reconhecer (entender, compreender) o ser humano. Sei que utilizo esta palavra para incluir técnicas complicadas de psicoterapia, mas na essência, essas técnicas são justamente recursos para entender o ser humano. Para compreender o doente, o médico deve primeiro conhece-lo como pessoa. São cada vez mais raros os médicos que sabem diagnosticar bem; não porque lhes falte conhecimento médico, mas porque não são capazes de levar em conta todos os fatos relevantes –emocionais, históricos, ambientais- e integrá-los com os físicos. Buscam aspectos específicos ao invés de buscar a verdade sobre o enfermo, que lhes sugeriria muitas outras dimensões. Um bom médico é aquele que é capaz de satisfazer as profundas e, com frequência, silenciosas expectativas do enfermo com um sentido de fraternidade. O médico o conhece, sempre. Pode falhar às vezes, mas possui o desejo constante e profundo de um professional que faz questão de conhecer o ser humano”.
Testemunho das vidas dos pacientes. Faz mais do que trata-los. É um testemunha das vidas dos pacientes. Os pacientes não se referem a ele como tal, e somente pensam nele quando precisam. É uma espécie de escrivão que registra as vidas dos que tem à volta. The clerk of their records.
Ativismo. Exceto quando está tratando com os pacientes, é uma pessoa impaciente. É incapaz de estar sem fazer nada, incapaz de descansar. Dorme fácil mas no fundo agradece quando é acordado para atender alguém durante a noite. Custa-lhe aceitar uma vida normal. Talvez porque, sendo consciente ou não, preenche com trabalho o tempo que dedicaria e refletir sobre as angústias que lhe cercam, provenientes do sofrimento dos seus pacientes.
Honorários. As duas últimas páginas são excepcionais, pois abordam o difícil tema do valor de uma atividade como a do Dr. Sassall. Qual é o valor social que se dá a aliviar o sofrimento e a dor? Quando se trata de valorar um procedimento (cirúrgico) ou uma descoberta científica, as medidas são mais adequáveis. Porém, quando do que se trata é de medir a contribuição normal e quotidiana de um médico rural, de um generalista, o assunto é mais complicado.
As Crises. O ponto anterior, não saber medir o valor do ordinário, faz com que o idealismo médico da juventude se transforme em cinismo, pois o médico já não é capaz de saber o valor da sua vida, e externamente também ninguém lhe ajuda, nem reconhece isto.
A conclusão que se pode tirar disto, é que é preciso uma motivação intrínseca e transcendental para superar essas crises, que sempre chegam. O vemos diariamente.
Erros. Tem mais consciência dos próprios erros do que a maioria dos médicos. Não porque cometa mais, ou porque saiba menos. Mas porque chama erros o que muitos outros médicos denominam –talvez com alguma justificativa- complicações desafortunadas.