Learning by reading

Everything we read has some relevance to what we do in general practice, and the potential to expand our horizons and inspire us to be better doctors or nurses

Healthcare professionals and, perhaps, those working in general practice in particular, are exposed to a breadth of human experience and behaviour unrivalled within almost all other working lives: covering a range from courage, endurance, generosity and dignity, to drunkenness, madness and every dimension of self-destruction. We see, listen to and try to help people of all ages, cultures and religions, especially those of us who see people whose heritage and diaspora spreads all over the world. This breadth, which seems to extend in every conceivable direction, means that almost everything we read has some relevance not only to the tasks we undertake but also to the extent to which these tasks encourage or undermine us personally.

To give just one example, a few months ago, I read The Shadow Line which was written by Joseph Conrad and published in 1917. I found these two passages:

It was there that my buoyancy abandoned me. The atmosphere of officialdom would kill anything that breathes the air of human endeavour, would extinguish hope and fear alike in the supremacy of paper and ink.

and

I was, in common with other seamen of the port, merely a subject for official writing, filling up forms with all the artificial superiority of a man of pen and ink to the men who grapple with the realities outside the consecrated walls of official buildings.1

Conrad was writing about the lives and employment of seamen in the far reaches of a colonial world and yet he seems to understand, very precisely, the frustrations of trying to do any practical job in the context of an overweening bureaucracy. Has anyone working in the Health Service not sometimes felt the suffocation of officialdom and its rules? I recall the instructions never to sit on a patient’s bed and the ban on toys in consulting rooms. Nurses and doctors are undoubtedly among those ‘who grapple with the realities outside the consecrated walls of official buildings’ and just reading Conrad’s words provides some recognition and some much-needed comfort.

Several decades into my life as a doctor and a reader, I began, tentatively, to be a writer too. Most recently, I have been writing a book about how much I have learnt from reading just one particular writer. That writer is John Berger.² He was born in 1926 and died in 2017. He trained as a painter and, although he continued to draw almost every day of his life, he discovered that his true art was writing. He started as an art critic but went on to write novels, winning the Booker Prize for G in 1972, alongside many other books and innumerable essays for publications all over the world. He became that rarest of people, loved and admired as a public intellectual.

The first of John Berger’s books that I read, while still a preclinical medical student, was A Fortunate Man,3 his account of the life and work of a rural English general practitioner in the 1960s, produced in collaboration with his great friend, the photographer Jean Mohr. I recall very little of this particular reading but I am certain that it had something to do with my decision not to pursue a career in hospitals but to become a general practitioner.

It is difficult, to the point of being almost impossible, to find time for reading when studying medicine and in those first hectic career years, especially when these are combined with creating a family of one’s own. It was not until I had been in practice for 15 years that a three-month sabbatical gave me the opportunity to read widely outside medicine again. I read many great novels and I reread A Fortunate Man and it was at that time I formed my habit of copying out the particular combinations of words that resonated with my own experience, either personal or professional. By copying them out I am able to read them repeatedly, to think about them at leisure, trying to understand why they are so particularly resonant, and to learn from them.

Since then, I have read and reread many books by John Berger and copied out thousands of his words and in this way, he has taught me about crucial aspects of the work of a general practitioner that were almost entirely absent from my studies and my training. Of these books, only A Fortunate Man was directly related to healthcare but I have learnt too from his other books which, ostensibly, have nothing to do with medicine.

LISTENING IS NOT THE SAME AS HEARING

I learnt that listening is not the same as hearing and that looking is not the same as seeing; that hearing and listening are essential within any therapeutic relationship, but that hearing cannot happen without listening nor seeing without looking. I learnt to appreciate the importance of time and place in both illness and health and I realised that part of the secret of any clinical consultation is to be acutely aware of moments without thinking about the pressure of time – or worse still, looking at the clock. There is almost always a crucial moment around which everything turns. Equally there are pivotal moments where things begin to go badly wrong and any hope of mutual understanding and effective communication is completely sabotaged.

I learnt to use my own imagination and memory and to explore those of each of my patients because it is important use these alongside our experience to move beyond our initial superficial impressions. The greatest barrier to understanding is almost always the assumption that one knows the answer already and so my maxim has become: never assume, always ask and always check that you have understood.

I learnt about pain, violence and justice and particularly about the pain and violence inflicted on the displaced, the rejected and the marginalised when social justice breaks down. In his 1984 book And Our Faces, My Heart, Brief as Photos, I learnt specifically about the pain and violence of homelessness. John Berger wrote:

To the underprivileged, home is represented, not by a house, but by a practice or set of practices. Everyone has his own. These practices, chosen and not imposed, offer in their repetition, transient as they may be in themselves, more permanence, more shelter than any lodging. Home is no longer a dwelling but the untold story of a life being lived. At its most brutal, home is no more than one's name - whilst to most people one is nameless.4

I learnt to treat homeless people with respect and gentleness and in doing so I was trusted with astonishing stories of courage and endurance in the context of some of the most tragic life stories I have ever had the painful privilege of hearing.

John Berger wrote a lot about story-telling and described himself as a story-teller. He helped me to try and see my patients as story -tellers too and when I do this, I discover that my attention not only deepens but broadens and I become interested in every apparently irrelevant detail. In the same book, he wrote:

Those who read or listen to our stories see everything as through a lens. This lens is the secret of narration, and it is ground anew in every story, ground between the temporal and the timeless.4

I learnt that I need to grind the lens of my listening for each new story that I listen to and, thinking about time again, I need to distinguish between the temporal that is specific to the individual patient story at this particular moment, and the timeless, that relates to the enduring totality of human experience in relation to suffering and fear.

I remember my first job as the most junior sort of doctor in a large, busy District General Hospital and I remember clerking a man in his sixties who had just been admitted as an emergency with a heart attack. Like all young doctors, I had a huge amount to do and I needed to get through all the mandatory questions involved in what was called ‘taking a patient’s history’ (taking not listening – words that speak volumes!) and I was most certainly not seeing the patient as a story-teller. I did manage to start with an open-ended question and ask what had happened to bring him into hospital that day. He began with his waking up that morning and proceeded through every detail of his breakfast. To my shame, I began to feel intensely irritated but, much later, I came to understand that, as a story-teller, he was trying to locate the clue, both for me and for himself, of why disaster had overtaken him at this particular point in his life. Perhaps, if more healthcare professionals listened more carefully to the stories our patients tell us, we could learn more about the underlying causes of illness and disease.

A MEMORABLE PATIENT

This possibility is exemplified by my favourite ‘Memorable patient’ article from the British Medical Journal, submitted by a general practitioner in 1997.5 The doctor had been summarising his patients’ records and had discovered the record of a consultation from ten years earlier that he remembered very well because what the patient said had surprised him. He had come for a repeat prescription of antibiotics for his acne rosacea and mentioned in passing that the antibiotics helped his indigestion. The doctor’s note read: ‘Occ. Indigestion. Says oxytet cures it!’ Ten years later, he reflected that ‘the patient may seem peculiar, but he may be telling you something that is revolutionary. We ignore such things that do not fit into the standard view at our peril.’ In the preceding years, how many other doctors, most probably including myself, heard patients making similar remarks and discounted them as irrelevant, so passing up any possibility of beating Barry Marshall and Robin Warren to the discovery of the infectious agent Helicobacter pylori and the subsequent Nobel Prize for Medicine in 2005. Our patients can teach us very much more than we give them credit for.

Perhaps the single most important thing that anyone can learn from reading great writers is the importance and power of words. Putting words together well is almost a definition of poetry. In And Our Faces, My Heart, Brief as Photos, John wrote:

Poems, regardless of any outcome, cross the battlefields, tending the wounded, listening to the wild monologues of the triumphant or the fearful. They bring a kind of peace. Not by anaesthesia or easy reassurance, but by recognition and the promise that what has been experienced cannot disappear as if it had never been. Yet the promise is not of a monument. The promise is that language has acknowledged, has given shelter, to the experience which demanded, which cried out.4

Healthcare professionals, if they do nothing else, try to tend the wounded and in doing so, they need to use language that acknowledges the experience of being wounded, in whatever sense the wounding has occurred. They need the example of poets. When they start out in clinical practice, they learn, often painfully, the potential impact of words, both spoken and heard, and either destructive or healing. A single word, carelessly spoken, can undo the work of building trust over months or even years. They need to learn to listen carefully and then to speak carefully.

All young doctors (and nurses) find themselves learning the absolute necessity of being able to explain their sophisticated biomedical understanding of the patients’ illnesses in language that is understandable to each particular patient in turn. They learn that if they get the words wrong, they can so easily cause pain, and that if they choose better, both patient and clinician will begin to have a better chance of understanding what is happening and a much better prospect of finding a way through.

In his 1991 book, Keeping a Rendezvous, John Berger wrote:

The credibility of words involves a strange dialectic. It is the writer’s openness to the ambiguity and uncertainty of any experience (even the experience of determination and certainty) which gives clarity, and thus a kind of certainty to his writing.5

And this is an example of the magic that happens repeatedly. He is not writing about healthcare and yet I am learning a vital lesson about being a doctor: about the need to be open to all the ambiguity and uncertainty of each patient’s story and so achieve a kind of clarity of understanding from within that.

This is the magic that has meant that reading and learning from John Berger has been one of the great joys of my life and I know that it has helped me to think so much more deeply about the challenges of being a doctor.

REFERENCES

1. Conrad J. The Shadow-Line: 1917. Penguin Books, 1986

2. Heath I. John Berger – Ways of Learning. Oxford: Oxford University Press, 2024

3. Berger J, Mohr J. A Fortunate Man; 1967. Penguin Books, 1969

4. J. And Our Faces, My Heart, Brief as Photos; 1984. Vintage International, 1991

5. Berger J. Lost off Cape Wrath in Keeping a Rendezvous; 1991. Vintage International, 1992.