By Polly Morland
Polly Morland is a writer and documentary maker. She is the author of several books, including The Society of Timid Souls, 2013. Her most recent book A Fortunate Woman (2022), with pictures by Richard Baker, offers a sustained exploration of the ‘humanity of primary care’. Taking her cue from John Berger’s portrait of a country doctor, A Fortunate Man, Morland spent many months studying an anonymous female GP working in the same rural practice Berger had visited half a century earlier. The book critically reflects the need for a sustained and compassionate doctor–patient relationship. Research Outreach was privileged to speak to Morland about her remarkable book, and about the changing role of the modern GP.
Could you briefly introduce our readers to your book A Fortunate Woman? What was it about Berger’s book that inspired you to undertake this extraordinary study of a rural doctor?
Early in the COVID pandemic, May 2020, I was up north, clearing my elderly mother’s house. She’d been suffering from Alzheimer’s and the isolation of lockdown plus a bout of COVID itself prompted a sharp decline in her health. A lot of different doctors and other healthcare professionals came and went, and finally she moved to a care home. It was a very sad, tricky time. So there I was, clearing the house and fallen behind one of mum’s bookshelves, I found this dusty old Penguin paperback of John Berger’s A Fortunate Man. I’d read some Berger, of course, but not this book, his classic account of a country doctor working in an unnamed rural backwater in the 1960s. I opened the book and flicked through the black-and-white photos that accompany the text. This was a thunderbolt, because the pictures showed the remote wooded valley that’s been my home for the last decade. Not only that, but I also realised I knew the doctor who heads up that same practice today, a remarkable woman, well loved by her patients, the kind of family doctor I wish my mother had had in those final years at home.
So that’s how A Fortunate Woman began – quite small and very personal. And there’s a lot I didn’t know at that point, not least the influence A Fortunate Man had had on the current doctor, nor how many of my neighbours, her patients, were once patients to the old doctor in Berger’s book.
Primary care has changed beyond recognition since Berger’s A Fortunate Man.
I spent the next year walking and talking with the doctor herself, watching her work when COVID allowed. So, at one level, A Fortunate Woman is about her compelling story and her relationship with her patients, the very particular way these things play out in a place like this valley. But I came to realise that there was also a much bigger and more urgently contemporary story underpinning all this. It’s about what it means to be a doctor today. It’s about the nature of medical vocation, the process of care and how fundamental the doctor–patient relationship is to both, at a time when primary care is in acute crisis.
What kind of changes in primary caregiving did you identify between today and Berger’s day?
Primary care has changed beyond recognition since Berger’s A Fortunate Man. The doctor in his book, pseudonymised as ‘Dr Sassall’, took up practice in the valley in 1947, the year before the NHS was established. He was from that first generation of NHS GPs, predominantly male, often working single-handed and with responsibility for their patients 24 hours a day, 7 days a week and, barring holiday leave, 365 days of the year.
The 24/7 model ended in the UK in 2004, with the introduction of the Out of Hours service, marking an immense cultural shift in the way that doctors worked and related to their patients. Single-handed practices are pretty much unheard of nowadays and, in general, practices have grown larger, with ever-growing patient lists and larger teams required to care for them. The gender shift within the profession is also huge. When A Fortunate Man was written in 1967, less than a quarter of family doctors were female. That changed slowly at first and since the millennium, at speed. By 2014, the majority of the GP workforce was female and, on the basis of numbers of female GPs in training, that figure is set to rise further. The archetypal ‘Fortunate Man’ is now a ‘Fortunate Woman’.
These cultural changes sit alongside a host of others, also hugely important, including an increasingly mobile population of patients, the move towards part-time working (for many GPs, the only way to endure the pressures of the job), the rise of evidence-based medicine, advances in the treatment of disease, but also ever-growing workloads and crises in the recruitment and retention of doctors.
You have spoken of the ‘transactional’ nature of modern doctor–patient relationships. What are some of the consequences of this, both on a personal level and for modern medicine more generally?
The shift from a relational model of primary healthcare, one based on the deep accumulated knowledge that comes from knowing your doctor over time, towards a transactional model has brought with it many unintended consequences.
While the drift away from meaningful long-term relationships between doctors and their patients has been driven by multiple, complex factors, the policy emphasis now rests on speed of access to a doctor, any doctor, above all else. Yes, there are ways for a doctor to build a quality relationship at pace with a patient they do not know. There’s a lot of soul-searching from within general practice about how to do this. Still, there’s no getting away from what a growing body of research reveals about the significant benefits of seeing the same doctor over time: greater patient satisfaction, closer adherence to medical advice and medication, better uptake of vaccines, reduced use of out-of-hours services, lower referral rates, better job satisfaction and retention of doctors, fewer A&E admissions, even, according to a large-scale study from Norway published in 2021, a reduction of up to 25% in mortality.
This evidence points to the real dangers baked into the transactional model, both at a personal and a population level, financial, relational, and clinical, and in such a way that they impact both the patient and the doctor. I suppose what my book shows is the human side of this story, the real lives that underpin these statistics, and how very important it is to prioritise the relationships that sustain high-quality primary care before it’s too late.
Landscape and place are central to your book, and to the working routines of a rural GP. Could you say a little about the centrality of landscape in your book?
Yes, we’ve talked a lot about medicine, haven’t we, and actually a significant element of A Fortunate Woman is about the world beyond the doctor’s surgery. It’s about the community that the doctor serves and the lives that are lived in the unique landscape of the valley where she lives and works.
Human stories, so the doctor in my book told me, are the very heart of a GP’s work.
What I was interested in was the relationship not just between the doctor and her community, but also between community and place. I wanted to explore that subjective experience of landscape and the role it plays in people’s lives. Indeed, the valley is very much one of the central characters in the book, the turning of seasons and the multitude of tiny natural details that mark time and change and continuity in the lives of the doctor’s patients.
I was very lucky to work with the documentary photographer Richard Baker on this book. His images, not only of the doctor at work with her patients, but also the landscape in which they all live, are a vital part of the storytelling. They helped me to show the life of this place. And, after all, what is a doctor caring for if not life?
Did you notice any convergence between the working preoccupations of the rural GP and those of the modern storyteller?
That’s such an interesting question. At one level, of course it’d be absurd to suggest any parity between doctor and documentarian, because in my work no one’s life hangs in the balance, thank God! I was hugely struck by the life-and-death responsibility that the doctor in A Fortunate Woman carries with her every day. I think people often underestimate the burden placed on general practitioners, perhaps because their branch of medicine is seen as lacking the mortal drama of hospital work, but what GPs have to deal with, the risk they have to calibrate at every turn, the host of significant decisions taken every hour, are breathtaking if you look at them close up.
That said, there is something about the building of relationships that I recognise in my own work – the balance of intimacy and distance, empathy and detachment, and also the emphasis on close observation that are essential to the doctor and also to the documentary storyteller. Human stories, so the doctor in my book told me, are the very heart of a GP’s work. They’re the raw material of each clinical encounter and the lifeblood of trust between doctors and the patients. They’re also key to what many GPs will say they love most about the job, the humanity of it. So I suppose, at some level, this is something we share, the doctor and I. Stories are our bread and butter.
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This post was previously published on researchoutreach.org under a Creative Commons License.
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Photo credit: iStockPhoto.com