One bright morning this summer, in a flower-filled garden in Govan, I sat with a 50 year old man – John – as he gave an eyewitness account of hell. His mother had died. That loss, coming on top of sedimentary layers of pressure and anxiety, some of it to do with money worries, had caused a pit to yawn open; and into this he fell.
‘There were five days when darkness was just comin’ aw aroon me,’ John said, his eyes fixed on the ground. ‘It’s like the only part of your body workin’ is a wee part of yer brain. It’s like some force has taken over you, and there’s nothin’ you can dae.’
The experience, as he described it, sounded more like demonic possession than what might be commonly understood by the medical and widely-used term ‘depression’, that bland and inadequate word. John had gone to see his doctor, who had referred him to a charity specializing in mental health counselling, and now, years later, he seemed in a not-bad place. He had a better house in a better part of town, had become interested in gardening, was planting roses. Still, one could see the shadow in his eyes as he talked, the pit reflected there.
I remembered John as I read The Human Kind: A Doctor’s Stories From The Heart Of Medicine, by Peter Dorward, a philosophical account of his work as a GP in Edinburgh and elsewhere. One chapter, When Darkness Falls, is named after something his mother would say when telling the story of her own depression: ‘It was as if, one day, suddenly, from nowhere, darkness fell.’
The chapter is typical of Dorward’s approach in that he presents two stories of ill health, in this case his mother, Joy, and the family of a young patient, Maddison, all of whom have mental health issues, and uses each case to reflect upon the other. He will start out telling one story, cut away to the other, circle back to the first, all the time piling up details, memorable phrases and ideas, as a way of trying for some wider truth about how we live, how we sicken, and how we live with that sickness. His surgery is society in microcosm.
‘On some days it can seem that every other patient that I see is complaining of unhappiness,’ he writes. ‘I try not to use the word “depression”, or at least I try not to be the first. Unhappiness is what we feel – from the most minor, delicate, grey-shaded garment that clings to our skin when we wake in the morning, the flimsy thing we shrug off like our night-clothes, all the way through to a muddy shroud that wraps and suffocates, the cold wet from its folds seeping through us so that we smell of its fabric.’
None of this cleverness is done to show Dorward as a heroic figure, swooping out from his consulting room, healing the sick, and then retiring to his study to write up his notes in elegant tranquility. He reveals himself, almost always, in a poor light: angry, fallible, fumbling. This book feels steeped in guilt. Maddison’s father makes an appointment with the doctor, admitting to a crime, saying he is depressed, hoping for pills to lift his mood and let him sleep; Dorward, a reluctant prescriber of anti-depressants and painkillers, does not help. Later, when the man takes his own life, the doctor is tasked by the police to certify that he is dead. ‘Why wasn’t I kinder?’ he asks himself, accusingly. During the examination, cold sweat from the body gets on his hands. Washing and washing he can still feel it there; he wakes in the night, sensing its clammy sheen. One thinks of Lady Macbeth and her phantom bloodstains.
That sort of literary allusion isn’t quite Dorward’s style. It’s more in Gavin Francis’s line. His Shapeshifters: On Medicine & Human Change is a feast of intertextuality. The Roman poet Ovid, in particular, is Francis’s companion throughout; Metamorphoses is a touchstone. ‘This book is a celebration of dynamism and transformation in human life,’ Francis writes in his opening chapter, ‘both as a way of thinking about the body, and as a universal truth… As a writer, I’m interested in change as a metaphor that has preoccupied poets, artists and thinkers for millennia, and as a doctor, I’m interested in the same theme because to practise medicine is to seek positive change, however modest, in the minds and the bodies of my patients.’
Like Dorward, Francis is a general practitioner. They are friends, their surgeries not far from one another, and Francis was the first person to read The Human Kind. They are very different writers, though interested in some of the same things. Francis’s description of medicine as ‘the alliance of science with kindness’ chimes with Dorward’s fretful explorations of how to be good when every circumstance – such as patients selling their prescription painkillers round the schemes – has the effect of eroding one’s capacity for empathy. ‘It’s a continual effort,’ Dorward tells a student, ‘to try to remember the humanity of the people that you’re interacting with, and imagine what it is that makes their lives what they are, and makes them do what they do, particularly if they’re being horrible to you. You’re lifting against gravity, all the time. This kind of caring: it’s effortful…’
Francis is the author of Adventures In Human Being, a series of essays on the organs and other parts of the body. Popular and well reviewed, it won the Saltire prize for non-fiction in 2015. Shapeshifters, at times, has the slightly padded-out feel of a book written in order to follow up on a success, not because of any urgent need to get ideas down on paper. Of its twenty-four chapters, most of them dedicated to a different sort of transformation – puberty, pregnancy, dementia, death – a few might have been cut, and the result would have been a book closer to its fighting weight.
He can write, though. A young woman, attending his surgery with nausea, is asked what she has had to eat in the last twenty-four hours. Intent on concealing her anorexia, she feels this question as dangerously exposing: ‘Her eyes looked trapped and frightened, like a stowaway under an opening hatch.’ He is perhaps even better when he keeps his sentences straight and scalpel-sharp, such as the chapter on psychosis, which begins: ‘I have a patient who believes her fingers are rotting.’ Elsewhere, his gifts for imagery and close observation come together beautifully. Here, he remembers the first time he delivered a baby: ‘She took her first gasps; to watch her body change from a pallid blue to pink was like seeing colour return to a landscape after an eclipse.’
It is a pity that Francis has decided to frame his own observations about the changing body by making frequent reference to other stories, other texts. It does sometimes work. While attending an old soldier with dementia who is suffering from delirium caused by a urine infection, he realizes that the nursing home is close by the former Craiglockhart Hospital, where Wilfred Owen and Siegfried Sassoon were treated for shell-shock. He then quotes from Sassoon’s poem ‘The Rear-Guard’, hinting that to lose one’s memory – if those memories are traumatic – can be a sort of mercy.
Mostly, though, it feels as if Francis uses literary references as a way of adding lustre to his own writing, or, worse, to show off his reading. If his motivation is the former, it’s counterproductive. Whenever the book drifts too far from his own experience, it dulls. He is at his best when using precise language to describe the workings of the body (the mechanics of the human heart have their own poetry, and need none added) or simply observing life in his surgery. As he puts it, medical practice is ‘thick with daily revelations, so daily textured with intimacies and details of so many lives…’ This access is a gift. To work as a GP – or as a social worker, police officer, paramedic, perhaps even a teacher – is to be confronted, daily, with the realities of life in a way that few other professions are. If, as we are told, there is a staffing crisis in general practice in parts of Scotland, perhaps recruiters should consider targeting journalists and novelists, and asking them to retrain. Goodness knows, we could use the material.
Both Francis and Dorward are careful to declare that the confidences of their patients have been protected. Names have been changed, identities obscured. This restriction is, one suspects, actually an advantage, allowing for poetic licence. A chapter on tattooing, in Shapeshifters, introduces us to a prisoner, Mark – head full of anger, skin full of ink – who is released with a prescription for methadone; over the next few months, as he and Francis reduce his dose, Mark spends what little money he has on having his facial tattoos lasered off; as the teardrops and barbed wire fade, so, too, does his rage dissipate. This is, in effect, a gleaming little short story, complete with symbolism and epiphany.
The Human Kind, at its best, is similarly novelistic. Only rarely is Dorward direct in his opinions, such as his belief that doctors are too quick to prescribe painkillers: ‘I think that we are implicated in a medical and social disaster. I think that we are living through an epidemic of chronic pain and opiate misuse – I think the pain and the opiates feed one another. I think that the medical profession and the pharmaceutical industry have fed both. I think that we are vectors in this epidemic.’ Whenever he allows a patient these drugs, in a case where he believes it is probably unnecessary or even, ultimately, harmful, he feels that his integrity has been undermined. Some days, though, it’s just easier to sign the form. The Human Kind might easily have been called Confessions Of A Scottish Opiate Prescriber.
The book has significant flaws. Dorward has a tendency towards the self-reflexive that an editor ought to have rooted out. A chapter on the nature of pain gets bogged down in his account of a conversation with a philosopher about how he planned to start a chapter on the nature of pain. It is painful – or at least annoying – to read. Elsewhere, he ties himself in semantic knots – ‘No one knows whether drugs can really make people happier, and how we would know, and what we really mean by “really” and “happier”.’
These are serious mis-steps in a book that is more often sure-footed. Dorward is, above all, a great noticer. There’s a scene early on: a man in his mid-sixties turns up at the surgery with his daughter. She’s worried her father has lung cancer. Jim, a recent widower, yearns for it. He asks for a moment alone with the doctor, without his daughter, as he puts it, yapping on. ‘Men do this often, I find, even decent men,’ Dorward writes. ‘The more vulnerable they are, the more disparagingly they speak of the women that love them and keep them alive.’ A fine observation, kind yet keen.
Gavin Francis, clearly, finds his patients – their lives and bodies and minds – fascinating. Peter Dorward gives the impression that he often finds his shaming. I finished The Human Kind on July 5th, the 70th anniversary of the NHS, and it was an odd sort of pleasure – on a day when the news was full of sentimental accounts of the health service – to read something so jaded and faded, so weary to its bones. To hear him say, in exasperation, to a confidant, ‘Fuck compassion’ – well, it felt, as with much in this book, like an uncomfortable truth.