Book Review

The Case of Doctor Sachs

N Engl J Med 2001; 344:778-779March 8, 2001

Article

The Case of Doctor Sachs
By Martin Winckler. Translated by Linda Asher. 432 pp. New York, Seven Stories Press, 2000. (Originally published in French, 1998.) $27.95. ISBN: 1-58322-056-9

The experience of illness and the intimate world shared by doctors and their patients have inspired a large body of literature by authors from widely varied backgrounds. In “A Doctor's Visit,” Anton Chekhov, one of history's more notable physician authors, tells the story of a physician whose ability to listen soothes a young woman who suffers from anxiety and isolation. Leo Tolstoy depicts the psychological agony of a terminally ill man in “The Death of Ivan Ilyich.” These themes have also been explored in 20th-century fiction by such authors as John Berger, William Carlos Williams, Richard Selzer, and Susan Mates. The Case of Dr. Sachs, by physician Martin Winckler, is a beautifully written novel that was recently translated from French into English. The novel, winner of the prestigious Prix du Livre Inter, places its doctor in a contemporary French provincial setting and uses an unusual, shifting point of view to capture the doctor's experience and that of his patients. It is a wonderful book, poignant without being maudlin or sentimental, and one that I had difficulty putting down.

Writing of his central character in the second person, Winckler tells the story of Dr. Bruno Sachs, a general practitioner in a small French town, and his relationships with his mother, his deceased father, his close friends, his neighbors, his patients, and his colleagues. By giving each of these characters in turn a first-person voice, the author invites the reader to step into the shoes of the different people in Dr. Sachs's life. This technique generates in the reader a deep empathy for the patients Dr. Sachs treats and an understanding of the effects of his actions and words. It is this style that separates Winckler's story of doctor and patient from others in this genre.

The novel is divided into seven sections, in parallel with the sequence traditionally followed by a physician in evaluating and treating a patient: “Presentation,” “History,” “Clinical Examination,” “Further Investigations,” “Diagnosis,” “Treatment,” and “Prognosis.” Each of these sections consists of several short chapters in which Dr. Sachs's patients and friends tell their stories and reveal their fantasies about the doctor's personal life.

The influence of Winckler's own experiences as a doctor and the son of a physician permeates these stories. The novel is full of the kind of insightful writing that can come only from someone who has watched people closely for a long time. Winckler renders this kind of intense scrutiny as the habit of Dr. Sachs's patients, who notice every aspect of their physician — the color of his jacket or shirt, whether he has shaved, how he greets them, how he writes a prescription, how he examines them, the tone and inflection of his speech, whether he is tired, annoyed, or angry, whether he listens, and whether he cares. Some patients like him and his style; a few find him ineffective, become disappointed in him, and seek care elsewhere. Dr. Sachs is quiet by nature, introspective, and scrupulous about maintaining patients' confidentiality and trust. He is dedicated to his work and critical of those who do not share his ethos. He loves to read and writes fiction as well, samples of which are included in the novel. Appropriately, he belongs to a “Balint group,” named for Michael Balint, author of The Doctor, His Patient, and the Illness (New York: International Universities Press, 1957), who designed seminars in which physicians discuss aspects of the doctor–patient relationship. In the course of the novel, at least one relationship between Dr. Sachs and a patient becomes personal, when he falls in love with a woman he formerly treated.

Insofar as it reflects reality, the novel gives the American reader a glimpse of the system of socialized medicine in France. A visit to the primary care physician seems much less complicated in Dr. Sachs's world than it can be in ours. There are no discussions about copayments, insurance coverage of medications, or insurance companies' regulations regarding consultations with specialists. Fewer people are involved in delivering care to the patient. Dr. Sachs himself measures blood pressure and weight, performs electrocardiography, draws blood, dresses wounds, and administers vaccines or other injections. It seems that the only focus in the examination room is the patient and his or her problem.

Despite such differences, however, the reader is struck by the similarities between doctor–patient relationships in provincial France and those in the United States. Universally, it seems, fear, anxiety, distrust, love, gratitude, and hope are woven into the fabric of these relationships, regardless of culture or country. Readers who are also physicians may take solace in learning that what sometimes seems to be a burden of responsibility in caring for patients is felt as well by both the fictional Dr. Sachs and the author, Dr. Winckler.

When I was reading this book, I had a brief illness for which I received treatment while I continued to see patients. As I watched my doctors care for me, I gained a better understanding of patients' views of their doctors. As a result, the conversations that I had with both my patients and my physicians became more honest and personal. In a similar way, The Case of Dr. Sachs reminds students and practitioners of medicine of the profound effect that illness has on patients, their families, and those entrusted with the responsibility and privilege of caring for them. This novel will inspire physician readers to reflect on the close attention with which their patients listen to and watch them during a time of illness.

Elena M. Massarotti, M.D.
New England Medical Center, Boston, MA 02111